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Laparoscopic and Robotic Management of the Adnexal Mass Javier Magrina, MD Mayo Clinic in Arizona

Laparoscopic and Robotic Management of the Adnexal Mass Javier Magrina, MD Mayo Clinic in Arizona. JFM072902. JFM100402. Prior to surgery differentiate. Functional vs benign neoplastic Benign vs malignant. Benign neoplastic adnexal masses by age. %. 100. 90. 80. 60. 34. 40. 27. 20.

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Laparoscopic and Robotic Management of the Adnexal Mass Javier Magrina, MD Mayo Clinic in Arizona

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  1. Laparoscopic and Robotic Management of the Adnexal MassJavier Magrina, MDMayo Clinic in Arizona JFM072902 JFM100402

  2. Prior to surgerydifferentiate • Functional vs benign neoplastic • Benign vs malignant

  3. Benign neoplastic adnexal masses by age % 100 90 80 60 34 40 27 20 0 Childhood Menstruating Postmenopausal Breen 1977; Spanos 1973; Hilgers Clin OG 49:535, 2006

  4. Functional vs Neoplastic bening ovarian cysts % Regression N 6 Wk 9 Wk ON 1/50 24 95 100 Observation 24 94 100 Randomized trial oral contraceptives Steinkampf 1990

  5. OVARIAN CYST REGRESSION Size, cm Regression, % 4 83 4-6 63 6-8 29

  6. OC AND FUNCTIONAL OVARIAN CYSTS % Reduction Boston ‘74 90 RCGP ‘74 65 Walnut Creek ‘81 40 Oxford ‘87 70 66

  7. Malignant adnexal masses by age % 30 24 25 20 15 10 8 5 2 0 Childhood Menstruating Postmenopausal Breen 1977; Spanos 1973; Hilgers Clin OG 49:535,2006

  8. OVARIAN CYSTSbenign vs malignant <5 cm  <5% malignant Volume: prem >20 cc postm >10 cc Gyn Onc 77:410,2000 Size: rule of 5s

  9. Benign vs malignant adnexal mass N=720 patients with adnexal mass • Pelvic exam negative • Ultrasound: bening • CA125 neg none had cancer

  10. CA-125 and HE-4 • CA-125 50% stage I 80% stage III HE4 90% stage III neg with bening gyn conditions CA-125 + HE4 n=531 sens 89% PPV 60% spec 75% NPV 94%

  11. Surgical management

  12. Adnexal Mass • Early Ca: appearances are deceiving • Advanced Ca: ascites +  CA-125: why to look? Contraindication for Laparoscopy : JUST TO LOOK

  13. The possibility of malignancy with a benign-appearing ovarian cyst at laparoscopy is: A) 0 % B) 1 % C) 5 % D) 10 % JFM100402

  14. LAPAROSCOPY FOR OVARIAN CYSTS % Benign pelvic exam or US or CA-125 1-2 Benign-appearing cyst at laparoscopy 1 Benign preop and at laparoscopy <1 Possibility of Malignancy Based on . . .

  15. Malignant adnexal mass • Borderline: cystectomy • Malignant: USO vs hyst+BSO • All patients require surgical staging

  16. The 5-year survival rate for patients with epithelial ovarian cancer Stage IA or IC undergoing USO is: a. 68 % b. 78 % c. 88 % d. 98 % GO 87:1,2002 JFM100402

  17. Malignant Ovarian Cyst Stage IA and IC (N=52) % Survival 5 Years 10 Years 98 93 *73% G1 GO 87:1, 2002

  18. Rupture of Malignant Cyst at Laparoscopy What To Do and Impact on Prognosis and Therapy

  19. Ruptured Malignant Ovarian Cyst Stage I What To Do? • Control spillage • Suction • Irrigate pelvis with water (pref. at 57ºF) • Take cytology at end of surgery • Irrigate trocar sites with water (pref.57F) • Surgical staging • If staging delayed >6wks : start chemo unless G1

  20. Rupture of a malignant stage 1 ovarian cyst is associated with: A) Decreased survival B) Increased recurrence C) No impact on survival or recurrence D) Always requiring chemotherapy JFM092104

  21. Studies with multivariate analysis have shown that the most important prognostic factor in stage I ovarian cancer is: A) Tumor grade B) Rupture of the cyst C) DNA ploidy D) Surface excrescences JFM100402

  22. Adjuvant Chemotherapy is Indicated for Stage I Ovarian Cancer Patients With : a. Unruptured tumors grade 2-3 b. Ruptured tumors regardless of grade c. Grade I tumors d. Grade I tumors with surface excrescences

  23. Malignant Ovarian Cyst G1* G2-3 Intact No Yes Ruptured No, yes? Yes Stage I Chemo *73%

  24. OVARIAN CYSTS • Laparoscopy is safe • Wait and operate 2nd trimester • CA-125  with pregnancy • Ca < 5% Pregnant Patients

  25. OVARIAN CYSTS DURING PREGNANCY % Regression 1st trimester 94 2nd trimester 25 Cancer <5

  26. OVARIAN CYSTS DURING PREGNANCY % Miscarriage Surgery 1st 2nd 3rd Emergency 50 25 100 Elective 10 0 0

  27. OVARIAN CYST ASPIRATION Recurrence, % Lipitz '92* 42 Dordoni '93 65 Marana '96* 84 • 63 N=276 • Age 16-86 • Follow-up: 3-36 months *Unilocular >3 cm

  28. Robotic vs laparoscopic adnexectomy for the adnexal massMayo Clinic in Arizona Robotic Laparoscopy p n=85 n=91 OR, min 83 71 0.01 EBL, ml 39 41 0.65 Hospital, >2 d, % 0 3 0.25 AJOG 201:566, 2009

  29. Robotic vs laparoscopic adnexectomy for the adnexal massMayo Clinic in Arizona Complications,% Robotic Laparoscopy P Intraop 1 2 1.00 Postop ≤ 6 wk 12 11 0.82 AJOG 201:566, 2009

  30. Laparoscopy for adnexal mass Endobag • Suspected or known malignancy • Solid tumors • Dermoids

  31. 22 yo presented to ENT with a supraclavicular mass. Bx: adenoca • CAT scan: large solid pelvic mass, enlarged pelvic, aortic, mediastinal nodes. . Options: laparotomy, laparoscopy, chemotherapy Final path: undiff adenoca

  32. JFM100402

  33. Large Ovarian Cysts Optimal Patient Selection for laparoscopy • US, CA-125, HE-4 and pelvic exam are benign • Unilocular, thin septations, no solid areas

  34. Large Ovarian Cysts • Laparoscopic exploration for malignancy • Controlled drainage • Verres, Trocar • SO • Frozen section Intraoperative Management

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