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Laparoscop ic Surgery in Gynaecologic Oncology An Added Value?

VVOG – PUS Gent, 16-11-2006. Laparoscop ic Surgery in Gynaecologic Oncology An Added Value?. Philippe De Sutter. Laparoscopic surgery in gynaecologic oncology. ’Some disputable applications and one fruitful indication’ D. Dargent …LS has not become wide spread

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Laparoscop ic Surgery in Gynaecologic Oncology An Added Value?

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  1. VVOG – PUS Gent, 16-11-2006 Laparoscopic Surgery in Gynaecologic OncologyAn Added Value? Philippe De Sutter

  2. Laparoscopic surgery in gynaecologic oncology • ’Some disputable applications and one fruitful indication’ D. Dargent • …LS has not become wide spread • …Results confirm that LS reduces risks without jeopardizing chances for cure • …First-level of evidence is still missing • Because we can, we should consider LS • …Radical operations are disputable indications • …Laparoscopic staging is an authentic breaktrough D. Dargent, Editorial in Gynecol Oncol 2005 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  3. SGO survey Appropriate laparoscopic procedures? Frumovitz, Gynecol Oncol 2004 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  4. Minimal Access Surgery Less invasive … more radical? • Laparoscopic / vaginal surgery • Advantages • Less blood loss • Lower overal morbidity and complications • Shorter duration of hospital admission • Faster recovery • Disadvantages • Longer operative time • Longer learning curve • Laparoscopic specific complications • BMI > 30-35 • Conversion to laparotomy Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  5. Laparoscopic surgery in gynaecologic oncology? • Not essential, even possible harmfull  Laparotomy • Not essential, but feasable and safe  Advantages of the laparoscopic approach  Advantages of avoiding laparotomy  At least equal oncologic safety • Essential, because of the added value  New diagnostic / therapeutic strategies  Better and refined oncologic results Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  6. Laparoscopic Surgery in Gynaecologic OncologyThe suspect adnexal mass and ovarian cancer

  7. The adnexal mass Laparoscopic management? • Rupture of an ovarian malignant tumour is a significant prognostic factor and should be avoided • Laparoscopic removal of ovarian cysts should be restricted to patients with preoperative evidence that the cyst is benign Vergote, Lancet 2001 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  8. The adnexal mass Laparoscopic management? • Laparoscopic management of adnexal masses: a gold standard? • The surgical diagnosis is the key to adequate management of adnexal tumours • Laparoscopy and gynaecologic cancer: is it still necessary to debate or only convince the incredulous? • The inadequate surgical management performed by laparoscopy as well as by laparotomy may worsen the prognosis of early ovarian cancer • The prognosis of cancer is more related to its biology than to the surgical approach Canis, Sem Surg Oncol 2000 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  9. The adnexal mass Lifetime risk • 5-10 % of women will undergo surgery for an adnexal mass • 13 – 21 % of these will have an ovarian malignancy • 75% of ovarian cancers are presenting with advanced disease • True stage I is rare • < 1% of apparently benign adnexal masses are “unexpected” ovarian carcinomas •  The majority (>95%) of adnexal masses are benign ! Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  10. The adnexal massPreoperative assessment of malignancy • Risk of malignancy index • Age • Size • Ultrasound / doppler / CT / MRI • CA125 • 1. Obviously malignant • 2. Definitely not malignant • Non-suspect • Benign • 3. The suspect adnexal mass • Not obvious malignant • Probably benign but could be malignant! Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  11. The adnexal massValue of preoperative assessment • Only final histology is proof that a mass is (not) malignant • Every adnexal mass is considered malignant until proven otherwise by final histology • Management according to the highest probability • Laparoscopic diagnosis is always worthwhile • Increased diagnostic power by refined inspection of ovary and peritoneum • Avoiding unnecessary laparotomies • Choise of incision Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  12. The suspect adnexal mass Laparoscopic procedure 1 • Laparoscopic inspection primary tumour and peritoneum • Irregular contours / vascularisation • Extracystic vegetations / extra ovarian local spread or invasion • Peritoneal fluid / ascites • Peritoneal metastases • Peritoneal cytology / washing • Complete adnexectomy without tumour spill • No puncture, incision, rupture or morcellation • Extraction of mass “in toto” through “endobag” • Maximum diameter 12cm • Primary 10 mm trocar for cystic mass • Colpotomy for large or solid mass • Macroscopy + frozen section Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  13. The suspect adnexal mass Detection of malignancy • Proceed to immediate surgical staging procedure • Extraovarian spread •  Laparotomy • No extraovarian spread •  Laparoscopic staging • Patient consent • Oncologic surgeon available • Operating room staff prepared Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  14. Laparoscopy for a malignant adnexal mass Surgical (re)staging of presumed stage I 2 • Inspection of abdominal cavity • Peritoneal washings • Peritoneal biopsies • Contralateral adnexectomy • Omentectomy • Lymphadenectomy • LAV Hysterectomy Tozzi, Gynecol Oncol 2004 Leblanc, Gynecol Oncol 2004 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  15. Laparoscopy for advanced ovarian cancer Assessment of optimal operability 3 • Diagnostic Open Laparoscopy • Visual assesment by oncologic surgeon • Biopsies • Optimal primary debulking surgery possible • Laparotomy  Chemotherapy (6x) • Optimal primary debulking surgery not possible • Chemotherapy (3x)  Interval debulking  Chemotherapy (3x) • Possible advantages •  Avoiding unnecessary laparotomy and delay in chemotherapy •  Increased succes rate of secundary cytoreductive surgery? •  Decreased peri-operative morbidity? •  Selection of chemoresistance? Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  16. Laparoscopy for advanced ovarian cancer Assessment of optimal operability • 61% Optimal primary debulking surgery possible • 96% optimal debulking achieved • 87% survival (FU 22 months) • 39% Optimal primary debulking surgery not possible • 26% progressive  no surgery • 74% partial response  interval debulking • 6% trocar metastasis • 80% optimal debulking achieved  81% survival • 60% overall survival •  Less surgery: 90% •  More optimal cytoreduction: 82% Angioli, Gynecol Oncol 2006 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  17. Laparoscopy for ovarian cancer Port site metastases • 1% ….19% • Causes ? • Spread and capture of malignant cells • Related to advanced stage, ascites, cyst spill • Positive pressure / chimney effect • Tissue fragmentation during extraction • Role of preventive measures are unclear • "Open" laparoscopy • Endobag for tissue extraction • Instrument decontamination / Irrigation of ports • Low pressure / Gasless laparoscopy • Closure of (midline) port incisions • Incisional recurrence also after laparotomy • No necessary negative effect on survival Ramirez, Gynecol Oncol 2003 Abu-Rustrum, Obstet Gynecol 2004 Vergote, Int J Gynecol Cancer 2005 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  18. Laparoscopy for ovarian cancer Port site metastases • Review 31 papers / 58 cases • 40 Ovarian cancer • 83% advanced stage • 71% ascites • 97% peritoneal carcinomatosis • Median time 17 days • 12 Cervical cancer • 75% therapeutic laparoscopy • Median time 5 months • 4 Uterine cancer • Median time 13,5 months Ramirez, Int J Gynecol cancer 2004 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  19. Laparoscopic Surgery in Gynaecologic Oncology Cervical Cancer

  20. Cervical cancer Laparoscopic lymphadenectomy 4-5 • Allows a vaginal approach for treatment of early stage: • Conisation • conservative treatment of micro-invasive stage Ia2 • Radical vaginal trachelectomy • stage Ib1 with desire to preserve fertility • Radical vaginal hysterectomy • stage Ia2 - Ib1 • Allows a surgical staging for advanced stage: • Selection for radio- / chemotherapy • Selection for pelvic exenteration • Curative / palliative intend • Sentinel node sampling Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  21. Laparoscopic AssistedRadical Vaginal Hysterectomy • Selected cases • Small cancers (Ia2-Ib1) • Sufficient vaginal access • Limited uterine size • Obesity / comorbidity • Increased intra- operative complications • Equal outcome • Node yield • Radicality / recurrence Renaud, Gynecol Oncol 2000 - Spirtos, Am J Obstet Gynecol 2002 Steed, Gynecol Oncol 2004 - Jackson, Gynecol Oncol 2004 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  22. Laparoscopic AssistedRadical Vaginal Hysterectomy Steed, Gynecol Oncol 2004 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  23. Laparoscopic AssistedRadical Vaginal Hysterectomy Jackson, Gynecol Oncol 2004 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  24. Cervical cancer Selection for radical trachelectomy • Small cancer stage Ib1 • < 2cm • Ectocervical • Preferably squamous • Young (reproductive) age • Strong desire for future pregnancy • Informed consent • Radical treatment if LN+ or involved margins >1987, Dargent, Cancer 2000 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  25. Cervical cancerOutcome radical trachelectomy • Review on 319 patients • Median FU 44 months • Recurrence rate: 4,1% • Death rate: 2,5% • Pregnancy outcomes on 72 RVT • 31(43%)women, 50 pregnacies • 36(72%) third trimester deliveries (8% <32w) • 12(25%) first trimester miscarriages / termination • 2(4%) second trimester miscarriages • 53(74%)women no children!! • 19(26%) one or more children Plante, Gynecol Oncol 2004 - 2005 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  26. Laparoscopic Surgery in Gynaecologic Oncology Endometrial Cancer

  27. Endometrial cancer Laparoscopic surgery 6 • Allows a surgical staging / treatment for clinical early stage: • Peritoneal cytology / biopsies • Pelvic (para-aortic) lymphadenectomy • Adnexectomy • LAVH • Feasible in 90% of stage I • Conversion 5,8% • Complications 10,5% • Similar surgical outcomes and survival • No trocar-site or vaginal vault recurrence • (…GOG LAP2 RCT: LAVH vs. TAH) Magrina, Am J Obstet gynecol 1999 Eltabbakh, Cancer 2000 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  28. Endometrial cancer Laparoscopy and outcome • RCT Stage I • FU 44 months Tozzi, J Minim Invasive Gynecol 2005 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  29. Endometrial cancer Laparoscopy and obesity • BMI > 30 • Difficult entry, limited Trendelenburg and visualization • Conversion to laparotomy: 7,5% • Compared to laparotomy controls • Longer operative time • Less complications • Similar surgical outcomes • Limitations • BMI > 60 • Para-aortic lymphadenectomy Eltabbakh, Gynecol Oncol 2000 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  30. Laparoscopic surgery in gynaecologic oncology Added value 1. Management of adnexal masses 2. Surgical (re)staging of stage I ovarian cancer 3. Assessment of optimal operability for advanced ovarian cancer 4. Allows a vaginal approach for treatment of early stage cervical cancer 5. Allows a surgical staging for advanced stage cervical cancer 6. Allows a surgical / pathological staging for treatment of clinical early stage endometrial cancer Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  31. Laparoscopic surgery in gynaecologic oncology Conclusion • Oncologic safety • Initial treatment  final outcome • Exception is not the rule • Appropriate selection of cases!! • Clinical stage • Vaginal access! • Meaningful indication • Anticipation of unsuspected findings • ….. Conversion to laparotomy Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

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