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Laparoscop ic Surgery in Gynaecologic Oncology The suspect adnexal mass and ovarian cancer

Laparoscop ic Surgery in Gynaecologic Oncology The suspect adnexal mass and ovarian cancer. Philippe De Sutter. 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

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Laparoscop ic Surgery in Gynaecologic Oncology The suspect adnexal mass and ovarian cancer

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  1. Laparoscopic Surgery in Gynaecologic Oncology The suspect adnexal mass and ovarian cancer Philippe De Sutter

  2. 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(a) is rare < 1% of apparently benign adnexal masses are “unexpected” ovarian carcinomas  The majority (>95%) of adnexal masses are benign ! The adnexal mass Lifetime risk Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  3. Laparoscopic / vaginalsurgery Advantages Lessbloodloss Loweroveralmorbidity and complications Shorterduration of hospital admission Fasterrecovery Disadvantages Longer operative time Longer learningcurve Laparoscopicspecific complications BMI > 30-35 Conversion to laparotomy Minimal Access Surgery Less invasive … more radical? Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  4. The adnexal mass Laparoscopy versus laparotomy Medeiros, Int J Gynecol Cancer 2008 Systematicreview and meta-analysis • 487 trials – 23 relevant studies • Inclusion of only 6 RCT involving 324 cases Laparoscopy is associatedwithreduction: • Febrilemorbidity • Urinarytractinfection • Postoperative pain and complications • Days in hospital (-3) • Total cost • Increasedoperative time (+11min) Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  5. 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 The adnexal mass Laparoscopic management? Vergote, Lancet 2001 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  6. 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 itsbiologythan to the surgicalapproach The adnexal mass Laparoscopic management? Canis, Sem Surg Oncol 2000 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  7. Assess risk of malignancy (index) Age (87% > 45y) Size TV Ultrasonography/ Colordoppler / CT / MRI / … CA125 Conclusion: 1. Obviously malignant 2. Definitelynot malignant Non-suspect Benign 3. The “suspect “adnexal mass Not obvious malignant Probably benign … But could be malignant! The adnexal massPreoperative assessment of malignancy Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  8. The adnexal massChoise … not chance! Benign Malignant Obvious benign Suspicious Obvious malignant Laparoscopy or Laparotomy Expectant management or Laparoscopy Gyn Onco and Surgical staging Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  9. Expert evaluation is not Always and everywhere available 100% failure proof Only final histology is proof that a mass is (not) malignant Everyadnexal mass is considered malignant until proven otherwise by final histology Management according to the highest probability Laparoscopicdiagnosisisalwaysworthwhile Increased diagnostic power by refined inspection of ovary and peritoneum Avoidingunnecessary laparotomies Choise of incision The adnexal massRelative value of preoperative assessment Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  10. 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 Completeadnexectomywithouttumour / cyst spill No puncture, incision, rupture or morcellation Extraction of mass “in toto” through “endobag” Maximum diameter 12,7cm Primary 10 mm trocar for cystic mass Colpotomy for large or solid mass Macroscopy+ frozen section The suspect adnexal mass Laparoscopic procedure 1 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

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

  12. No spill Delay of treatment will probably not alter prognosis Acute spill  Intended / controlled puncture / aspiration Minimal /theoretical contamination Will probably not alter the prognosis If appropriate staging is immediately performed Chronic spill  unintended capsule rupture / incomplete resection Clear / chronic contamination May worsen the prognosis Type and amount of spill Upstaging by extra-ovarian spread If appropriate treatment is delayed > 8-17 days Laparoscopy for a malignant adnexal mass Tumour spill Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  13. 1% ….19% Causes ? Spread and capture of malignant cells Related to advanced stage, ascites, cystspill 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 / O² Closure of (midline) port incisions Incisionalrecurrencealsoafterlaparotomy No necessary negative effect on survival Laparoscopy for ovarian cancer Port site metastases Ramirez, Gynecol Oncol 2003 Abu-Rustrum, Obstet Gynecol 2004 Vergote, Int J Gynecol Cancer 2005 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  14. 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 Laparoscopy for ovarian cancer Port site metastases Ramirez, Int J Gynecol cancer 2004 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  15. Laparoscopy for adnexal mass Does size matter? Ghezzi, BJOG 2008 Size (n= 186) • 10-20cm: 169 (91%) • 20-30cm: 13 (7%) • > 30cm: 4 (2%) • No exclusionfor US features orelevated CA125! Histology / size • Benign: 161 (86,6%) 10cm (10-36) • LMP: 8 (4,3%) 22,5cm (10-40) • Malignant: 16 (8,6%) 10,2cm (10-28) • 10 > CA125 • 12 > US+  avoid 9/10 unnecessarylaparotomies Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  16. Laparoscopy for a suspect adnexal mass Surgical management Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  17. Procedure is feasible and surgicaloutcomes are equal Inspection of abdominalcavity Peritonealwashings Peritonealbiopsies Contralateraladnexectomy Omentectomy Lymphadenectomy LAV Hysterectomy Upstaging ~10-20% Oncologicsafety? Laparoscopy versus Laparotomy ? Surgical (re)staging of presumed stage I 2 Querleu, BJOG 2003 Tozzi, Gynecol Oncol 2004 Leblanc, Gynecol Oncol 2004 Leblanc, Gynecol Oncol 2004 Park, Int J Gynecol Cancer 2008 Nezhat, AJOG 2008 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  18. 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? Laparoscopy for advanced ovarian cancer Assessment of optimal operability 3 Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

  19. Is a pragmatic and therefore standard approach  ~100% Se, Sp, NPV Avoid unnecessary laparotomy Benefits of minimal access surgery Not minimally invasive surgery Feasible, safe and benificial if : Cases are carefully selected Referral if necessary Strict adherence to protocol No delay of appropriate staging procedure if malignancy is detected Laparoscopy for a (suspect) adnexal mass Conclusions Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

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