Laparoscopic Surgical Management of Epithelial Ovarian Cancer

Cagatay Taskiran, MD, Assoc. Prof. VKV

American Hospital, Division of Gynecologic Oncology

L/S & EOC

Primary trt for early stage disease

Restaging

Primary cytored’n for advanced disease

Surgical trt for recurrent disease

To assess resectability: Neoadjuvant CT

VATS

Early Stage is Rare

Comprehensive surgical staging

Exploration - Cytology and biopsiesHyst-BSO- fertility sparing surgeryPPLND-Total OmentectomyAppendectomy

Standard Surgery for Early Stage Ovarian Cancer

Schuler et al, 1999, EJOGRB401 patients, 24% up-staging

DiaphragmaOmentumPPALNCytology

Up-staging

Distribution of LN Metastasis

Early stage ovarian cancer & Laparoscopy

Retrospective seriesCase-control studies

Meta-analysisCochrane review

Literature

Early stage ovarian cancer & Laparoscopy

1994, Querleu-Leblanc 9 patients

Still small series, number low

11 studies, 9-42 pt, 88 multicenter

Approximately 400 patients

Literature

Chi, AJOG, 2005, 50 ptLN number, omental size: no

problemNo conversion to L/TSurvival rates similar

Park, Ann Surg Oncol, 2008, 36 ptLN number, omental size: no

problemUpstaging rate is sameNo recurrence within 20 months

Comparative Studies & Feasibility

Comparative Studies & Feasibility

Whole Literature

Endometrial cancer – randomized studiesEBL lowerShorter hospital stayFewer postoperative complicationsImproved QOLFaster return to normal function

Similar for ovarian cancer – no RCT, shorter interval to adjuvant chemotherapy

Benefits of Laparoscopy

Ghezzi, 2 012, 88 ptBlood tx rate 2.8% vs 19.2%

Postoperative complications 3.2% vs 31%

Febrile morbidityIleusWound dehiscenceWound infection

Benefits of Laparoscopy

CostComplicationsHospital stayPerformance – return to work – CT ??

Improved fecundity after fertility sparing surgery - adhesions

Potential Benefits & Some Conflicts

Rupture – IC – Chemo – survival is worsened

L/T 10% and L/S 15-20%

Size and endobag usage

Rupture vs puncture ??

Possible Risks & Rupture

11 studiesEBL lowerUpstaging rate 23%Conversion to L/T 3.7%Recurrence rate 9.9% (6.7-14)Intraop rupture 25% !!!!!

Only 1 port site-metastasis

Meta-Analysis & Accepted 4 April AJOG

Overall 12 hastaBorderline 8 ptEOC 4 pt (all

restaging)LN number 31-84Omentectomy no problem

No conversionNo intra-postop compMedian time 5 hr

Data

Trocar Sites

>20 cases PLN number satisfactory, time shorter, complications decrease; LN number: 17-22

Paraaortic LN number increase by years:6----19

Transperitoneal LA & Learning curve

Kohler, GO, 2004

Transperitoneal LA & Duration

Kohler, GO, 2004

14 studies 1971-1994

0 5 10 15 20 25

cytology

diaphragm

omentum

pelvic lln

pao lln

pevic perit.

abdom.perit.

bowel

%

Re-staging & Up-staging

Timing of Restaging

Lehner 1998 max. 15 daysKinderman 1996 max. 8 days

Adequate staging is very important

Primary Debulking for Advanced Disease

Fanning, 2011, GOCT: omental metastasis – ascites25 cases – 2 conversions: severe omental-RS

36% no residualHospiatal stay median 1 dayBlood loss 340 ml

Median OS: 3.5 years

Primary Debulking for Advanced Disease

Nezhat, JSLS, 201028 pt, 11 open after diagnostic L/S%88 optimal

Time and complication rates are sameBlood loss and hospital stay less

9 NED, 6 AWD, 2 DOD

Secondary Cytoreduction

Magrina, 2013, GO, 2006-2010L/S: 9, Robot:10, L/T:33 patients15 types of different proceduresNo conversion

No difference: Op. Time, comp’n, complete debulking, survival

Endoscopy: Blood loss and hospital stay

L/T: 3 major procedures, upper and lower quadrants

Secondary Cytoreduction Nezhat, JSLS, 2012, only L/S1999-2009, secondary 20, tertiary 3 cases%82 optimal200 min, 75 ml, stay 2 days1 conversionNo intraop complication

NED:12AWD:6DOD:4Median DFS: 72 months

ConclusionConclusion There is limited data on the role laprascopic surgery for early stage

ovarian cancer

Although it was started at nearly the same time periods with EC and

CC it was not populirezed

It seems feasible for surgical procedures, upstaging rates, adequacy It seems feasible for surgical procedures, upstaging rates, adequacy

of lymphadenectomy and omentectomyof lymphadenectomy and omentectomy

Survival rates are similar with laparotomySurvival rates are similar with laparotomy

Port site metastasis is rare, Major problem is tumor rupturePort site metastasis is rare, Major problem is tumor rupture

ConclusionConclusion

There is limited data on the value of laparoscopic surgery

for recurrent disease. It seems feasible for highly selected

patients at very experienced centers

It may be good way to assess resectability for advanced It may be good way to assess resectability for advanced

cases both before primary surgery and after NACTcases both before primary surgery and after NACT

VATS should be performed for patients having moderate to VATS should be performed for patients having moderate to

severe pleural effusion beforre abdominal cytoreductionsevere pleural effusion beforre abdominal cytoreduction

Thanks for your attention ….