Laparoscopy versus laparotomy for FIGO Stage I ovarian cancer

Laparoscopic Surgery for Ovarian Neoplasms - What is Possible, What is Useful?

The use of minimally invasive surgical techniques is becoming increasingly important in gynecologic oncology due to technical advances and the increasing level of surgical expertise. In addition to laparoscopic approaches for the treatment of benign neoplasms, minimally invasive surgical methods have also become established in some areas for treating gynecologic malignancies. For tumor entities such as endometrial and cervical carcinoma, there are conclusive studies emphasizing the role of laparoscopy in surgical therapy. By contrast, due to a lack of prospective data with survival analyses, no clear conclusions can be drawn on the significance of laparoscopy in the surgical treatment of ovarian carcinoma. However, some smaller, mostly retrospective case-control studies and cohort studies open the way for a discussion, positing the possibility that laparoscopic surgical procedures, particularly for early ovarian carcinoma, are technically feasible and of a quality equivalent to that of conventional longitudinal laparotomy, and may also be associated with lower perioperative morbidity. In this article we discuss the most important aspects of using minimally invasive surgical techniques for ovarian carcinoma based on the current literature. In particular we look at the relevance of laparoscopy as a primary approach for surgical staging of early ovarian carcinoma, and we evaluate the role of diagnostic laparoscopy in assessing the operability of advanced ovarian carcinoma.

Laparoscopy versus laparotomy for FIGO stage I ovarian cancer

BACKGROUND

This is an updated version of the original review that was first published in the Cochrane Database of Systematic Reviews 2008, Issue 4. Laparoscopy has become an increasingly common approach to surgical staging of apparent early-stage ovarian tumours. This review was undertaken to assess the available evidence on the benefits and risks of laparoscopy compared with laparotomy for the management of International Federation of Gynaecology and Obstetrics (FIGO) stage I ovarian cancer.

OBJECTIVES

To evaluate the benefits and harms of laparoscopy in the surgical treatment of FIGO stage I ovarian cancer (stages Ia, Ib and Ic) when compared with laparotomy.

SEARCH METHODS

For the original review, we searched the Cochrane Gynaecological Cancer Group Trials (CGCRG) Register, Cochrane Central Register of Controlled Trials (CENTRAL 2007, Issue 2), MEDLINE, Embase, LILACS, Biological Abstracts and CancerLit from 1 January 1990 to 30 November 2007. We also handsearched relevant journals, reference lists of identified studies and conference abstracts. For the first updated review, the search was extended to the CGCRG Specialised Register, CENTRAL, MEDLINE, Embase and LILACS to 6 December 2011. For this update we searched CENTRAL, MEDLINE, and Embase from November 2011 to September 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-RCTs and prospective cohort studies comparing laparoscopic staging with open surgery (laparotomy) in women with stage I ovarian cancer according to FIGO.

DATA COLLECTION AND ANALYSIS

There were no studies to include, therefore we tabulated data from non-randomised studies (NRS) for discussion as well as important data from other meta-analyses.

MAIN RESULTS

We performed no meta-analyses.

AUTHORS' CONCLUSIONS

This review has found no good-quality evidence to help quantify the risks and benefits of laparoscopy for the management of early-stage ovarian cancer as routine clinical practice.

Criteria for selection of laparoscopy for women with adnexal mass

Objectives:

We compared the indication of laparoscopy for treatment of adnexal masses based on the risk scores and tumor diameters with the indication based on gynecology-oncologists' experience.

Methods:

This was a prospective study of 174 women who underwent surgery for adnexal tumors (116 laparotomies, 58 laparoscopies). The surgeries begun and completed by laparoscopy, with benign pathologic diagnosis, were considered successful. Laparoscopic surgeries that required conversion to laparotomy, led to a malignant diagnosis, or facilitated cyst rupture were considered failures. Two groups were defined for laparoscopy indication: (1) absence of American College of Obstetrics and Gynecology (ACOG) guideline for referral of high-risk adnexal masses criteria (ACOG negative) associated with 3 different tumor sizes (10, 12, and 14 cm); and (2) Index of Risk of Malignancy (IRM) with cutoffs at 100, 200, and 300, associated with the same 3 tumor sizes. Both groups were compared with the indication based on the surgeon's experience to verify whether the selection based on strict rules would improve the rate of successful laparoscopy.

Results:

ACOG-negative and tumors ≤10 cm and IRM with a cutoff at 300 points and tumors ≤10cm resulted in the same best performance (78% success = 38/49 laparoscopies). However, compared with the results of the gynecology-oncologists' experience, those were not statistically significant.

Discussion:

The selection of patients with adnexal mass to laparoscopy by the use of the ACOG guideline or IRM associated with tumor diameter had similar performance as the experience of gynecology-oncologists. Both methods are reproducible and easy to apply to all women with adnexal masses and could be used by general gynecologists to select women for laparoscopic surgery; however, referral to a gynecology-oncologist is advisable when there is any doubt.

Comparison of laparoscopy and laparotomy for the management of early-stage ovarian cancer: surgical and oncological outcomes

Objective

To investigate the surgical and oncological outcomes of laparoscopic surgery compared with laparotomy for the treatment of early-stage ovarian cancer.

Methods

Data from patients who underwent surgical management for early-stage ovarian cancer between 2006 and 2012 were retrospectively reviewed. All patients presented with stage I or II disease, and underwent comprehensive staging surgery consisting of a total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, omentectomy, and peritoneal cytology.

Results

Seventy-seven patients who underwent laparoscopic surgery (24 patients) or laparotomy (53 patients) were identified. Surgery for none of the patients was converted from laparoscopy to laparotomy. The mean operation time was shorter and the estimated blood loss was lower in the laparoscopy group than in the laparotomy group, though the differences were not statistically significant (193 min vs. 224 min, p=0.127; 698 mL vs. 973 mL, p=0.127). There were no differences in the intraoperative or postoperative complications. During a mean follow-up period of 31 months, tumor recurrence occurred in 4 patients: 2 (8.3%) in the laparoscopy group and 2 (3.8%) in the laparotomy group. The mean disease-free survival was 59 months after laparoscopy and 66 months after laparotomy (p=0.367).

Conclusion

Laparoscopic surgery seems to be adequate and feasible for the treatment of early-stage ovarian cancer with comparable results to laparotomy in terms of the surgical outcomes and oncological safety.

Laparoscopy versus laparotomy for FIGO stage I ovarian cancer

BACKGROUND

This is an updated version of the original review that was first published in the Cochrane Database of Systematic Reviews 2008, Issue 4. Laparoscopy has become an increasingly common approach to surgical staging of apparent early-stage ovarian tumours. This review was undertaken to assess the available evidence on the benefits and risks of laparoscopy compared with laparotomy for the management of International Federation of Gynaecology and Obstetrics (FIGO) stage I ovarian cancer.

OBJECTIVES

To evaluate the benefits and risks of laparoscopy compared with laparotomy for the surgical treatment of FIGO stage I ovarian cancer (stages Ia, Ib and Ic).

SEARCH METHODS

For the original review, we searched the Cochrane Gynaecological Cancer Group Trials (CGCRG) Register, Cochrane Central Register of Controlled Trials (CENTRAL 2007, Issue 2), MEDLINE, EMBASE, LILACS, Biological Abstracts and CancerLit from 1 January 1990 to 30 November 2007. We also handsearched relevant journals, reference lists of identified studies and conference abstracts. For this updated review, we extended the CGCRG Specialised Register, CENTRAL, MEDLINE, EMBASE and LILACS searches to 6 December 2011.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-RCTs and prospective case-control studies comparing laparoscopic staging with open surgery (laparotomy) in women with stage I ovarian cancer according to FIGO.

DATA COLLECTION AND ANALYSIS

There were no studies to include, therefore we tabulated data from non-randomised studies (NRS) for discussion.

MAIN RESULTS

We performed no meta-analyses.

AUTHORS' CONCLUSIONS

This review has found no good-quality evidence to help quantify the risks and benefits of laparoscopy for the management of early-stage ovarian cancer as routine clinical practice.

Accuracy of magnetic resonance imaging in ovarian tumor: a systematic quantitative review

OBJECTIVE

To estimate the diagnostic accuracy of magnetic resonance in ovarian tumors.

STUDY DESIGN

A quantitative systematic review was performed. Studies that compared magnetic resonance and paraffin sections within subjects for diagnosis of ovarian tumors were included.

RESULTS

Fifteen primary studies were analyzed, which included 1267 ovarian masses. For borderline or malignant ovarian cancer vs benign ovarian lesions, the pooled likelihood ratio for the occurrence of a positive magnetic resonance result was 6.6 (95% confidence interval, 4.7-9.2) and the posttest probability for borderline or malignant diagnosis was 77% (95% confidence interval, 70-82). Because specificity and likelihood ratio positive were heterogeneous, a random effect model was used and a summary receiver operating characteristic curve was generated. For borderline or malignant ovarian cancer vs benign ovarian lesions, the area under curve was 0.9526.

CONCLUSION

Magnetic resonance seems to be a useful preoperative test for predicting the diagnosis of pelvic masses.

Epithelial ovarian carcinoma: current evidences and future perspectives in the first-line setting

Epithelial ovarian carcinoma is still the most common cause of death from gynaecological cancer in USA and western Europe. The optimal therapy of epithelial ovarian carcinoma requires participation of a multidisciplinary team - from diagnosis through the entire natural history of each individual patient. Only 20-30% of patients are diagnosed at the initial stage, when appropriate staging surgery in combination with adjuvant chemotherapy for high-risk patients can be curative. Treating patients with advanced disease consists of a staging surgery with maximum cytoreductive effort, followed by chemotherapy with a combination of taxane and carboplatin. Unfortunately, the majority of patients with advanced disease will relapse and become candidates for therapy that comprises individualised chemotherapy, and surgery in selected cases. For this reason, there is still a need for new treatments and strategies in the first-line setting.