Laparoscopic surgery in gynaecological oncology

Laparoscopic Radical Hysterectomy Results in Higher Recurrence Rate Versus Open Abdominal Surgery for Stage IB1 Cervical Cancer Patients With Tumor Size Less Than 2 Centimeter: A Retrospective Propensity Score-Matched Study

Objective

To compare the oncologic outcomes between laparoscopic and open radical hysterectomy in patients with stage IB1 cervical cancer lesion less than 2 cm.

Methods

Patients diagnosed FIGO (2009) stage IB1 (tumor diameter <2 cm) and underwent radical hysterectomy in our hospital between March 2008 and November 2018 were studied. A propensity-matched comparison (1:2) was conducted to minimize selection biases. Demographic and baseline oncologic characteristics were balanced between groups. Overall survival (OS) and disease-free survival (DFS) were assessed using the Kaplan–Meier model, along with univariable and multivariable regression analysis.

Results

A total of 261 patients were enrolled in this study after propensity-matching, with 174 in the open group and 87 in the laparoscopic group. Disease relapsed in seven patients in laparoscopy group, and the recurrence rate was 8.0% (7/87). There were eight patients underwent abdominal radical hysterectomy experienced recurrence, and the recurrence rate was 4.6% (8/174). The multivariate analysis model revealed that laparoscopic operation was associated with higher risk of recurrence than abdominal radical hysterectomy (HR, 3.789; 95% CI, 1.143–12.559; p = 0.029). There were five patients or 2.9% (5/174) died in open surgery group and the corresponding percentage in laparoscopy group was 2.3% (2/87). No difference was found in OS between the two groups (HR, 1.823; 95% CI, 0.2673–12.44; log-rank p = 0.5398). All the recurrence occurred within two years after operation in the laparoscopy group, among which pelvic recurrence (85.7%) was dominant.

Conclusion

Traditional laparotomy radical hysterectomy has a lower recurrence rate when compared with laparoscopic operation in those cervical cancer patients with a foci diameter less than 2 cm. However, no detrimental effect on survival was found in minimal invasive operation group. Further multi-center prospective trials are needed to confirm our results on a large scale.

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.

[Feasibility and fiability of laparoscopic surgery in the uterine cancers in normal-weight patients]

OBJECTIVES

Evaluate the fiability and feasibility of laparoscopic surgery for the management of uterine cancers [endometrial cancer (EC) and early-stage cervical cancer (ESCC)] with patients who have a BMI ≤ 30 kg/m(2), within the setting of a gynaecological oncology department.

PATIENTS AND METHODS

This retrospective, monocentric and descriptive study was carried out between January 2003 and May 2011 at the Institute Claudius-Regaud, a centre for cancer diagnosis, treatment and research. A policy promoting laparoscopy as a first choice treatment has been established at the institute since 2003.

RESULTS

Two hundred and three patients were included. Eighty-five patients were early-stage cervical cancer patients and 118 patients were endometrial cancer patients. The study shows a high fiability rate for laparoscopy in non-obese patients, with a 98.8% rate for EC patients and a 98.8% rate for ESCC patients. The feasibility rates were 80.1% and 96.6%, respectively. The incidence of laparoconversion was reported at 1.2% and 3.1% for ESCC and EC patients, respectively, while the incidence of peroperative complications was 5.9% and 7.4%. The incidence of postoperative complications rank ≥ 3 according to "Memorial secondary events grading system" was 3 (3.5%) for CCUP and 3 (2.5%) for CE.

DISCUSSION AND CONCLUSION

The results of this study show high fiability and feasibility levels for the laparoscopic treatment of uterine cancers in non-obese patients. There is no need to implement the more expensive robotic-assisted surgery in this group of patients. Mastering advanced laparoscopic surgery remains a mainstay in gynaecologic oncology.

Laparoscopic lymphadenectomy in advanced cervical cancer: prognostic and therapeutic value

OBJECTIVE

Clinical benefit of surgical staging in locally advanced cervical cancer has not yet been proved. The goal of this study was to analyze the prognostic and therapeutic value of laparoscopic para-aortic lymphadenectomy with selective excision of suspicious pelvic nodes in patients with locally advanced cervical cancer.

METHODS

This is a retrospective study including 109 women treated in a single institution from 2000 to 2009. The International Federation of Gynecology and Obstetrics stage was IB2 in 12 women, IIB in 58 women, and IIIB in 39 women. None had suspicious para-aortic nodes by presurgical imaging evaluation. All patients underwent extraperitoneal para-aortic laparoscopic lymphadenectomy with selective excision of enlarged pelvic nodes and received pelvic radiotherapy with concomitant chemotherapy. Extended lumboaortic radiation therapy was added to patients with metastatic para-aortic nodes. The mean ± SD follow-up time was 43.1 ± 33.7 months.

RESULTS

Metastatic lymph nodes were identified in 23 (21.1%) of 109 patients in the para-aortic area and in 24 (53.3%) of 45 patients who underwent selective excision of pelvic nodes. Patients with nodal metastases had increased risk of mortality than those with negative nodes independently of the location (pelvic and/or para-aortic) of the metastases (hazard ratio, 4.07; 95% confidence interval, 1.36-12.16 for patients with pelvic metastases [P = 0.012]; and 3.73; 95% confidence interval, 1.38-10.09 for patients with para-aortic metastases [P = 0.010]). In the subset of women with para-aortic metastases treated by extended lumboaortic radiation therapy, neither the number of lymph nodes removed nor the number of positive nodes were associated with survival (P = 0.556 and P = 0.195, respectively).

CONCLUSION

Para-aortic and pelvic lymphadenectomy provides valuable information about mortality risk in patients with locally advanced cervical cancer.

Large twisted ovarian fibroma associated with Meigs' syndrome, abdominal pain and severe anemia treated by laparoscopic surgery

BACKGROUND

The Meigs' syndrome is a rare but well-known syndrome defined as the triad of benign solid ovarian tumor, ascites, and pleural effusion. Meigs' syndrome always requires surgical treatment. However, the optimal approach for its management has not been sufficiently investigated.

CASE PRESENTATION

We report a patient with a large twisted ovarian fibroma associated with Meigs' syndrome, abdominal pain and severe hemolytic anemia that was treated by laparoscopic surgery. This case highlights the difficulties that may be encountered in the management of patients with Meigs' syndrome, including potential misdiagnosis of the tumor as a malignant ovarian neoplasm that may influence the medical and surgical approach and the adverse impact that Meigs' syndrome can have on the patient's condition, especially if it is associated with acute pain and severe anemia. Considering the patient's serious clinical condition and assuming that she had Meigs' syndrome with a twisted large ovarian mass and possible hemolytic anemia, we first concentrated on effective medical management of our patient and chose the most appropriate surgical treatment after laparoscopic examination. The main aim of our initial approach was preoperative management of the anemia. Blood transfusions and glucocorticoid therapy resulted in stabilization of the hemoglobin level and normalization of the bilirubin levels, which confirmed the appropriateness of this approach. Laparoscopic surgery 4 days after admission enabled definitive diagnosis of the tumor, confirmed torsion and removed the bulky ovarian fibroma, resulting in timely resolution of symptoms, short hospitalization, relatively low morbidity and a rapid return to her social and professional life.

CONCLUSIONS

This case highlights the difficulties that may be encountered in the management of patients with Meigs' syndrome, including potential misdiagnosis of the tumor as a malignant ovarian neoplasm that may influence the medical and surgical approach, and the adverse impact that Meigs' syndrome can have on the patient's condition, especially if it is associated with acute pain and severe anemia. The present case suggests that laparoscopic surgery for potentially large malignant tumors is feasible and safe, but requires an appropriate medical and gynecological oncology expertise.

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.

Laparoscopy versus laparotomy for FIGO Stage I ovarian cancer

BACKGROUND

Over the past ten years laparoscopy has become an increasingly common approach for the surgical removal of early stage ovarian tumours. There remains uncertainty about the value of this intervention. This review has been undertaken to assess the available evidence of the benefits and harms of laparoscopic surgery for the management of early stage ovarian cancer compared to laparotomy.

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 STRATEGY

Trials were identified by searching the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library Issue 2, 2007, MEDLINE (January 1990 to November 2007), EMBASE (1990 to November 2007), LILACS (1990 to November 2007), BIOLOGICAL ABSTRACTS (1990 to November 2007) and Cancerlit (1990 to November 2007). We also searched our own publication archives, based on prospective handsearching of relevant journals from November 2007. Reference lists of identified studies, gynaecological cancer handbooks and conference abstract were also scanned.

SELECTION CRITERIA

Studies including patients with histologically proven stage I ovarian cancer according to the International Federation of Gynaecology and Obstetrics (FIGO).Studies comparing laparoscopic surgery with laparotomy for early stage ovarian cancer were only available from 1990. It was anticipated that a very small number of randomised controlled trials (RCTs) were conducted studying the management of early stage ovarian cancer. Therefore, non-randomised comparative studies, cohort studies and case-controls studies, but not studies with historical controls, were also considered.

DATA COLLECTION AND ANALYSIS

Data extraction was performed independently by five review authors (LRM, DDR, MIR, MCB and MIE) who assessed study quality and quality of extracted data. Extracted data included trial characteristics, characteristics of the study participants, interventions and outcomes. The quality of non RCTs was assessed using appropriate quality evaluations tools from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and from the Newcastle-Ottawa tool for observational studies (NOS).

MAIN RESULTS

No RCTs were identified. Three observational studies were identified.

AUTHORS' CONCLUSIONS

This review has found no evidence to help quantify the value of laparoscopy for the management of early stage ovarian cancer as routine clinical practice.

Role of surgery in ovarian carcinoma

Surgery plays a critical role in the optimal management of all stages of ovarian carcinoma. In apparent early-stage ovarian cancer, a comprehensive surgical evaluation allows stratification of patients into low- and high-risk categories. Low-risk patients may be candidates for fertility-sparing surgery and can safely avoid chemotherapy and be observed. Treatment of patients with high-risk early- or advanced-stage ovarian cancer usually requires a combined modality approach. Although it is well known that epithelial ovarian cancer is moderately chemosensitive, what distinguishes it most from other metastatic solid tumors is that surgical cytoreduction of tumor volume is highly correlated with prolongation of patient survival. Procedures such as radical pelvic surgery, bowel resection, and aggressive upper abdominal surgery are commonly required to achieve optimal cytoreduction. Women who develop recurrent disease may be eligible for a secondary cytoreductive surgery or may require a surgical intervention to palliate disease-related symptoms. For women at high risk of ovarian cancer, prophylactic bilateral salpingo-oophorectomy significantly reduces the incidence of this disease. The purpose of this article is to provide a comprehensive review of the surgical management of ovarian carcinoma. The roles of primary, interval, and secondary cytoreductive surgeries; second-look procedures; and palliative surgery are reviewed. The indications for fertility-sparing and minimally invasive surgery as well as the current guidelines for prophylactic surgery in high-risk mutation carriers are also discussed.