Laparoscopic staging of apparent early stage ovarian cancer: Results of a large, retrospective, multi-institutional series

Laparoscopic predictability of minimally invasive interval debulking in advanced ovarian cancer: The MIID-SOC trial

BACKGROUND

We sought to create a laparoscopic-based model to predict the ability to perform a minimally invasive (MIS) cytoreductive surgery in advanced epithelial ovarian cancer patients who have received neoadjuvant chemotherapy (NACT).

METHODS

Fifty women were enrolled in a multi-institutional prospective pilot study (NCT03378128). Each patient underwent laparoscopic evaluation of 43 abdominopelvic sites followed by surgeon dictated surgical approach, either continue MIS or laparotomically. However, if the procedure continued MIS, the placement of a hand-assist port for manual palpation was mandated to emulate a laparotomic approach and all 43 sites were re-evaluated. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for each site to predict MIS resectability. Each parameter was assigned a numeric value based on the strength of statistical association and a total predictive index score (PIV) was assigned for each patient. Receiver operating characteristic curve analysis was used to assess the ability of the model to predict the MIS approach.

RESULTS

Twenty-seven patients (61%) underwent MIS surgery. The following abdominopelvic sites were selected for inclusion in the model: gastrosplenic ligament, rectum, left mesocolon, transverse colon, right colon, cecum, appendix, liver capsule, intrahepatic fossa/gallbladder, ileum/jejunum. Using the PIV, a ROC was generated with an AUC = 0.695. In the final model, a PIV <2 identified patients able to undergo an optimal MIS cytoreductive surgery with an accuracy of 68.2%. The specificity, or the ability to identify patients who would not be able to undergo an optimal MIS interval cytoreductive surgery, was 66.7%.

CONCLUSION

This predictive index model may help to guide future inclusion criteria in randomized studies evaluating the MIS approach in advanced epithelial ovarian cancer.

The role of minimally invasive surgery in gynaecological cancer: an overview of current trends

Background

The capabilities of minimally invasive surgery, either as conventional laparoscopy, or as robotic surgery, have increased to an extent that it enables complex operations in the field of gynaecological oncology.

Objective

To document the role of minimally invasive gynaecological surgery in cancer.

Materials and methods

A review of the literature that shaped international guidelines and clinical practice.

Main outcome measures

Current guidelines of major international scientific associations and trends in accepted clinical practice.

Results

In recent years, evidence on oncologic outcome has limited the role of minimally invasive techniques in cervical cancer, while the treatment of early endometrial cancer with laparoscopy and robotic surgery has become the international standard. In ovarian cancer, the role of minimally invasive surgery is still limited. Current evidence on perioperative morbidity underlines the necessity to implicate minimally invasive techniques whenever possible.

Conclusion

The optimal surgical route for the treatment of gynaecological cancer remains in many cases controversial. The role of minimally invasive surgery remains increasing in the course of time.

What is new?

This comprehensive review offers an entire perspective on the current role of minimally invasive surgery in gynaecological cancer therapy.

Is minimally invasive surgical approach a reasonable option in apparent early stage epithelial ovarian cancer restaging? Results from a multicentric retrospective study

INTRODUCTION

To perform surgical staging of early stage ovarian cancer (EOC), conventional laparoscopy (LS) and robot-assisted laparoscopy (RLS) appear to be reliable procedures compared to open surgery. But oncologicals results with long-term follow up are limited in the literature. The objective of this study is to evaluate the surgical and long-term survival for patients managed by minimally invasive surgery (MIS).

MATERIALS AND METHODS

We conducted a multicentric retrospective study in 6 institutions. All patients referred for epithelial EOC (apparent stage I-IIa) managed with LS and RLS were involved.

RESULTS

From December 2008 to December 2017, 140 patients were included (109 in LS group and 31 in RLS group). A total of 27 (19.2 %) patients were upstaged to an advanced ovarian cancer (FIGO stage > IIA), and 73 % of patients received chemotherapy. Mean operative time was 265,8 ± 88,4 min and significantly longer in RLS group (LS = 254,5 ± 86,8; RLS = 305,6 ± 85,5; p = 0,008). Rate of severe post-operative complications (grade 3) was 5,7 %. Thirteen conversion to laparotomy occurred, including one per-operative hemorrhaege. After a mean follow-up of 60,7 months, 29 (20.7 %) patients recurred, with a time to recurrence was >24 months in 51,7 % of cases. Overall survival (OS) was 88.6 % and disease-free survival (DFS) was 79.3 %. Oncologic outcomes were similar between LS and RLS group (OS: p = 0,504 and DFS: p = 0,213).

CONCLUSION

Surgical staging of EOC by LS or RLS approach has long-term equivalent surgical and oncological approach. These results seem to be equivalent to open surgery according to literature review.

Laparoscopic versus laparotomic surgical treatment in apparent stage I ovarian cancer: a multi-center retrospective cohort study

BACKGROUND

Laparoscopic treatment shows non-inferior survival outcomes and better surgical outcomes in apparent stage I ovarian cancer (OC) in some studies but has not been well defined.

METHODS

We conducted a retrospective study of patients with apparent stage I OC treated in two hospitals between 2012 and 2022. The surgical and oncologic outcomes were evaluated between patients receiving laparoscopic and laparotomic surgery.

RESULTS

We identified 37 patients with apparent stage I OC, including 15 (40.5%) serous carcinomas, 9 (24.3%) mucinous cancers, 3 (8.1%) endometroid cancers, 2 clear cell carcinomas, and 8 (21.6%) non-epithelial cancers. Sixteen patients received laparoscopic surgery and the other 21 patients underwent laparotomic surgery. The median age (44.5 vs. 49.0 years), mean mass size (10.5 vs. 11.3 cm), and median follow-up time (43.5 vs. 75.0 months) showed no statistically significant differences between patients in laparoscopic and laparotomic groups (all P > 0.05). All the patients underwent comprehensive surgical staging surgery, and the mean surgical time (213.5 vs. 203.3 min, P = 0.507), number of lymph nodes sampling (18.6 vs. 17.5, P = 0.359), proportion of upstaging (12.5% vs. 19.0%, P = 0.680), and postoperative complications (no Accordion Severity Grading System grade ≥ 3) were comparable between two surgical groups. Moreover, patients in the laparoscopic group had significantly less intraoperative blood loss (231.3 vs. 352.4 mL, P = 0.018), shorter interval between surgery and postoperative adjuvant chemotherapy (7.4 vs. 9.5 days, P = 0.004), shorter length of hospital stay (9.9 vs. 13.8 days, P < 0.001) than those treated with laparotomic surgery. During a median follow-up of 54.0 months, 9 (24.3%) relapsed and 1 (2.7%) died, with a 5-year recurrence-free survival (RFS) and disease-specific survival (DSS) rate of 70.6% and 100%, respectively. However, the 5-year RFS (93.3% vs. 58.8%, P = 0.084) and DSS (100% vs. 100%, P = 0.637) rates did not significantly differ between the two groups.

CONCLUSION

Laparoscopic surgical treatment had less intraoperative blood loss, earlier postoperative adjuvant chemotherapy administration, shorter hospitalization time, and non-inferior survival outcomes in apparent stage I OC when compared with laparotomic surgery.

Case report: Minimally invasive primary debulking surgery for advanced stage epithelial ovarian cancer

The surgical management of advanced ovarian cancer has historically emphasized an open technique, but advances in minimally invasive surgery (MIS) have led to its increasing use in ovarian cancer. Most research has focused on the utility of MIS in the interval debulking setting. Here, we present a case of a 38-year-old patient with incidentally diagnosed advanced stage ovarian cancer. We describe the robotic surgery techniques used to achieve complete primary cytoreduction, including resection of disease on the diaphragm. The patient has completed standard adjuvant chemotherapy and maintenance treatment and remains without evidence of disease for more than 2 years. This case details the techniques utilized to achieve complete cytoreduction including trocar placement, robotic instrument preference, and rotation of the robotic boom. This patient has had successful perioperative and oncologic outcomes, and her case highlights the role for minimally invasive primary debulking surgery for select patients with advanced ovarian cancer.

Laparoscopic Fertility-Sparing Surgery for Early Ovarian Malignancies

The demand for fertility-sparing surgery (FSS) has increased in the last decade due to increased maternal age, increased incidence of ovarian malignancies in younger patients, and technical advances in surgery. Data on oncological safety and fertility outcomes of patients with ovarian cancer after laparoscopic FSS are sparse, but some retrospective studies have shown that open FSS may be offered to selected patients. We assessed the role of minimally invasive FSS in comparison with radical surgery (RS) in terms of oncological safety and reproductive outcomes after FSS in this multicenter study. Eighty patients with FIGO stage I/II ovarian cancer treated with laparoscopic FSS or RS between 01/2000 and 10/2018 at the participating centers (comprehensive gynecological cancer centers with minimally invasive surgical expertise) were included in this retrospective analysis of prospectively kept data. Case-control (n = 40 each) matching according to the FIGO stage was performed. Progression-free survival [150 (3-150) and 150 (5-150) months; p = 0.61] and overall survival [36 (3-150) and 50 (1-275) months; p = 0.65] did not differ between the FSS and RS groups. Eight (25.8%) women became pregnant after FSS, resulting in seven (22.5%) deliveries; three (37.5%) patients conceived after in vitro fertilization, and five (62.5%) conceived spontaneously. Laparoscopic FSS seems to be applicable and oncologically safe for patients with early-stage ovarian cancer, with adequate fertility outcomes.

Critical elements in the operative management of pediatric malignant ovarian germ cell tumors

Performance of the appropriate operation is highly important to ensure that any patient with a suspected ovarian germ cell tumor receives optimal therapy that prioritizes cure while simultaneoulsy minimizing risk of short and long-term toxicities of treatment. The following critical elements of any operative procedure performed for a suspected pediatric or adolescent ovarian germ cell tumor are reviewed: 1. Complete resection of the tumor via ipsilateral oophorectomy while avoiding tumor rupture and spillage, and 2. Performance of complete intraperitoneal staging at the time of initial tumor resection.

Robotic surgery in ovarian cancer

Ovarian cancer (OC) represents one of the most lethal cancers in women. The aim of surgical treatment is complete cytoreduction in advanced stages and a surgical staging in early stages. Although the guidelines still suggest laparotomy as the standard approach, in recent years minimally invasive surgery (MIS) has become increasingly popular in the treatment of OC, especially in early stages, because the 5-year relative survival exceeds 90% and the patients' quality of life cannot be overshadowed. However, MIS has been demonstrated to have a role even in advanced stages, in the prediction of optimal cytoreduction, identification patients who may benefit from neoadjuvant chemotherapy, and, more recently, in the interval debulking surgery, as in selected cases of secondary cytoreduction for recurrent ovarian cancer. The aim of this review is to describe the MIS (especially robotic surgery), with its advantages and pitfalls, in the treatment of OC.

The role of minimally invasive surgery in epithelial ovarian cancer treatment: a narrative review

Objectives

The aim of this narrative review is to summarize the available evidence on the use of minimal invasive surgery (MIS) in the management of epithelial ovarian cancer (EOC).

Background

MIS is currently performed to stage and treat EOC at different stage of presentation. We will evaluate risks and benefits of minimally invasive surgery for early stage EOC treatment, then potential advantages provided by staging laparoscopy in identifying patients suitable for primary cytoreductive surgery (PDS) will be discussed. Finally we will investigate the growing role of MIS in the treatment of advanced EOC after neoadjuvant chemotherapy (NACT) and in the treatment of EOC recurrence.

Methods

An electronic database search was performed on PubMed, Medline, and Google Scholar for relevant studies up to December 2022.

Conclusion

LPS represents a feasible surgical procedure for the staging and treatment in early, advanced and EOC relapse in selected patients treated in high-volume oncological centers by surgeons with adequate experience in advanced surgical procedures. Despite the increasing use of MIS over the last few years, randomized clinical trials are still needed to prove its effectiveness.

A prospective randomized multicenter trial for lymphadenectomy in early-stage ovarian cancer: LOVE study

BACKGROUND

The Lymphadenectomy in Ovarian Neoplasms (LION) study revealed that systemic lymphadenectomy did not bring survival benefit for advanced ovarian cancer patients with clinically normal lymph nodes and was associated with a higher incidence of operative complications. However, there is no consensus on whether lymphadenectomy has survival benefit or not in early epithelial ovarian cancer (EOC).

METHODS

We designed the LOVE study, a multicenter, randomized controlled, phase III trial to compare the efficacy and safety of comprehensive staging surgery with or without lymphadenectomy in stages IA-IIB EOC and fallopian tube carcinomas (FTC). The hypothesis is that the oncological outcomes provided by comprehensive staging surgery without lymphadenectomy are non-inferior to those of conventional completion staging surgery in early-stage EOC and FTC patients who have indications for post-operative adjuvant chemotherapy. Patients assigned to experimental group will undergo comprehensive staging surgery, but lymphadenectomy. Patients assigned to comparative group will undergo completion staging surgery including systematic pelvic and para-aortic lymphadenectomy. All subjects will receive 3-6 cycles of standard adjuvant chemotherapy. Major inclusion criteria are pathologic confirmed stage IA-IIB EOC or FTC, and patients have indications for adjuvant chemotherapy either confirmed by intraoperative fast frozen section or previous pathology after an incomplete staging surgery. Major exclusion criteria are non-epithelial tumors and low-grade serous carcinoma. Patients with severe rectum involvement which lead to partial rectum resection will be excluded. The sample size is 656 subjects. Primary endpoint is disease-free survival.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04710797.

Comparison of Laparoscopy and Laparotomy in the Management of Early-stage Ovarian Cancer

Objectives

The objective of this study was to assess the feasibility of minimally invasive surgery for early-stage ovarian cancer (EOC) by comparing the surgical and survival outcomes between laparoscopy and laparotomy.

Materials and Methods

This was a retrospective, single-center observational study that included all patients who underwent surgical staging for EOC by laparoscopy or laparotomy between 2010 and 2019.

Results

Forty-nine patients were included; of which 20 underwent laparoscopy, 26 laparotomy, and three conversion from laparoscopy to laparotomy. No significant differences were observed between the two groups regarding operative time, number of lymph nodes dissected, or intraoperative tumor rupture rate, while estimated blood loss and transfusion requirements were lower in the laparoscopy group. The complication rate tended to be higher in the laparotomy group. Patients in the laparoscopy group had a faster recovery, with earlier urinary catheter and abdominal drain removal, shorter hospital stay, and a trend toward earlier tolerance of oral diet and mobilization. At a mean follow-up of 45.7 months, 14 patients had disease recurrence, with no differences in the mean progression-free survival between the two groups (36 months for laparoscopy vs. 35.5 months for laparotomy, P = 0.22).

Conclusion

Laparoscopic surgery performed by a trained gynecological oncologist is a safe and effective surgical approach for comprehensive staging of EOC, with the additional benefits of a faster recovery compared to laparotomy.

Primary Laparoscopic Surgery Does Not Affect the Prognosis of Early-Stage Ovarian Clear Cell Cancer

Purpose

Minimally invasive surgery (MIS) is performed frequently in early-stage ovarian cancer patients, especially in ovarian clear cell carcinoma (OCCC). The aim of this study was to investigate whether primary laparoscopic surgery influences prognosis in patients with early-stage OCCC.

Patients and Methods

Patients with International Federation of Gynecology and Obstetrics (FIGO) stage I  OCCC were retrospectively reviewed in two hospitals between April 2010 and August 2020. Clinical data were abstracted, and patients were followed up until February 2021. Patients were divided into open surgery (laparotomy) and laparoscopy groups, and the Kaplan–Meier method was applied to compare progression-free survival (PFS) and overall survival (OS) between the groups. Statistical differences were determined by the Log rank test.

Results

Eighty-nine patients were included in the study; 20 (22.5%) and 69 (77.5%) patients underwent laparoscopic and open surgery, respectively. The patients’ characteristics were well-balanced except that patients in the laparoscopy group tended to have smaller tumors and lower frequency of omentectomy and lymphadenectomy compared with the open surgery group. The median follow-up duration was 42.6 and 36.5 months in the laparoscopy and open surgery groups, respectively. Nine (10.1%) patients developed recurrence, and 4 (4.5%) died of the disease; all in the open surgery group. The estimated 2-year PFS rates were 100.0% and 90.1%, and the estimated 5-year OS rates were 100.0% and 91.9% in the laparoscopy and open surgery groups, respectively. No significant survival differences were found between the groups.

Conclusion

Survival was not compromised when primary laparoscopic surgery was performed in early-stage OCCC patients. A well-designed randomized controlled trial is warranted.

The complex relationship between infertility and female genital tract cancer: A review

INTRODUCTION

The link between female infertility and gynecological cancer has always been a debated and challenging topic. Although cervical cancer has the worst impact on female fertility, as it is usually diagnosed in patients of reproductive age, endometrial and ovarian cancer are also diagnosed and treated often in relatively younger patients in which fertility preservation is a relevant issue. The aim of this review is to highlight the correlation between therapy for female infertility and the developing cancer's risk and to describe the fertility sparing treatments in gynecological oncology.

MATERIAL AND METHODS

A systematic review of the literature through the main scientific search engines (PubMed and Google Scholar) was performed. We selected the most relevant articles based on the largest case series and the latest updates. All selected documents have been listed in the references.

RESULTS

Fifty-six relevant articles published between 1996 and 2019 were identified.Results from the available evidence report no significant increased risk of endometrial, cervical, and ovarian cancer in patients having infertility treatments.In young patients diagnosed with gynecological cancer, preservation of fertility is a personalized choice depending on several factors (type, stage, age and desire to conceive, safety of the treatment, and feasibility of fertility sparing surgery). For ovarian cancer FIGO stage IA G1, IA G2 (grade), and IC G1; for endometrial adenocarcinoma grade 1 with no lymphovascular space invasion (LVSI) or myometrial invasion and for early-stage cervical cancer (FIGO stage 2018: IA1-IB1), fertility sparing treatment is possible. The role of fertility sparing treatment with the increase of personalization of therapies therapy is always a theme of discussion and research.

CONCLUSION

At present data regarding the risk of gynecological cancers after infertility treatments are reassuring. Careful evaluation of female fertility-sparing options in young women interested by ovarian, endometrial, or cervical tumors should be carried out involving a multidisciplinary team and ensuring safety and efficacy.

Intraoperative Rupture of the Ovarian Capsule in Early-Stage Ovarian Cancer: A Meta-analysis

OBJECTIVE

To examine the effects of intraoperative ovarian capsule rupture on progression-free survival and overall survival in women who are undergoing surgery for early-stage ovarian cancer.

DATA SOURCES

MEDLINE using PubMed, EMBASE (Elsevier), ClinicalTrials.gov, and Scopus (Elsevier) were searched from inception until August 11, 2020.

METHODS OF STUDY SELECTION

High-quality studies reporting survival outcomes comparing ovarian capsule rupture to no capsule rupture among patients with early-stage epithelial ovarian cancer who underwent surgical management were abstracted. Study quality was assessed with the Newcastle-Ottawa Scale, and studies with scores of at least 7 points were included.

TABULATION, INTEGRATION, AND RESULTS

The data were extracted independently by multiple observers. Random-effects models were used to pool associations and to analyze the association between ovarian capsule rupture and oncologic outcomes. Seventeen studies met all the criteria for inclusion in the meta-analysis. Twelve thousand seven hundred fifty-six (62.6%) patients did not have capsule rupture and had disease confined to the ovary on final pathology; 5,532 (33.7%) patients had intraoperative capsule rupture of an otherwise early-stage ovarian cancer. Patients with intraoperative capsule rupture had worse progression-free survival (hazard ratio [HR] 1.92, 95% CI 1.34-2.76, P<.001), with moderate heterogeneity (I2=41%, P=.07) when compared with those without capsule rupture. Pooled results from these studies showed a worse overall survival (HR 1.48, 95% CI 1.15-1.91, P=.003), with moderate heterogeneity (I2=53%, P=.02) when compared with patients without intraoperative capsule rupture. This remained significant in a series of sensitivity analyses.

CONCLUSION

This systematic review and meta-analysis of high-quality observational studies shows that intraoperative ovarian capsule rupture results in decreased progression-free survival and overall survival in women with early-stage ovarian cancer who are undergoing initial surgical management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021216561.

Minimally invasive surgical staging for early stage ovarian cancer: A long-term follow up

INTRODUCTION

The standard treatment for epithelial early stage ovarian cancer (eEOC) includes laparotomic surgical staging, according to ESGO-ESMO guidelines. In the last decade, many investigators have assessed the safety and feasibility of minimally invasive surgery (MIS) staging in properly selected patients. However, survival data related to different surgical approaches (open versus MIS) are extremely limited. The aim of this study is to analyze the long-term oncological outcomes in eEOC patients treated with MIS.

MATERIALS AND METHODS

This is a multicenter observational retrospective study conducted in two tertiary oncological centers. We selected all consecutive women who underwent a laparoscopic or robotic staging for eEOC.

RESULTS

From January 2008 to December 2016, 254 eEOC patients underwent a MIS staging (188 laparoscopic staging and 66 robotic staging). Overall, 18.1% of patients were upstaged due to pathological findings. A total of 203 (79.9%) patients received platinum-based adjuvant chemotherapy. After a median follow-up of 61 months (range 13-118), 39 (15.3%) patients experienced recurrence. The 5-years progression free survival (PFS) and overall survival rates were 84.0% and 93.8%, respectively. In the univariate analysis, favorable variables influencing PFS were young age (≤45 years), non-serous histotype, tumor grade 1-2, and FIGO stage IA/IB. In the multivariate analysis, only grade 3 was shown to keep its negative independent prognostic value (HR = 3.47; p = 0.004), whereas FIGO stage ≥ IC showed a trend toward significance (HR = 1.75; p = 0.099).

CONCLUSION

This retrospective study represents the longest follow-up of eEOC patients managed by MIS. The MIS is a valuable therapeutic option in appropriately selected patients, although a randomized controlled trial is needed.

The impact of lymph node dissection on survival in patients with clinical early-stage ovarian cancer

Objective

To estimate the impact of lymph node dissection on survival in patients with apparent early-stage epithelial ovarian cancer (EOC).

Methods

We conducted a retrospective review of patients with clinical stage I–II EOC. All patients underwent primary surgery at Sun Yat-sen University Cancer Center between January 2003 and December 2015. Demographic features and clinicopathological information as well as perioperative adverse events were investigated, and survival analyses were performed.

Results

A total of 400 ovarian cancer patients were enrolled, and patients were divided into 2 groups: 81 patients did not undergo lymph node resection (group A), and 319 patients underwent lymph node dissection (group B). In group B, the median number of removed nodes per patient was 25 (21 pelvic and 4 para-aortic nodes). In groups A and B, respectively, the 5-year progression-free survival (PFS) rates were 83.3% and 82.1% (p=0.305), and the 5-year overall survival (OS) rates were 93.1% and 90.9% (p=0.645). The recurrence rate in the retroperitoneal lymph nodes was not associated with lymph node dissection (p=0.121). The median operating time was markedly longer in group B than in group A (220 minutes vs. 155 minutes, p<0.001), and group B had a significantly higher incidence of lymph cysts at discharge (32.9% vs. 0.0%, p<0.001).

Conclusion

In patients with early-stage ovarian cancer, lymph node dissection was not associated with a gain in OS or PFS and was associated with an increased incidence of perioperative adverse events.

Surgical complications comparing extraperitoneal vs transperitoneal laparoscopic aortic staging in early stage ovarian and endometrial cancer

OBJECTIVE

To determine whether the extraperitoneal approach for paraaortic staging lymphadenectomy results in a lower rate of surgical complications compared to the transperitoneal approach, without compromising oncological outcomes.

METHODS

Prospective randomized multicenter study of patients with early endometrial or ovarian cancer undergoing paraaortic lymphadenectomy in 2010-2019. Patients were randomized to minimally invasive surgery (laparoscopy or robotic-assisted) using an extraperitoneal or a transperitoneal approach. The primary end point measure was a composite outcome that included developing one or more of the following surgical complications: bleeding during paraaortic lymphadenectomy ≥500 mL, any intraoperative complication related to paraaortic lymphadenectomy, severe postoperative complication (Dindo ≥ IIIA), impossibility to complete the procedure, or conversion to laparotomy.

RESULTS

There were 103 patients in the extraperitoneal group and 100 in the transperitoneal group. Differences in the composite outcome (transperitoneal 26.0% vs, extraperitoneal 18.4%; P = 0.195) were not found. Differences in the operative time, conversion to laparotomy, intraoperative bleeding, or survival were not observed. A higher number of lymph nodes were retrieved through the extraperitoneal approached (median, interquartile range [IQR] 12 [7-17] vs, 14 [10-19]: P = 0.026). Older age and greater body mass index (BMI) or waist-to-hip ratio (WHR) increased the risk for surgical complications independently of the laparoscopic approach.

CONCLUSIONS

The extraperitoneal approach did not show differences regarding surgical and oncological parameters compared with the transperitoneal approach, although the number of aortic nodes retrieved was higher. The decision to use one or another laparoscopic route is a matter of the surgeon preference. Trial registration ClinicalTrials.gov.identifier: NCT02676726.

A Swedish Nationwide prospective study of oncological and reproductive outcome following fertility-sparing surgery for treatment of early stage epithelial ovarian cancer in young women

Background

Epithelial ovarian cancer (EOC) is rare in women of reproductive age and fertility-sparing surgery (FSS) may be applied in early stages. The purpose of this study was to investigate the safety and efficacy of FSS for treatment of EOC.

Methods

The Swedish nationwide population-based Quality Register for Gynecological Cancer was used to identify all women 18–40 years of age diagnosed with stage I EOC between 2008 and 2015. Detailed data on surgery, staging, histopathology, and follow-up were extracted and reviewed. Cross-linking of individuals to population-based registries allowed retrieval of data on obstetrical and reproductive outcomes after FSS. Disease-free survival (DFS) and overall survival (OS) rates were compared (Kaplan-Meier method) between women who underwent FSS vs. radical surgery (RS).

Results

In total 83 women were identified; 36 who had FSS performed and 47 RS. The 5-year OS rate was 92% and no statistical differences between DFS or OS were found between women treated by FSS or RS. The recurrence rate after RS was 13% compared to 6% after FSS. Recurrences were more frequently found in women with stage IC tumor or with histologic subtypes with more aggressive behavior. In the FSS cohort, nine women gave birth to 12 healthy children, all delivered at fullterm. Only one women had received assisted reproductive technology treatment.

Conclusion

In this nationwide population-based cohort study natural fertility was maintained after FSS. Specific histologic subtypes showed greater prognostic impact on the oncological outcome than the use of FSS. Recurrences occurred after FSS, but none in the uterus, which questions the need of hysterectomy in young women with EOC.

Trial registration

This article reports the results of a healthcare intervention using the data prospectively registered in the Swedish population-based registries including the Quality Register for Gynecological Cancer, the National Death Register, the Swedish Medical Birth Register, and the National Quality Register for Assisted Reproduction.

Laparotomy vs. minimally invasive surgery for ovarian cancer recurrence: a systematic review

The objective of the present review is to thoroughly investigate the role of minimally invasive surgery (MIS) in the setting of secondary cytoreduction for ovarian cancer recurrence, comparing this approach to traditional open surgery. PubMed, ClinicalTrials.gov, Scopus and Web of Science databases (between 1st January 1989 and 1st January 2020), have been systematically queried to identify all articles reporting either laparoscopic or robotic-assisted secondary surgical cytoreduction for recurrent ovarian cancer. We also manually searched the reference lists of the identified studies. Only English language papers were considered. Two independent reviewers screened and identified the reports. A sub-analysis was performed including studies comparing MIS vs. open abdominal secondary cytoreduction. A total of 617 articles were considered. Among them, we included 12 retrospective studies on minimally invasive secondary cytoreduction, enrolling 372 patients (260 of whom were submitted to whether robotics or laparosopy). Three studies compared 69 patients who underwent MIS vs. 112 cases of open abdominal secondary cytoreduction. Other 9 articles described a total of 191 patients who had minimally invasive secondary cytoreduction for recurrent ovarian cancer without a comparative arm. The quality of the evidence was low. The decision regarding the use of MIS was left to surgeon's discretion; in general, the candidates to MIS were selected patients with single-site disease or few localizations of relapse. Compared to open surgery, MIS was associated with significantly lower blood loss, shorter hospital stay and less postoperative complications; the rate of complete cytoreduction to residual tumor =0 was 95.5% in MIS cases vs. 87.5% in laparotomy cases. The risk of complications was generally low. Disease-free and overall survival were comparable between groups. There is no consensus on the criteria to select patients for laparoscopic or robotic secondary cytoreduction. Intra-operative ultrasound has been proposed as a possible tool to better identify the site of recurrence and for confirmation of complete resection of disease. In conclusion, MIS is an option in selected patients with recurrent ovarian cancer, provided there is no widespread disease. Selection of patients appears of utmost importance to obtain satisfactory survival outcomes.

Survival outcomes for robotic-assisted laparoscopy versus traditional laparoscopy in clinical stage I epithelial ovarian cancer

BACKGROUND

The US Food and Drug Administration recently called for studies addressing long-term survival after robotic-assisted laparoscopy in oncologic settings. Long-term clinical outcomes of robotic-assisted laparoscopy among ovarian cancer patients are understudied.

OBJECTIVE(S)

To investigate the long-term mortality of robotic-assisted laparoscopy compared to traditional laparoscopy for clinical stage I epithelial ovarian cancer.

MATERIALS AND METHODS

Using data from the National Cancer Database, we identified a total of 1901 patients who received minimally invasive surgery (ie, robotic-assisted laparoscopy or traditional laparoscopy) for clinical stage I epithelial ovarian cancer between 2010 and 2014. Multivariable logistic or linear regression analyses were conducted to evaluate the short-term outcomes, including conversion-to-open surgery, number of lymph nodes examined, length of hospitalization, unplanned 30-day readmission, and 30- and 90-day mortality. Multivariable Cox proportional hazards models were used to derive adjusted hazard ratios and 95% confidence intervals for 1-, 3-, and 5-year total mortality associated with surgical approaches. Covariates adjusted for included age, tumor size and upstaging, number of lymph nodes evaluated, time from diagnosis to surgery, length of hospitalization, histologic subtype, insurance status, region, distance to care, surgical procedure type, and hospital experience with these procedures.

RESULTS

Compared to traditional laparoscopy, robotic-assisted laparoscopy was less likely to result in conversion-to-open surgery (conversion rate: 7.2% versus 17.9%, P < .001; adjusted odds ratio, 0.49; 95% confidence interval, 0.33-0.73). In multivariable analyses, there were no significant differences in survival between robotic-assisted laparoscopy- and traditional laparoscopy-treated patients. Compared with traditional laparoscopy, the adjusted hazard ratios for 1-, 3-, and 5-year mortality were 0.97 (95% confidence interval, 0.43-2.18), 0.68 (95% confidence interval, 0.43-1.08), and 0.78 (95% confidence interval, 0.53-1.16), respectively.

CONCLUSION(S)

Robotic-assisted laparoscopy had comparable overall mortality in comparison to traditional laparoscopy when treating clinical stage I epithelial ovarian cancer.

Prior uterine myoma and risk of ovarian cancer: a population-based case-control study

Objective

Uterine myoma which results in the magnitude of ovarian cancer remains uncertain. This study aimed to assess the association between women with previous uterine myoma and the risk of ovarian cancer.

Methods

This population-based case-control study was conducted using the Taiwan National Health Insurance Research Database between 2006 and 2010. We identified 4,088 adult women with newly diagnosed ovarian cancer with 16,348 women without ovarian cancer matched for age, urbanization level, income and initial diagnosis date. Logistic regression analyses were used to evaluate the variables associated with ovarian cancer. In addition, the effect of surgical interventions on the risk of ovarian cancer was also evaluated.

Results

Women with previous uterine myoma were more likely than those who did not to have ovarian cancer (adjusted odds ratio [aOR]=2.26; 95% confidence interval [CI]=2.06−2.49). Patients with uterine myoma who either received (aOR=1.79; 95% CI=1.51−2.13) or did not receive hormone replacement therapy (aOR=2.51; 95% CI=2.24−2.82) experienced a significantly higher risk of ovarian cancer than those without uterine myoma, respectively. However, patients with uterine myoma who underwent either myomectomy (aOR=0.55; 95% CI=0.39−0.77) or hysterectomy (aOR=0.33; 95% CI=0.26−0.42) had a significantly lower risk of ovarian cancer.

Conclusion

The results revealed that a significantly higher risk of ovarian cancer in women with previous uterine myoma, through an indirect mechanism. Furthermore, a lower risk of ovarian cancer was observed in women who underwent surgical removal of the uterine myoma.

The Risk of Para-Aortic Lymph Node Metastases in Apparent Early Stage Ovarian Cancer

Background and objectives: To identify the risk factors for para-aortic lymph node metastases in cases with presumed early stage ovarian cancer. Materials and methods: Between 2014 and 2019, 48 patients with apparent early stage ovarian cancer were submitted to surgery. In all cases, pelvic and para-aortic lymph node dissection was performed for staging purposes. Results: Among the 48 cases we identified nine cases with positive pelvic lymph nodes and 11 cases with positive para-aortic lymph nodes. The positivity of the retrieved lymph nodes was significantly correlated with the histopathological subtype represented by serous histology (p = 0.02), as well as with the degree of differentiation (p = 0.004). Conclusions: Patients with serous ovarian carcinomas in association with a poorer degree of differentiation are at risk of associated lymph node metastases even in presumed early stages of the disease. Therefore, lymph node dissection should be performed in such cases in order to provide adequate staging and tailoring of further treatment.

Sentinel-node biopsy in early stage ovarian cancer: a prospective multicentre study (SELLY)

BACKGROUND

Systematic para-aortic and bilateral pelvic lymphadenectomy is included in the standard comprehensive surgical staging in presumed early epithelial ovarian cancer. No prospective randomized evidence suggests it has potential therapeutic value, and related morbidity is not negligible.

PRIMARY OBJECTIVES

To assess sensitivity, safety, and feasibility of the sentinel lymph node technique in identifying the presence of lymph node metastases in patients with early stage epithelial ovarian cancer.

STUDY HYPOTHESIS

Sentinel lymph node detection with indocyanine green can accurately predict nodal status in a cohort of women with early stage epithelial ovarian cancer.

TRIAL DESIGN

The SELLY trial is a prospective phase II interventional multicenter study.

MAJOR INCLUSION/EXCLUSION CRITERIA

Inclusion criteria: Eastern Cooperative Oncology Group 0-1, apparent International Federation of Gynecology and Obstetrics (FIGO) stage I-II, histologically proven epithelial ovarian cancer.

EXCLUSION CRITERIA

evidence of carcinomatosis, mucinous only at definitive histology.

ENDPOINTS

Primary endpoint is sensitivity (true positive rate). Secondary endpoints include safety (complications rate of the procedure) and feasibility.

SAMPLE SIZE

Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (ie, the maximum marginal error) d=5%, and a type I error α=0.05, a sample size of 160 patients is needed to test the general hypothesis (ie, to answer whether sentinel lymph nodes identified with indocyanine green can accurately predict nodal status at histology of patients with apparently early epithelial ovarian cancer). Assuming a drop-out rate of 10%, a total of 176 patients will be enrolled in the study.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

The accrual should be completed by December 2020 and results should be presented by March 2021.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT03563781).

LESS with Suture Suspension for Early-Stage Adnexa Cancer Staging

Background and Objective:

Laparoendoscopic single-site surgery has been used in treating gynecologic diseases including early-stage cervical and endometrial cancer, but less so in early-stage adnexal cancer. We aimed to demonstrate the use of laparoendoscopic single-site surgery with suture suspension for staging of early-stage ovarian/fallopian-tube cancer and describe the study results.

Methods:

Seven patients with early-stage adnexal cancer underwent staging surgery via laparoendoscopic single-site surgery at West China Second University Hospital of Sichuan University from November 2017 to September 2018.

Results:

All cases were successfully staged via this technique. Two patients underwent the high-level para-aortic lymphadenectomy up to the infrarenal vein, and four patients underwent para-aortic lymphadenectomy at the level of the inframesenteric artery; one patient underwent the para-aortic lymph node sampling. The operation time was 305–365 minutes. The estimated intraoperative blood loss was 50–200 mL. No intra-operative complications occurred; one patient developed pneumonia 48 hours postoperation. The number of pelvic and para-aortic nodes was 15–39 and 1–18, respectively. Pain scores 12 and 24 hours postsurgery were 2–3 and 1–2 with the use of butorphanol tartrate, respectively. On 4–14 months followup, the umbilical incision had good cosmesis; no umbilical hernia or vaginal dehiscence and no neoplasm recurrence were noted.

Conclusion:

Laparoendoscopic single-site surgery may be a feasible and safe technique for staging early-stage ovarian/tubal cancer. This approach has some advantages included providing easier access to the upper abdominal regions when performing high-level infrarenal para-aortic lymphadenectomy; the 2-cm elastic incision favors fast specimen extraction and colpotomy are avoided. However, the long-term oncologic outcomes need to be further investigated.

Incorporating robotic surgery into the management of ovarian cancer after neoadjuvant chemotherapy

INTRODUCTION

With the rapid uptake of robotic surgery in surgical oncology, its use in the treatment of epithelial ovarian cancers is being evaluated. Complete cytoreduction represents the goal of surgery either at primary cytoreduction or after neoadjuvant chemotherapy in the setting of interval cytoreduction. In selected patients, the extent of disease would enable minimally invasive surgery. The objective of this study was to evaluate the impact of introducing robotic surgery for interval cytoreduction of selected patients with stage III-IV ovarian cancer.

METHODS

All patients who underwent surgery from November 2008 to 2014 (concurrent time period when robotic and open surgery were used simultaneously) after receiving neoadjuvant chemotherapy for advanced ovarian cancer (stage III-IV) were compared with all consecutive patients who underwent cytoreductive surgery by laparotomy after neoadjuvant chemotherapy between January 2006 and November 2008. Inclusion criteria included an interval cytoreductive surgery by laparotomy or robotic assistance for stage III-IV non-mucinous epithelial ovarian, fallopian tube, or primary peritoneal cancer. Exclusion criteria included patients treated concurrently for a non-gynecologic cancer, as well as secondary cytoreductive surgeries and diagnostic surgeries without an attempt at tumor reduction. Overall survival, progression-free survival, and peri-operative outcomes were compared for the entire patient cohort with those with advanced ovarian cancer who received neoadjuvant chemotherapy immediately before and after the introduction of robotic surgery.

RESULTS

A total of 91 patients were selected to undergo interval cytoreduction either via robotic surgery (n=57) or laparotomy (n=34) after the administration of neoadjuvant chemotherapy. The median age of the cohort was 65 years (range 24-88), 78% had stage III disease, and the median follow-up time was 37 months (5.6-91.4 months). The median survival was 42.8±3.1 months in the period where both robotic surgery and laparotomy were offered compared with 37.9±9.8 months in the time period preceding when only laparotomy was performed (p=0.6). All patients selected to undergo interval robotic cytoreduction following neoadjuvant chemotherapy had a reduction of cancer antigen 125 by at least 80%, resolution of ascites, and CT findings suggesting the potential to achieve optimal interval cytoreduction. All these patients achieved optimal cytoreduction with <1 cm residual disease, including 82% with no residual disease. The median blood loss was 100 mL (mean 135 mL, range 10-1250 mL), and the median hospital stay was 1 day.

CONCLUSION

Robotic interval cytoreductive surgery is feasible in well-selected patients. Future studies should aim to define ideal patients for minimally invasive cytoreductive surgery.

Sentinel-node biopsy in early-stage ovarian cancer: preliminary results of a prospective multicentre study (SELLY)

BACKGROUND

Systematic paraaortic and bilateral pelvic lymphadenectomy is the standard of a comprehensive surgical staging in presumed early epithelial ovarian cancer, but no prospective randomized evidence suggests a possible therapeutic value. Moreover, this procedure is associated with potential severe morbidity. The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective study designed to test whether sentinel node detection can accurately predict nodal status in a cohort of women with early epithelial ovarian cancer.

OBJECTIVES

We here present the results of the first part of the Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial, regarding the feasibility of the sentinel lymph node technique and the preliminary findings regarding its safety and accuracy.

STUDY DESIGN

The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective, phase II, single-arm study included patients with presumed stages I-II epithelial ovarian cancer planned for immediate or delayed minimally invasive comprehensive staging. The ovarian pedicle is injected with 2 mL of a 1.25 mg/mL indocyanine green solution. The pelvic and lumboaortic retroperitoneum is then accessed and inspected to identify and remove sentinel nodes. After sentinel node procedure, staging is completed including systematic pelvic and paraaortic lymphadenectomy. Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (ie, the maximum marginal error) d = 5%, a type I error α = 0.05, a sample size of 160 patients is needed to test the general hypothesis. Here we present the preliminary results on the first 31 patients enrolled.

RESULTS

Thirty-one patients were included. Sentinel node was identified in 21 patients (detection rate, 67.7%). The detection rate was significantly higher in women undergoing immediate vs delayed staging (88.9% vs 41.7%, P = .003). Four patients had positive nodes. In all the patients with lymphatic dissemination, a positive sentinel node was identified (sensitivity, 100%; false-negative rate, 0%; negative predictive value, 100%). One (3.2%) intra- and 2 (6.5%) postoperative grade I complications occurred.

CONCLUSION

Our data show that the detection of sentinel node in early epithelial ovarian cancer is low when patients are submitted to delayed-staging surgery. However, sentinel node procedure is feasible and has the potential to provide reliable and useful information on nodal status and may allow the avoidance of systematic lymphadenectomy in the majority of patients.

Laparoscopy vs. laparotomy for advanced ovarian cancer: a systematic review of the literature

INTRODUCTION

In the last decade, laparoscopy has been progressively introduced in the management of advanced-stage ovarian cancer (AOC) to evaluate tumor resectability, avoiding an explorative laparotomy, to identify non-responders to submit to second-line chemotherapy and to perform primary or interval minimally invasive debulking surgery in selected patients. This review aims to deeply focus on the differences between laparoscopy and laparotomy in the management of advanced ovarian cancer.

EVIDENCE ACQUISITION

The electronic database search provided a total of 80 results. Out of these, 63 results were excluded because considered not relevant to the review, for linguistic reasons or case reports. A total of 17 articles were considered eligible for the review.

EVIDENCE SYNTHESIS

Many studies have assessed the value of laparoscopy in predicting the optimal resectability of AOC patients avoiding exploratory laparotomies. More recently, its role in primary and interval cytoreduction has been investigated for selected patients in terms of safety, feasibility and oncological outcomes. Published data are comparable to the standard laparotomic management in terms of oncological outcomes but with improved perioperative and psychological results. The selection of patients is crucial to perform a successful surgery.

CONCLUSIONS

To date, laparoscopy has replaced the primary laparotomic approach in the evaluation of optimal resectability. As far as primary and interval minimally invasive debulking surgery are concerned, instead, most of the works report an overlap of oncological outcomes compared to traditional surgery. The selection of patients is a crucial point to reach a successful minimally invasive surgical treatment, taking into account surgical complexity and surgical adequacy.

The role of sentinel node in early ovarian cancer: a systematic review

INTRODUCTION

Early ovarian cancer (EOC) is defined as ovarian cancer macroscopically limited to the ovaries at the time of initial diagnosis. Approximately only 25% of patients with ovarian cancer are affected by EOC. This condition requires complete surgical staging, including systematic lymphadenectomy up to the level of the renal vessels, with the consequent risk of complications and morbidity. With the aim to reduce the procedure-related morbidity, sentinel lymph node mapping (SLNm) has been introduced as an experimental procedure in EOC staging. The aim of the present study is to systematically review the available series on this interesting issue.

EVIDENCE ACQUISITION

Studies were identified by searching electronic databases. The search was systematically applied to PubMed, ClinicalTrials.gov, Scopus and Web of Science looking for records describing the use of sentinel lymph node technique in EOC from January 1st, 1989 to January 1st, 2019. A total of 10 studies were identified for inclusion. Of the 121 patients involved in these studies, only 43 had a histologically-confirmed diagnosis of EOC and were included in the present analysis.

EVIDENCE SYNTHESIS

SLN (paraaortic and/or pelvic) overall detection rate (DR) was of 97.6%. The overall sensitivity (SS) and negative predictive value (NPV) of the included cases were 66.7% and 96.6%, respectively. We calculated also NPV, SS and DR based on the anatomical lymph node district, with a value of 100% both in the lumbo-aortic and in the pelvic district and a DR of 83.3% and 43% respectively.

CONCLUSIONS

This review shows that evidence on SLNm in EOC is still scant. Based on the limited data available, SLNm may provide potentially useful information on nodal status in patients affected by this disease.

Sexual function and quality of life of patients affected by ovarian cancer

INTRODUCTION

The sexual function (SF) in patients affected by malignancies represents an important aspect influencing the quality of life (QoL). The most frequent symptoms reported are the decreased sexual desire, dyspareunia, and/or problems with arousal or achieving orgasm. The present study is aimed at analyzing the available scientific evidence regarding the QoL and especially SF of patients affected by ovarian cancer who underwent surgical and medical treatment.

EVIDENCE ACQUISITION

A preliminary research was conducted using Pubmed database with specific keywords combinations regarding SF, QoL and ovarian cancer. The principal findings considered in the present review were: the study design, the number of patients included in each study, the information about the malignancy (histology and stage of disease), the questionnaires administered and the principal findings concerning SF and QoL.

EVIDENCE SYNTESIS

The studies selected were 5 prospective series and 3 case control cross-sectional studies. The scores used were focused on SF, QOL, fatigue and psychological aspects. All studies reported a decreased SF and QOL. Different factors coexist in the influence on outcomes such as physical, hormonal, psychological, self body image, and mechanic outcomes.

CONCLUSIONS

SF represents a fundamental aspect strictly related with QoL. Patients with ovarian cancer (as well all oncological patients) experience a reduction in their SF after diagnosis of malignancy and they should receive adequate counseling regarding this aspect.

The role of robotic aortic lymphadenectomy in gynecological cancer: surgical and oncological outcome in a single institution experience

BACKGROUND AND OBJECTIVE

This study aims to investigate the surgical outcomes observed in robotic transperitoneal aortic lymphadenectomy (AL) in gynecological cancer patients.

METHODS

Retrospective data were collected and analyzed on 71 patients undergoing robotic surgical procedures for gynecological cancers, including transperitoneal AL, between December 2014 and February 2018 at the Catholic University of the Sacred Heart, Rome, Italy.

RESULTS

Median age of the sample population was 50 years (range, 26-76 years). The median operative time was 210 minutes (range, 75-480 minutes), the median estimated blood loss was 50 ml (range, 20-300 ml). The number of para-aortic nodes removed was 12 (range, 7-43). In the whole series, 13 patients (18.3%) had at least one metastatic node. Overall, 10 patients (14.1%) experienced any grade early postoperative complications. Three patients experienced more than one complication. Three intraoperative complications occurred with two cases of vascular injury. Conversion to laparotomy was necessary for one patient (1.4%).

CONCLUSIONS

The present study shows the safety and adequacy of robotic transperitoneal AL as surgical staging step for gynecological cancers in terms of perioperative and postoperative outcomes.

Serum relaxin as a diagnostic and prognostic marker in patients with epithelial ovarian cancer

BACKGROUND AND AIM

Relaxin is a short circulating peptide hormone. The aim of this study was to understand the role of relaxin in progression of epithelial ovarian cancer (EOC) and to assess its diagnostic and prognostic significance.

METHODS

A total of 124 patients with EOC, 46 patients with benign ovarian diseases, and 50 healthy controls were recruited. Serum levels of relaxin were determined by ELISA method. The relationship between serum relaxin level and each of the clinicopathological parameters was analyzed using the χ2 test. Survival curves were plotted using the Kaplan-Meier method. The statistical difference in survival between the different groups was compared using the log-rank test. Survival correlation with the prognostic factors was further investigated by multivariate analysis using the Cox proportional hazards model with backward stepwise likelihood ratio.

RESULTS

The results showed that serum relaxin level was significantly higher in patients with EOC than those with benign ovarian diseases and healthy controls (p< 0.01). Serum relaxin level was associated with FIGO stage, lymph node metastasis, tumor resectability, survival of the patients, chemotherapy and tumor recurrence (p< 0.05). Analysis using the Kaplan-meier method indicated that patients with high serum relaxin had significantly shorter overall survival time than those with low relaxin (p< 0.01). In a multivariate analysis along with clinical prognostic parameters, serum relaxin was identified as an independent adverse prognostic variable for survival.

CONCLUSIONS

These results indicated that serum relaxin may be a clinically useful indicator for diagnostic and prognostic evaluation in EOC patients.

Is It the Time for Laparoscopic Management of Early-stage Ovarian Malignancies?

The laparoscopic management of early-stage ovarian cancer remains controversial. Some surgeons hesitate to perform laparoscopic staging due to concern with the adequacy of staging, the possibility of tumor spillage and risk of port-site metastasis. Previous studies and literature reviews have reinforced the argument and supported the use of laparoscopy. However, the results were drawn with limited sample size obtained from case-series and case-control studies which result in difficult to make definite conclusions. Till date, the list of laparoscopic procedures has grown at a pace consistent with improvements in technology and technical skill of the surgeon. The number of studies with larger sample size, more prospective data, and longer duration of follow-up has been increasing. This review serves as an update on safety, feasibility, surgical, and oncological outcomes in cases of early-stage ovarian cancer treated by laparoscopic surgery of the literature published since 2008. We aim to clarify whether laparoscopy is safe and effective enough to be considered as standard management. Rely on nonrandomize studies, the current clinical evidence supports the role of laparoscopy in the management of early-stage ovarian cancer. Laparoscopy appears to offer several perioperative benefits without compromise of surgical morbidity and oncological outcome.

Minimally Invasive Staging of Apparent Stage I Malignant Ovarian Germ Cell Tumors: Prevalence and Outcomes

STUDY OBJECTIVE

Evaluate the prevalence, trends, and outcomes of minimally invasive surgical (MIS) staging of malignant ovarian germ cell tumors (MOGCTs) apparently confined to the ovary.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Participating hospitals in the National Cancer Data Base.

PATIENTS

Women diagnosed between 2010 and 2014 with a MOGCT apparently confined to the ovary with information on the planned surgical approach.

INTERVENTIONS

Staging with MIS or laparotomy.

MEASUREMENT AND MAIN RESULTS

A total of 918 patients were identified. MIS was planned for 294 patients (32%): a laparoscopic approach for 237 patients and a robotic-assisted approach for 57 patients. Rate of conversion to laparotomy was 11% (46 cases), 1.7% and 15.6% in the robotic and laparoscopy groups, respectively (p = .003). No difference in the use of MIS was noted based on year of diagnosis (p = .38). By multivariate analysis white race, higher level of education, and smaller tumor size were associated with the receipt of MIS. Patients in the MIS group were less likely to undergo lymph node dissection (39.6% vs 51.3%, p = .001) and omentectomy (18.7% vs 28.5%, p = .002). Hospital stay after surgery was shorter for patients who had MIS (median, 2 vs 3 days; p <.001). Unplanned 30-day readmission rate was also lower in the MIS group (1.4% vs 3.9%, p = .043). No difference in overall survival was noted between the 2 groups (p = .81).

CONCLUSION

MIS for apparent early-stage MOGCTs was less comprehensive but associated with a decreased hospital stay and unplanned readmission rate.

New Developments in Minimally Invasive Gynecologic Oncology Surgery

Minimally invasive surgery continues to transform the field of gynecologic oncology and has now become the standard of care for many early-stage malignancies. The proven benefits of minimally invasive surgery are driving the rapid introduction and dissemination of novel technologies and the increasing ability to perform even the most complex procedures less invasively. In this article, we will review the current literature on traditional multiport laparoscopy, robotic-assisted laparoscopy, laparoendoscopic single-site surgery as well as robotic-assisted laparoendoscopic single-site surgery, with a specific focus on their role in the treatment of gynecologic malignancies.

Secondary Laparoscopic Cytoreduction in Recurrent Ovarian Cancer: A Large, Single-Institution Experience

STUDY OBJECTIVE

To analyze the feasibility and safety of laparoscopic secondary cytoreductive surgery in a retrospective series of patients with platinum-sensitive recurrent ovarian cancer.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Catholic University of the Sacred Heart, Rome, Italy.

PATIENTS

Between October 2010 and October 2016, 58 patients with recurrent ovarian cancer were selected for a retrospective analysis of data.

INTERVENTIONS

All patients underwent a laparoscopic secondary cytoreduction with single or multiple procedures.

RESULTS

The most frequent pattern of recurrence was peritoneal (48.3%); 6 patients (10.3%) experienced parenchymal disease (spleen, n = 5; liver, n = 1), and 24 patients (41.4%) had lymph node recurrence. Complete debulking was achieved in all patients. The median operative time was 204 minutes (range, 55-448 minutes), median estimated blood loss was 70 mL (range, 20-300 mL), and the median length of hospital stay was 4 days (range, 1-21 days). Four patients (6.8%) experienced intraoperative complications. Early postoperative complications were documented in 6 patients (10.3%), but only 1 G3 complication was noted. The median duration of follow-up since secondary cytoreduction was 24 months (range, 9-71 months). Twenty-one patients (36.2%) experienced a second disease relapse. The median progression-free survival (PFS) was 28 months, and the 2-year PFS was 58.7%. Five patients died (8.6%); the 2-year overall survival was 90.7%.

CONCLUSIONS

For selected patients, laparoscopy is a feasible and safe approach to optimal cytoreduction for patients with recurrent ovarian cancer.

Role of hysterectomy and lymphadenectomy in the management of early-stage borderline ovarian tumors

OBJECTIVE

To examine survival of women with stage T1 borderline ovarian tumors (BOTs) stratified by hysterectomy and lymphadenectomy status at surgery.

METHODS

This is a retrospective study examining The Surveillance, Epidemiology, and End Results Program to identify surgically-treated stage T1 BOTs between 1988 and 2003 (n=4943). Association of surgery patterns and cause-specific survival (CSS) was examined in multivariable analysis.

RESULTS

Mean age was 48.7. The majority had stage T1a disease (75.3%). Median follow-up was 15.6years and 159 (3.2%) women died of BOTs. Hysterectomy and lymphadenectomy were performed in 1909 (38.6%) and 1295 (26.2%) cases, respectively. Most commonly, neither procedure was performed (46.5%), followed by hysterectomy alone (27.3%), lymphadenectomy alone (14.9%), and both procedures (11.3%). Surgery patterns for hysterectomy and lymphadenectomy significantly differed across age, ethnicity, marital status, registry area, year at diagnosis, histology type, sub-stage, and tumor size (all, P<0.001). On multivariable analysis, surgery patterns for hysterectomy and lymphadenectomy were not associated with CSS: 20-year rates for neither hysterectomy and lymphadenectomy 96.7%, hysterectomy alone 94.5%, lymphadenectomy alone 95.7%, and both procedures 95.2% (adjusted-P>0.05). Age≥50, T1b-c stages, and mucinous histology remained independent prognostic factors for decreased CSS (all, P<0.05). Among 3723 women with stage T1a disease, hysterectomy and lymphadenectomy patterns were not associated with CSS in 2115 women aged <50 (P=0.14) and 1608 women aged ≥50 (P=0.48).

CONCLUSION

Our study suggests that both hysterectomy and lymphadenectomy may be omitted in the surgical management of women with stage T1 BOTs, especially for those with T1a disease regardless of age.

Laparoscopic staging for apparent stage I epithelial ovarian cancer

BACKGROUND

Whereas advances in minimally invasive surgery have made laparoscopic staging technically feasible in stage I epithelial ovarian cancer, the practice remains controversial because of an absence of randomized trials and lack of high-quality observational studies demonstrating equivalent outcomes.

OBJECTIVE

This study seeks to evaluate the association of laparoscopic staging with survival among women with clinical stage I epithelial ovarian cancer.

STUDY DESIGN

We used the National Cancer Data Base to identify all women who underwent surgical staging for clinical stage I epithelial ovarian cancer diagnosed from 2010 through 2012. The exposure of interest was planned surgical approach (laparoscopy vs laparotomy), and the primary outcome was overall survival. The primary analysis was based on an intention to treat: all women whose procedures were initiated laparoscopically were categorized as having had a planned laparoscopic procedure, regardless of subsequent conversion to laparotomy. We used propensity methods to match patients who underwent planned laparoscopic staging with similar patients who underwent planned laparotomy based on observed characteristics. We compared survival among the matched cohorts using the Kaplan-Meier method and Cox regression. We compared the extent of lymphadenectomy using the Wilcoxon rank-sum test.

RESULTS

Among 4798 eligible patients, 1112 (23.2%) underwent procedures that were initiated laparoscopically, of which 190 (17%) were converted to laparotomy. Women who underwent planned laparoscopy were more frequently white, privately insured, from wealthier ZIP codes, received care in community cancer centers, and had smaller tumors that were more frequently of serous and less often of mucinous histology than those who underwent staging via planned laparotomy. After propensity score matching, time to death did not differ between patients undergoing planned laparoscopic vs open staging (hazard ratio, 0.77, 95% confidence interval, 0.54-1.09; P = .13). Planned laparoscopic staging was associated with a slightly higher median lymph node count (14 vs 12, P = .005). Planned laparoscopic staging was not associated with time to death after adjustment for receipt of adjuvant chemotherapy, histological type and grade, and pathological stage (hazard ratio, 0.82, 95% confidence interval, 0.57-1.16).

CONCLUSION

Surgical staging via planned laparoscopy vs laparotomy was not associated with worse survival in women with apparent stage I epithelial ovarian cancer.

Robotic Versus Laparoscopic Staging for Early Ovarian Cancer: A Case-Matched Control Study

STUDY OBJECTIVE

To evaluate the feasibility, surgical outcome, and oncologic results observed after robotic staging compared with conventional laparoscopic staging for patients with early-stage ovarian cancer patients.

DESIGN

A retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Catholic University of the Sacred Heart, Rome, Italy.

PATIENTS

Ninety-six patients underwent minimally invasive staging for presumed stage I ovarian cancer; 32 underwent the robotic approach (cases), and 64 underwent the laparoscopic approach (controls).

MEASUREMENTS AND MAIN RESULTS

There was no statistically significant difference between the 2 approaches with regard to final Fédération Internationale de Gynécologie et d'Obstétrique stage, histology, and grade of tumors. In the whole series, 15 patients (15.6%) were upstaged, with no statistically significant difference between the 2 groups. The median number of pelvic lymph nodes removed was 14 (range, 3-42) and 11 (range, 2-29) in the robotic and laparoscopic groups (p = .235), respectively. The median number of aortic lymph nodes removed was 11 (range, 3-26) and 12 (range, 1-39) in the robotic and laparoscopic groups (p = .263), respectively. The operative time was significantly shorter in the robotic group compared with the laparoscopic group (p = .043), whereas the amount of estimated blood loss was similar (p = .691). No difference was found in terms of early and postoperative complications. Overall, 72 patients were considered as requiring adjuvant treatment. Two patients experienced peritoneal recurrence.

CONCLUSION

The present study suggests that there is no relevant difference between the robotic and laparoscopic approaches in staging early-stage ovarian cancer. Further prospective trials are needed to confirm our results.

Current Recommendations for Minimally Invasive Surgical Staging in Ovarian Cancer

OPINION STATEMENT

Minimally invasive surgery (MIS) currently is performed to stage and treat ovarian cancer at different stages of disease; however, the higher level of evidence from existing studies is IIB. Despite the absence of randomized controlled trials, MIS represents a safe and adequate procedure for treating and staging early ovarian cancer, and its use has increased significantly in clinical practice. Major concerns are related to minimizing tumor disruption or dissemination, removing the adnexal mass intact, adequate retroperitoneal staging, and fertility-sparing surgery for young patients. The main goal for patients with advanced ovarian cancer is to determine the best therapeutic strategy by evaluating the risks and benefits of primary debulking surgery versus neoadjuvant chemotherapy followed by interval debulking surgery. The use of staging laparoscopy in patients with advanced epithelial ovarian cancer appears to be the most researched and accepted approach. Regarding other types and stages of ovarian cancer, although the evidence is very promising, clinical trials performed by expert gynecologic oncology surgeons in referral centers are still needed to prove the efficacy of such an approach in these patients. In particular, MIS has provided an opportunity to remove localized recurrences, with both retroperitoneal and intraperitoneal diffusion.

Laparoscopic surgery: a narrative review of pharmacotherapy in pain management

Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5 units on a 0-10 pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.