[Prevention of port-site metastasis after laparoscopy]

Role of laparoscopy in initial tumour staging in advanced epithelial ovarian cancer: A systematic review

BACKGROUND

The aim of this systematic review was to investigate the accuracy of additional staging laparoscopy (SL) in advanced epithelial ovarian cancer (AEOC) to predict futile laparotomy (FL).

METHODS

Systematic review according to preferred reporting items for systematic reviews and meta-analyses statement (PRISMA) criteria. Clinical studies investigating the role of SL in selecting women with AEOC for primary debulking surgery (PDS) were included. Index test: SL. Reference test: laparotomy. Target condition: incomplete cytoreduction (CR) with remaining disease<1 cm.

RESULTS

Nine prospective and retrospective studies reporting on eight cohorts totalizing 778 LS were included. Reference test was completed in 76 % cases. PPV for FL was between 0.69 and 1.0. In three studies examining the value of a predictive index value (PIV) for predicting FL, sensitivity of the index test (LS with PIV ≥8) was between 46% and 70 %, and specificity between 89 % and 100 %. The proportion of patients that received CR during PDS differed widely between studies (from 50 to 91). Using a PIV did not increase the sensitivity and might result in more patients receiving FL. In the only randomized trial, FL occurred in 10 (10 %) of 102 patients in the LS group versus 39 (39 %) of 99 patients in the primary PDS group (relative risk, 0.25; 95 % CI, 0.13-0.47; p<0.001). Port-site recurrences occurred in 2%-6 % patients. Overall costs of with or without SL were comparable.

CONCLUSIONS

The evidence available from this systematic review supports the inclusion of an additional LS to the conventional initial diagnostic workup in women with AEOC.

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.

[Port-site metastasis after retroperitoneal lymphadenectomy for endometrial adenocarcinoma]

Port-site metastasis is a rare but serious complication of laparoscopic surgery. The etiologies are poorly identified and multiple. We report the case of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma. In the literature, three cases of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy are reported: two cases concerning cervical cancer and one case concerning a kidney cancer. To our knowledge, this is the only case about port site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma.

Port-site metastasis after laparoscopic surgery for urological malignancy: forgotten or missed

Purpose. Port-site metastasis has been a concern with the common use of laparoscopy in urologic oncology. We conducted this study to provide a review of port-site metastases reported after the laparoscopy in managing urologic malignancies, possible contributing factors and preventative measures. Materials and Methods. An electronic search of MEDLINE using the combined MESH key words “port-site metastasis” and “Urology”. Results. 51 articles addressing port-site metastasis after laparoscopic surgery for urolo¬gical malignancy were identified. Conclusion. Port-site metastasis after laparoscopic surgery for urolo¬gical malignancy is rare. The incidence is comparable to the rate for surgical wound metastases.

Cœlioscopie et cancer en gynécologie : le point en 2005

All the surgical procedures, which may be required to treat a gynecologic cancer, can be performed endoscopically. However prospective randomized studies required to confirm the oncologic efficacy of the technique are still lacking in gynecology, whereas such studies are available in digestive surgery. Animal studies suggested that the risk of tumor dissemination in non traumatized peritoneum is higher after a pneumoperitoneum than after a laparotomy. Experimental studies also emphasized two points: the surgeon and the surgical technique are essential, all the parameters of the pneumoperitoneum may influence the postoperative dissemination. Changing these parameters we may, in the future, be able to create a peritoneal environment adapted to oncologic patients in order to prevent or to decrease the risks of peritoneal dissemination and/or of postoperative tumor growth. Until the results of prospective randomized studies become available, the preoperative selection of the patients and the surgical technique should be very strict. In patients with endometrial cancer, the laparoscopic approach should be reserved to clinical stage I disease, if the vaginal extraction is anticipated to be easy accounting for the volume of the uterus and the local conditions. In cervical cancer, the laparoscopic approach should be reserved to patients with favorable prognostic factors: stage IB of less than 2 cm in diameter. Laparoscopy is the gold standard for the surgical diagnosis of adnexal masses. But the puncture should be avoided whenever possible. The surgical treatment of invasive ovarian cancer should be performed by laparotomy whatever the stage. In contrast restaging of an early ovarian cancer initially managed as a benign mass, is a good indication of the laparoscopic approach. The laparoscopic management of low malignant potential tumors should include a complete staging of the peritoneum. Knowledge of the principles of endoscopy and of oncologic surgery is required. Teaching and diffusion of endoscopic oncological techniques are among the major challenges of gynecologic surgery within the next few years.