Clinical outcome after laparoscopic pure management of borderline ovarian tumors: results of a series of 34 patients

The feasibility of fertility-sparing surgery in treating advanced-stage borderline ovarian tumors: A meta-analysis

OBJECTIVE

To evaluate the feasibility of fertility-sparing surgery in treating advanced-stage borderline ovarian tumors (BOTs).

MATERIALS AND METHODS

The databases of PubMed, Cochrane Library, EMbase, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Weipu (Chinese), and Wanfang (Chinese) were searched using the keywords "advanced-stage borderline ovarian tumors", "fertility-sparing surgery", "conservative surgery", and "borderline ovarian tumor" to collect the clinical controlled trails (CCTs) regarding fertility-sparing surgery for the treatment of advanced-stage BOT. The references of those CCTs were also searched manually. Data extraction and quality assessment were done using Review manager Version 5.1 and R software Version 2.11.1.

RESULTS

Four studies involving 74 patients were included. The results of meta-analysis showed that: (1) compared with radical surgery, the recurrence of the fertility-sparing surgery during the follow time is higher with significant difference [odds ratio (OR)=3.87, 95% confidence interval (CI) (1.20,12.44), p=0.02]; (2) the difference of survival rate between the two groups was not significant [5-year survival: OR=0.85, 95%CI (0.03, 23.82), p=0.92; 7-year survival: OR=0.80, 95%CI (0.08, 8.41), p=0.85]; and (3) concerning fertility results in fertility-sparing surgery, 18 patients tried to become pregnant, 15 pregnancies were achieved in the 11 patients, 11 full-term deliveries.

CONCLUSION

The rate of ovarian recurrence in patients who underwent conservative treatment was higher than in patients with radical treatment, but it did not affect patient survival; fertility-sparing surgery could be induced to preserve the fertility potential of young patients.

Controversies in borderline ovarian tumors

Borderline ovarian tumors (BOTs) represent about 15% to 20% of all ovarian malignancies and differ from invasive ovarian cancers (IOCs) by many characters. Historically, standard management of BOT is peritoneal washing cytology, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, complete peritoneal resection of macroscopic lesions; in case of mucinous BOTs, appendectomy should be performed. Because BOTs are often diagnosed at earlier stage, in younger age women and have better prognosis, higher survival rate than IOCs, fertility-sparing surgery is one of the option to preserve childbearing capacity. The study of such conservative surgery is being released, and still controversial. After surgery, pregnancy and ovarian induction followed by in vitro fertilization are also significant issues. In surgery, laparoscopic technique can be used by a gynecologic oncology surgeon. So far postoperative chemotherapy, radiotherapy and hormone therapy are not recommended. We will discuss controversial issues of BOTs on this review and present the outline of the management of BOTs.

Association Between Reproductive Cancer and Fetal Outcomes: A Systematic Review

Objective

This study aimed to review studies that addressed the impact of previous reproductive cancer diagnosis on selected fetal birth outcomes.

Materials and Methods

We searched PubMed and Web of Knowledge to identify peer-reviewed articles published from January 1992 to December 2012, investigating the association between reproductive cancer and birth outcomes. After applying exclusion criteria, 49 articles were identified for full review, and 36 articles were finally selected for this systematic review. The quality of the studies was assessed by independent reviewers.

Results

We found 13 cervical cancer studies, 16 ovarian cancer studies, and 7 corpus uteri cancers that reported subsequent pregnancies (n = 688 pregnancies in 477 women). Of these, 489 pregnancies reached third trimester. Among viable pregnancies, only 416 pregnancies had information on maturity status based on gestational age and/or birth weight. For those with cervical cancer, the preterm birth (PTB) rate was 48.5%. For those with ovarian cancer, there were no cases of PTB. For those with corpus uteri cancers, the PTB was 7.7%. All studies had small sample sizes, and there was considerable heterogeneity of results. Abortions, ectopic pregnancies, and terminations were also reported.

Conclusions

Reproductive cancers may be associated to subsequent adverse fetal birth outcomes; however, the quality of evidence is still insufficient to infer a relationship between reproductive cancers treated conservatively and adverse fetal birth outcomes in subsequent pregnancies.

A minimally invasive approach to laparoscopic surgery for large adnexal cysts with a multichannel port using a wound retractor

This study explored and evaluated the feasibility and safety of laparoscopy with a multichannel port using a wound retractor for large adnexal masses. Seven patients scheduled to undergo single-port or 2-port laparoscopy for large adnexal cysts were enrolled. The cystic mass surface was exposed by inserting the wound retractor through the umbilical port, and cystic fluid was aspirated using a suction-irrigation system after puncture with an Ochsner trocar. Then, laparoscopic adnexal surgery was performed in the usual manner. The mean maximal diameter of cysts, mean operation time, and mean postoperative hospital stay were 17.8 ± 5.4 cm, 81.3 ± 28.2 minutes, and 4.4 ± 2.0 days, respectively. Use of multichannel ports for large adnexal cystic masses seems safe and does not require additional cost. The procedure is also cosmetically effective and highly appreciated by patients, because it results in minimal abdominal scarring.

Laparoscopy in the treatment of ovarian tumours of low malignant potential

Laparoscopy is increasingly used by gynaecologists for the investigation of adnexal masses. Uncertainty exists whether ovarian tumours of low malignant potential can effectively be treated by laparoscopy, whether staging bears a benefit for all patients, whether port-site metastases are a problem and how long patients need to be followed up after surgery. This review summarises the evidence to address these important questions.

Management of borderline ovarian neoplasms

Over the last decades, the management of borderline ovarian tumors (BOTs) has changed from radical surgery to more conservative therapy as a result of the need for fertility-sparing surgery and the increasing use of laparoscopy. The question is whether this is good clinical practice from an oncologic point of view. Here, recent literature regarding management of borderline ovarian neoplasms is reviewed, and oncologic concerns are discussed with emphasis on the mode of surgery and the possibility of fertility-sparing surgery and its consequences. Proper staging is defined as an exploration of the entire abdominal cavity with peritoneal washings, infracolic omentectomy, and multiple peritoneal biopsies as the cornerstone of a successful treatment, and this is only possible through a midline incision. For stage I disease, conservative surgery consisting of unilateral salpingo-oophorectomy or cystectomy in case of bilateral ovarian involvement or when the disease develops in the only remaining ovary is a valuable alternative in a number of young patients who want to preserve their fertility. Patients with advanced-stage disease or who are finished childbearing are treated with radical surgery consisting of peritoneal washings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, complete peritoneal resection of macroscopic lesions, or multiple peritoneal biopsies; in case of mucinous BOTs, patients also are treated with an appendectomy.

[Impact of the surgical route on staging and outcome of early borderline ovarian tumors]

OBJECTIVE

To assess the impact of the surgical route on the management and outcome of early borderline ovarian tumors (BOT).

PATIENTS AND METHODS

We have retrospectively analysed BOT operated on between January 1st 1985 and December 31st 2001. We included cases with clinical stages Ia to Ic. We compared the prevalence of deleterious acts according to the surgical access, as well as the quality of staging. Univariate and multivariate analysis assessed the impact of factors on quality of staging. Survival was also compared according to the initial surgical access. Data were computed and analysed using SPPS 7.5 and STATA 8.

RESULTS

118 cases have been included, 48 (41%) have been operated on by laparoscopy, 54 (45%) by laparotomy and 16 (14%) had a conversion. A conservative treatment has been done in 57% of patients, with increased frequency in case of laparoscopy (P<0.05) and in aged patients (P<0.001). A tumor rupture occurred in 9% of cases, without difference between accesses (P=0.1). A bag was used for the specimen delivery in only 40% of cases of laparoscopy. Most of patients (73%) had an incomplete staging. Year of treatment, and a radical treatment were associated with a better staging. Survival curves showed no detrimental effect of laparoscopy.

DISCUSSION AND CONCLUSION

Despite an incomplete staging, this series does not show any detrimental effect of laparoscopy on the outcome of early BOT.

Laparoscopic management of the adnexal mass

Ovarian neoplasms are common in women of all ages. As many as 10% of women in the United States will undergo surgical removal of an adnexal mass sometime in their lifetime. Gynecologic surgeons have pioneered laparoscopic surgery, developing what was originally a diagnostic tool into a safe and effective approach to management of adnexal masses. Accumulating scientific data support the laparoscopic approach to the adnexal mass as the preferred treatment.

Comparison of two fertility-sparing approaches for bilateral borderline ovarian tumours: a randomized controlled study

BACKGROUND

During the childbearing years, the standard fertility-sparing treatment for bilateral borderline ovarian tumours (BOTs) is the unilateral oophorectomy plus controlateral cystectomy. The aim of the present study was to compare the effects of two laparoscopic fertility-sparing surgical procedures for the treatment of bilateral BOTs on recurrence and fertility in young women who desire to conceive as soon as possible.

METHODS

Thirty-two women affected by bilateral early-stage BOTs who desired to conceive were randomized to receive bilateral cystectomy (experimental group, n=15) or oophorectomy plus controlateral cystectomy (control group, n=17). At the first recurrence after childbearing completion, each patient was treated with non-conservative standard treatment. Recurrences and reproductive events were recorded.

RESULTS

After a follow-up period of 81 months (19 inter-quartile; 60-96 range), the cumulative pregnancy rate (CPR) (14/15 versus 9/17; P=0.003) and the cumulative probability of first pregnancy (P= 0.011) were significantly higher in the experimental than in control group. No significant (P=0.358) difference between groups was detected in cumulative probability of first recurrence.

CONCLUSIONS

The laparoscopic bilateral cystectomy followed by non-conservative treatment performed at the first recurrence after the childbearing completion is an effective surgical strategy for patients with bilateral early-stage BOTs who desire to conceive as soon as possible.

The management of borderline tumours of the ovary

PURPOSE OF REVIEW

The treatment of borderline ovarian tumours has been similar to that for their invasive counterparts for a long time. However, in view of the good prognosis for borderline ovarian tumours, their occurrence in a younger age group and the development of less invasive techniques, the question can be asked as to whether a more conservative treatment is warranted.

RECENT FINDINGS

Recent articles discuss the mode of surgery (laparotomy or laparoscopy), the possibility of fertility-sparing surgery, the need for restaging procedures and adjuvant therapy.

SUMMARY

The ultimate goal in treating patients with borderline ovarian cancer is defining those patients with bad prognostic factors and risk for recurrence and who consequently require more aggressive therapy. A proper staging procedure is crucial to estimate the risk. Translational research might help identify borderline tumours with poor prognosis. Fertility-sparing surgery is often a good option in young patients with Fédération International de Gynécologie et Obstétrie (FIGO) stage I disease or in selected cases with noninvasive implants, since long-term survival does not seem to be negatively influenced by conservative surgery.

Laparoscopic surgery in gynaecological oncology

AIMS

The use of laparoscopic staging and/or surgery in the field of gynaecological oncology was pioneered in the late 1980s and the first reports were published in the early 1990s. The issue has been initially most controversial, and is still debated, with some justification considering the possible adverse consequences of surgical mismanagement of gynaecologic malignancy.

METHODS

The current literature has been reviewed and updated, concentrating on long-term, and/or comparative studies. Large observational studies have also been included. Recent papers concerning new developments have been selected.

FINDINGS

A number of papers have confirmed the absence of significant adverse effects on survival after laparoscopic diagnosis or surgery in gynaecological cancers. New developments cover virtually all the basic techniques in cancer surgery, including major exenterative surgery. The use of extraperitoneal technique for aortic dissections is emerging as a new tool. New indications, such as radical vaginal trachelectomy, radical parametrectomy, pelvic sentinel node identification, interval debulking surgery of adnexal malignancies, or the use of pretherapeutic surgical staging of uterine cancers, have been developed in direct relation with the use of laparoscopic techniques.

CONCLUSIONS

Current available data and worldwide interest clearly demonstrate that laparoscopic techniques must now be part of the armamentarium of the gynaecologic oncologist. Postoperative morbidity and recurrence risk do not seem to be affected. Cost-efficiency of laparoscopic procedures is based on the reduction of hospital stay and recovery time, although operating room time is increased in some procedures. Combined training in gynaecologic oncology and in laparoscopic and/or vaginal surgery is more than ever mandatory to avoid the risk of inadequate staging or management of pelvic malignancies.

Faisabilité et limites du traitement cœlioscopique des tumeurs frontières de l'ovaire

Borderline ovarian tumours (BOT) are mainly diagnosed in young women with early stage disease. Due to the absence of specific pre operative criteria for BOT, a laparoscopy is usually performed. A review of the literature found no pejorative data on laparoscopic approach for BOT. Strict surgical procedures must be performed to avoid incomplete surgical staging, cells dissemination and port-site metastases. The limits of the laparoscopic management are the stage of disease and the tumour size. Laparoscopic treatment of BOT for women with early stage disease is feasible. This treatment should be evaluated in specialized centres for women with advanced stage diseases and/or peritoneal implants.

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.

Borderline tumours of the ovary and fertility

Standard management of borderline ovarian tumours (BOT) is historically radical and based on hysterectomy, bilateral salpingo-oophorectomy and peritoneal staging. But, as 1/3 of BOTs are diagnosed in patients aged less than 40 years, treatments preserving fertility-potential (with preservation of the uterus and at least part of one ovary) has seen great developments in the last decade. Such treatments increase the rate of recurrences (between 15% and 35% depending on the type of conservative surgery), but without any impact on patient survival as most recurrent diseases are of the borderline type, easily curable and with excellent prognosis. The spontaneous pregnancy rate is nearly 50%. In case of persistent infertility, it seems that the use of ovarian induction or in vitro fertilization procedures could be proposed in selected cases. Follow-up is essential and based on clinical examination and routine ultrasonography. The interest of completion surgery (removal of the retained ovary) in patients who obtained pregnancy remains debated. In conclusion, conservative management of at least part of one ovary and uterus could be safely proposed at least to patients with early stage BOT, in order to preserve fertility-potential. The rate of recurrence is increased but without any impact on survival.

Impact of surgical approach on the management of macroscopic early ovarian borderline tumors

OBJECTIVE

The aim of this study was to evaluate the impact of the surgical approach on the management and outcomes of patients with early borderline ovarian tumors (BOTs).

MATERIAL AND METHODS

We retrospectively reviewed the medical charts of patients with stage Ia to Ic BOT treated surgically between January 1, 1985, and December 31, 2001. We compared patients initially managed by laparoscopy vs. laparotomy in terms of potentially harmful procedures and quality of staging.

RESULTS

Of the 118 included patients, 48 (41%) had laparoscopy for initial surgery, 54 (45%) had laparotomy, and 16 (14%) had conversion from laparoscopy to laparotomy. Conservative treatment (57% of patients) was more common with laparoscopy (vs. laparotomy, P < 0.05) and in women older than 44 years (vs. younger than 44 years, P < 0.001). Intraoperative tumor rupture occurred in 9% of patients and was not associated with the surgical approach (P = 0.1). Bag extraction was used in 19 (40%) of the 48 laparoscopy patients. Staging was incomplete in 73% of patients overall. By univariate analysis, better quality of staging was associated with bilateral adnexectomy, age >44 years, laparotomy, hysterectomy, and treatment after 1995. By multivariate analysis, bilateral adnexectomy or hysterectomy was associated with better staging. Mean follow-up was 40 months, during which recurrence and survival rates were similar in the laparoscopy and laparotomy groups.

CONCLUSION

Staging of macroscopic early stage BOTs was better in patients requiring radical surgery. After adjustment on disease severity, type of surgical access was not related to staging quality.

Results after laparoscopic management of serous borderline tumor of the ovary with peritoneal implants

OBJECTIVE

The aim of this study is to assess the clinical outcomes of laparoscopic treatment of borderline ovarian tumor (BOT) with peritoneal implants.

METHODS

Retrospective analysis of patients treated initially and/or for recurrent disease using a laparoscopic approach for a stage II or stage III BOT between January 2001 and January 2004.

RESULTS

Nine patients underwent a laparoscopic pure treatment of stage II/III serous borderline tumor. Three of them had a previous history of BOT. Three patients had a stage II and 6 a stage III disease. A conservative management was performed in 7 patients. Laparoscopic treatment of peritoneal implants included: omentectomy (or omental biopsies) in 4 patients and/or large peritoneal resection in 5 patients (pelvic peritoneum in all patients associated with peritonectomies of paracolic gutters in 2 and of the peritoneum of the right diaphragmatic peritoneum in 3). Implants were nonivasive in 8 patients. Each of implant had a size <5 mm. Four patients recurred, 3 of them had a borderline ovarian recurrence after conservative management. Two patients had peritoneal disease found during a second-look surgery (associated with ovarian recurrence in 1). Three spontaneous pregnancies were observed. All patients are alive without evidence of disease with a median time of follow-up of 35 months following the laparoscopic treatment.

CONCLUSION

Our series suggests that laparoscopic treatment of patients with BOT associated with small size non-invasive implants is feasible and seem to be safe. The main indication of this management consists in young patients treated conservatively to preserve their fertility.