Role of laparoscopy in the management of the adnexal mass and staging of gynecologic cancers

Laparoscopy versus laparotomy for FIGO stage I ovarian cancer

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We performed no meta-analyses.

AUTHORS' CONCLUSIONS

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

Single-port or Classic Laparoscopy Compared With Laparotomy to Assess the Peritoneal Cancer Index in Primary Advanced Epithelial Ovarian Cancer

A thorough laparoscopic assessment of the abdominopelvic cavity is a crucial step in the workup of primary advanced epithelial ovarian cancer to decide whether up-front cytoreductive surgery or neoadjuvant chemotherapy is the best option for adequate management. The purpose of our study was to compare single-port laparoscopy (SPL), classic laparoscopy (CL), and laparotomy using the peritoneal cancer index (PCI). Patients treated for Fédération Internationale de Gynécologie et d'Obstétrique stage 3 or 4 epithelial ovarian cancer were included in our study when they underwent a PCI evaluation by laparoscopy followed by laparotomy for cytoreduction. According to the technique used for the "noninvasive" procedure (SPL vs CL), 2 groups were compared retrospectively. The individual records of all patients were reviewed and analyzed. From 2011 to 2014, 21 patients were assessed for PCI by SPL plus laparotomy versus 21 by CL plus laparotomy. The clinicopathological features were similar in both groups (not significant [NS]), except for performance status >0, which was more frequent in the SPL group (39% vs 6%, p = .04). Quotation of PCI was possible for all patients. Nonbrowsing areas marked 3 procedures in the SPL group and 2 procedures in the CL group (NS). The mean PCI score and the score of each region assessed by SPL and CL were comparable with the evaluation by laparotomy (NS). Completeness of cytoreduction was achieved in 78% of cases in both groups (NS). SPL and widely mini-invasive procedures seem to be effective tools compared with laparotomy to adequately assess the resectability of a peritoneal carcinomatosis using the PCI.

Comparison of the prognosis and recurrence of apparent early-stage ovarian tumors treated with laparoscopy and laparotomy: a meta-analysis of clinical studies

Background

This meta-analysis aimed to evaluate the prognosis and recurrence of apparent early-stage ovarian tumors treated with laparoscopy compared with laparotomy.

Methods

Clinical studies published in English were retrieved from the computerized databases Medline and Embase. A meta-analysis was performed to investigate the differences in the efficacy and safety of laparoscopy versus laparotomy in terms of postoperative complications, lengths of hospital stay, recurrence rates, and disease-free survival times using the random effects model. The studies were independently reviewed by two investigators. Data from the eligible studies were extracted, and the meta-analysis was performed using the Comprehensive Meta-Analysis program, version 2 (CMA-2; Biostat, Englewood, NJ, USA).

Results

A total of 8 studies were included in the analysis. The results showed that laparoscopic surgery was significantly associated with lower rates of complications (OR = 0.433, P = 0.019) and shorter postoperative hospital stays (weighted mean difference [WMD] = −0.974, P < 0.001). There was no significant difference in the rates of recurrence (OR = 0.707, P = 0.521) between patients with apparent early-stage ovarian tumors who were treated using laparoscopy and those who underwent laparotomy. No publication bias was detected.

Conclusions

Laparoscopic surgery shows favorable prognostic outcomes in terms of postoperative complication rates and postoperative hospital stay durations. Further studies with longer follow-up periods are required to confirm recurrence and survival outcomes after laparoscopic surgery in patients with apparent early-stage ovarian tumors.

Evaluation of single-port laparoscopy for peritoneal carcinomatosis assessment in advanced ovarian cancer

OBJECTIVES

Ovarian cancers are usually diagnosed at an advanced stage. The extent of the disease before surgery partly determines the ability to perform a complete cytoreduction. The peritoneal cancer index (PCI) is used to evaluate peritoneal carcinomatosis and has been validated in ovarian cancer and correlated with resectability. The aim of our study was to assess the feasibility of single-port laparoscopy (SPL) for suspicion of advanced ovarian cancer and to describe the ability to calculate the PCI score at the time of laparoscopy.

STUDY DESIGN

Between February 2011 and January 2013, 33 patients underwent SPL for suspected advanced ovarian cancer. Individual records for all patients were prospectively reviewed and analyzed. For each patient, we determined the PCI score.

RESULTS

33 patients underwent initial SPL, 85% had increased carcinological markers and 67% a radiological suspicion of peritoneal carcinomatosis. The median operative time was 90min. During SPL, 76% of patients underwent ascites evacuation; all patients had peritoneal cytology and peritoneal biopsies. Only 3 patients experienced perioperative complications. Two open conversions were recorded. Quotation of the PCI score was possible for all patients. Eighteen patients (55%) had a PCI score below 10; one had a maximal PCI score of 39. The PCI score was null for 9 patients. Non-browsing areas marked 8 procedures.

CONCLUSIONS

SPL appeared to be feasible, with satisfying immediate results and postoperative outcome, compared to conventional laparoscopy. It allowed a satisfying exploration of the abdomino-pelvic cavity and a good description of peritoneal carcinomatosis with only a few non-browsing PCI areas.

Laparoscopy versus laparotomy for FIGO stage I ovarian cancer

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We performed no meta-analyses.

AUTHORS' CONCLUSIONS

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

Peritoneal carcinosis of ovarian origin

Epithelial ovarian cancer (EOC) is the second most common genital malignancy in women and is the most lethal gynecological malignancy, with an estimated five-year survival rate of 39%. Despite efforts to develop an effective ovarian cancer screening method, 60% of patients still present with advanced disease. Comprehensive management using surgical cytoreduction to decrease the tumor load to a minimum, and intraperitoneal chemotherapy to eliminate microscopic disease on peritoneal surface, has the potential to greatly improve quality of life and to have an impact on survival in ovarian cancer patients. Despite achieving clinical remission after completion of initial treatment, most patients (60%) with advanced EOC will ultimately develop recurrent disease or show drug resistance; the eventual rate of curability is less than 30%. Given the poor outcome of women with advanced EOC, it is imperative to continue to explore novel therapies.

Differences in perioperative outcomes after laparoscopic management of benign and malignant adnexal masses

Objective

To compare the feasibility and safety of the laparoscopic management of adnexal masses appearing preoperatively benign with those suspicious for malignancy.

Methods

Retrospective study of 694 women that underwent laparoscopic management of an adnexal mass.

Results

Laparoscopic management of an adnexal mass was completed in 678 patients. Six hundred and thirty five patients had benign pathology (91.5%) and 53 (7.6%) had primary ovarian cancers. Sixteen patients (2.3%) were converted to laparotomy; there were 13 intraoperative (1.9%) and 16 postoperative complications (2.3%). Patients divided in 2 groups: benign and borderline/malignant tumors. Patients in the benign group had a higher incidence of ovarian cyst rupture (26% vs. 8.7%, p<0.05). Patients in the borderline/malignant group had a statistically significant higher conversion rate to laparotomy (0.9% vs. 16.9%, p<0.001), postoperative complications (1.9% vs. 12.2%, p<0.05), blood loss, operative time, and duration of hospital stay. The incidence of intraoperative complications was similar between the 2 groups.

Conclusion

Laparoscopic management of masses that are suspicious for malignancy or borderline pathology is associated with an increased risk in specific intra-operative and post-operative morbidities in comparison to benign masses. Surgeons should tailor the operative risks with their patients according to the preoperative likelihood of the mass being carcinoma or borderline malignancy.

Peritoneal carcinosis of ovarian origin

Epithelial ovarian cancer (EOC) is the second most common genital malignancy in women and is the most lethal gynecological malignancy, with an estimated five-year survival rate of 39%. Despite efforts to develop an effective ovarian cancer screening method, 60% of patients still present with advanced disease. Comprehensive management using surgical cytoreduction to decrease the tumor load to a minimum, and intraperitoneal chemotherapy to eliminate microscopic disease on peritoneal surface, has the potential to greatly improve quality of life and to have an impact on survival in ovarian cancer patients. Despite achieving clinical remission after completion of initial treatment, most patients (60%) with advanced EOC will ultimately develop recurrent disease or show drug resistance; the eventual rate of curability is less than 30%. Given the poor outcome of women with advanced EOC, it is imperative to continue to explore novel therapies.

Prospective validation of a laparoscopic predictive model for optimal cytoreduction in advanced ovarian carcinoma

OBJECTIVE

The purpose of this study was to validate the performance of a laparoscopy-based model to predict optimal cytoreduction in advanced ovarian cancer patients.

STUDY DESIGN

In a consecutive prospective series of 113 advanced ovarian cancer patients, the presence of omental cake, peritoneal and diaphragmatic extensive carcinosis, mesenteric retraction, bowel and stomach infiltration, spleen and/or liver superficial metastasis were investigated by laparoscopy. By summing the scores relative to all parameters, a laparoscopic assessment for each patient (total predictive index value = PIV) has been calculated. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy have been calculated for each PIV.

RESULTS

The overall accuracy rate of the laparoscopic procedure ranged between 77.3 and 100%. At a PIV >/= 8 the probability of optimally resecting the disease at laparotomy is equal to 0, and the rate of unnecessary exploratory laparotomy is 40.5%.

CONCLUSION

The proposed laparoscopic model appears a reliable and flexible tool to predict optimal cytoreduction in advanced ovarian cancer.

Laparoscopy versus laparotomy for FIGO Stage I ovarian cancer

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

No RCTs were identified. Three observational studies were identified.

AUTHORS' CONCLUSIONS

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

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.

Role of laparoscopy to evaluate candidates for complete cytoreduction in advanced stages of epithelial ovarian cancer

The objective of this study was to evaluate the role of laparoscopy in selecting candidates for complete cytoreduction surgery in epithelial ovarian carcinoma. We performed an explorative laparoscopy in 15 women presenting with advanced ovarian carcinoma, and for whom the preoperative evaluation was considered unsatisfactory, to define the possibility of achieving a complete cytoreduction. We focused on three sites of carcinomatosis: bowel, liver pedicle, and right diaphragmatic dome. Laparoscopic evaluation was successful in all 15 patients. Four patients were considered to have unresectable carcinomatosis because of extensive involvement of the small bowel and therefore had no laparotomy. These women underwent neoadjuvant chemotherapy in the following 2 weeks. Eleven patients were considered to have resectable peritoneal carcinomatosis (PC). Ten women had no macroscopic residual tumor after surgery. A modified posterior exenteration was performed in five patients. The laparoscopic exploration had underestimated the liver pedicle involvement in two patients, but only one had an infracentimetric residual tumor after surgery. Laparoscopy is a reliable method of exploring PC in advanced-stage ovarian cancer. Laparoscopy may obviate the need for unnecessary laparotomy in many cases and may, therefore, contribute to a better quality of life for patients found to have unresectable disease.

Role of laparoscopy to assess the chance of optimal cytoreductive surgery in advanced ovarian cancer: a pilot study

OBJECTIVE

To investigate whether laparoscopy can be considered as adequate and reliable as standard laparotomy in predicting optimal cytoreduction (RT < or = 1 cm) in patients with advanced ovarian cancer.

METHODS

From March to November 2003, 95 patients with suspected advanced ovarian or peritoneal cancer have been evaluated. Thirty-one cases were excluded due to an anesthesiological class of risk ASA III-IV (51.6%) and for the presence of a large size mass reaching the xiphoid (48.4%). Sixty-four patients completed the study. All patients were submitted to preoperative clinico-radiological evaluation and then to both laparoscopy and standard longitudinal laparotomy, sequentially. Some specific preoperatively defined parameters were analyzed during each procedure in order to obtain the most accurate evaluation on the possibility to get an optimal cytoreduction.

RESULTS

The overall accuracy rate of laparoscopy in assessing optimal cytoreduction was 90%. The negative predictive value (NPV) of the clinical-radiologic evaluation corresponded to 73%, whereas in no case was the judgment of unresectable disease obtained by laparoscopy changed by the laparotomic approach (NPV 100%). On the contrary, an optimal debulking was achievable in 34 of 39 cases (87%) selected as completely resectable by explorative laparoscopy.

CONCLUSIONS

Laparoscopy can be considered super imposable to standard longitudinal laparotomy in identifying not optimally resectable advanced ovarian cancer patients.

The Role of Laparoscopy in Ovarian Tumors of Low Malignant Potential and Early-Stage Ovarian Cancer

Although it is feasible today to perform laparoscopic surgical staging and treatment of ovarian low malignant potential tumors and early-stage ovarian cancer safely, it is still generally agreed that a patient with ovarian cancer should have a laparotomy. Concerns related to laparoscopy in managing gynecologic malignancy include the accuracy of intraoperative diagnosis, inadequate resection, significance of tumor spillage, improper or delay in surgical staging, delay in therapy, and the possibility of port-site metastasis. On the other hand, laparoscopy has the advantages of being a minimally invasive surgery, with shorter hospitalization, decreased postoperative pain, and quicker return to normal daily activities. We review the current literature discussing the consequences of laparoscopic surgery in ovarian tumors of low malignant potential and early-stage ovarian cancer.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to list the concerns related to laparoscopic management of ovarian malignancies, to outline the accuracy of the diagnosis of low malignant potential (LMP) ovarian tumors on frozen section, and to summarize the data on the effect of capsule rupture on overall prognosis for patients with ovarian cancer.

Endometrial cancer

OBJECTIVES

To provide an update for nurses involved in the care of women at risk or being treated for endometrial cancer.

DATA SOURCES

Review articles, research reports, and medical and nursing text-books.

CONCLUSIONS

Endometrial cancer is the most common gynecologic malignancy. Although most women with endometrial cancer present with early stage disease and have an excellent chance of cure, approximately 6,600 women in the United States are expected to die from the disease in 2002. Treatment of patients with advanced or recurrent disease remains challenging, with no proven best standard of treatment.

IMPLICATIONS FOR NURSING PRACTICE

Nursing plays an important role in prevention and early detection of endometrial cancer, patient education, patient care, and rehabilitation.