Transcript ls.ov_.ca_.tjod_.2013.ÇT

Laparoscopic Surgical Management of
Epithelial Ovarian Cancer
Cagatay Taskiran, MD, Assoc. Prof.
VKV American Hospital, Division of
Gynecologic Oncology
L/S & EOC
Primary trt for early stage disease
Restaging
Primary cytored’n for advanced disease
Surgical trt for recurrent disease
To assess resectability: Neoadjuvant CT
VATS
Early Stage is Rare
Standard Surgery for Early Stage
Ovarian Cancer
Comprehensive surgical staging
Exploration - Cytology and biopsies
Hyst-BSO- fertility sparing surgery
PPLNDTotal Omentectomy
Appendectomy
Up-staging
Schuler et al, 1999, EJOGRB
401 patients, 24% up-staging
Diaphragma
Omentum
PPALN
Cytology
Distribution of LN Metastasis
Literature
Early stage ovarian cancer & Laparoscopy
Retrospective series
Case-control studies
Meta-analysis
Cochrane review
Literature
Early stage ovarian cancer & Laparoscopy
1994, Querleu-Leblanc 9 patients
Still small series, number low
11 studies, 9-42 pt, 88
multicenter
Approximately 400 patients
Comparative Studies & Feasibility
Chi, AJOG, 2005, 50 pt
LN number, omental size: no problem
No conversion to L/T
Survival rates similar
Park, Ann Surg Oncol, 2008, 36 pt
LN number, omental size: no problem
Upstaging rate is same
No recurrence within 20 months
Comparative Studies & Feasibility
Whole Literature
Benefits of Laparoscopy
Endometrial cancer – randomized studies
EBL lower
Shorter hospital stay
Fewer postoperative complications
Improved QOL
Faster return to normal function
Similar for ovarian cancer – no RCT, shorter
interval to adjuvant chemotherapy
Benefits of Laparoscopy
Ghezzi, 2 012, 88 pt
Blood tx rate 2.8% vs 19.2%
Postoperative complications 3.2% vs 31%
Febrile morbidity
Ileus
Wound dehiscence
Wound infection
Potential Benefits & Some Conflicts
Cost
Complications
Hospital stay
Performance – return to work – CT ??
Improved fecundity after fertility sparing
surgery - adhesions
Possible Risks & Rupture
Rupture – IC – Chemo – survival is
worsened
L/T 10% and L/S 15-20%
Size and endobag usage
Rupture vs puncture ??
Meta-Analysis & Accepted 4 April AJOG
11 studies
EBL lower
Upstaging rate
Conversion to L/T
Recurrence rate
Intraop rupture
23%
3.7%
9.9% (6.7-14)
25% !!!!!
Only 1 port site-metastasis
Data
Overall 12 hasta
Borderline
EOC
LN number
Omentectomy
8 pt
4 pt (all restaging)
31-84
no problem
No conversion
No intra-postop comp
Median time 5 hr
Trocar Sites
Transperitoneal LA & Learning curve
 >20 cases PLN number satisfactory, time shorter,
complications decrease; LN number: 17-22
 Paraaortic LN number increase by years: 6----19
Kohler, GO, 2004
Transperitoneal LA & Duration
Kohler, GO, 2004
Re-staging & Up-staging
bowel
abdom.perit.
pevic perit.
pao lln
pelvic lln
omentum
diaphragm
cytology
%
0
5
10
15
20
25
14 studies 1971-1994
Timing of Restaging
Lehner 1998
Kinderman 1996
max. 15 days
max. 8 days
Adequate staging is very important
Primary Debulking for Advanced Disease
Fanning, 2011, GO
CT: omental metastasis – ascites
25 cases – 2 conversions: severe omental-RS
36% no residual
Hospiatal stay median 1 day
Blood loss 340 ml
Median OS: 3.5 years
Primary Debulking for Advanced Disease
Nezhat, JSLS, 2010
28 pt, 11 open after diagnostic L/S
%88 optimal
Time and complication rates are same
Blood loss and hospital stay less
9 NED, 6 AWD, 2 DOD
Secondary Cytoreduction
Magrina, 2013, GO, 2006-2010
L/S: 9, Robot:10, L/T:33 patients
15 types of different procedures
No conversion
No difference: Op. Time, comp’n, complete
debulking, survival
Endoscopy: Blood loss and hospital stay
L/T: 3 major procedures, upper and lower
quadrants
Secondary Cytoreduction
Nezhat, JSLS, 2012, only L/S
1999-2009, secondary 20, tertiary 3 cases
%82 optimal
200 min, 75 ml, stay 2 days
1 conversion
No intraop complication
NED:12
AWD:6
DOD:4
Median DFS: 72 months
Conclusion
 There is limited data on the role laprascopic surgery for early stage
ovarian cancer
 Although it was started at nearly the same time periods with EC
and CC it was not populirezed
 It seems feasible for surgical procedures, upstaging rates,
adequacy of lymphadenectomy and omentectomy
 Survival rates are similar with laparotomy
 Port site metastasis is rare, Major problem is tumor rupture
Conclusion
 There is limited data on the value of laparoscopic surgery for
recurrent disease. It seems feasible for highly selected patients at
very experienced centers
 It may be good way to assess resectability for advanced cases both
before primary surgery and after NACT
 VATS should be performed for patients having moderate to severe
pleural effusion beforre abdominal cytoreduction
Thanks for your attention ….