• Concept of surgery for ovarian cancer

    Ovarian cancers are diagnosed based on imaging (ultrasound, CT or MRI scans) findings as complex ovarian cysts. Histological proof is not seeked for as needle biopsy (FNAC) can rupture the cyst & spread the disease. Ovarian cancers may arise from the surface epithelium (more common) or from the deeper substance (germ cell tumors or sex cord-stromal cell origin).

    Standard treatment of suspected epithelial ovarian and fallopian tube cancers includes a comprehensive surgical staging. This procedure includes a total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytologic washings, biopsies of adhesions and peritoneal surfaces, omentectomy, and retroperitoneal lymph node sampling from the pelvic and para-aortic regions through a generous vertical midline laparotomy incision. As there is no preoperative histological proof, a frozen section or imprint cytology is performed on the oophorectomy or on-table biopsy specimen.

    Non-epithelial tumors are also treated similarly. However, usually these are detected earlier than epithelial cancers due to pain & they occur at younger age when fertility preservation is important. In most of the cases fertility preserving surgery is possible.

  • Role of laparoscopy in ovarian cancer
    • Laparoscopic staging of apparent early ovarian cancer:Laparoscopic staging of apparent early ovarian cancer may be accomplished in patients where disease appears limited to the adnexa. For example a completely resected complex adnexal mass with intraoperative frozen-section or imprint cytology revealing malignancy and no obvious limitation to complete laparoscopic staging. Laparoscopic staging may also be utilized in patients who have apparent early ovarian cancer and have undergone incomplete surgical staging. For example patients who underwent ovarian cystectomy or salpingo-oophorectomy and final pathology reveals ovarian cancer with no obvious measurable metastasis and no obvious limitation to complete laparoscopic staging.
    • Assessment of the feasibility of optimal cytoreductive surgery in ovarian cancer: Laparoscopy may also be utilized to assess the extent of intraabdominal disease in advanced ovarian cancer and the potential for optimal or complete tumor resection. Some patients, originally selected for comprehensive staging, will only be able to undergo only limited dissection due to extremely advanced disease. A laparoscopy would allow a better case selection for surgical or medical line of treatment. Those cases judged unresectable by clinical–radiological evaluation could really benefit from a laparoscopic approach that can improve the predicted surgical outcome and provide a histological diagnosis by a less traumatic access.
    • Fertility preservation in early ovarian cancer: Many centers are using MACS approach to perform the conservative treatment of borderline ovarian tumors or non-epithelial cancers. This is attractive because such management theoretically reduces post-operative adhesions and therefore could increase fertility results.
    • Comprehensive laparoscopic staging procedure in advanced cancers: Assessment of disease extent and potential for respectability followed by a comprehensive resection may be performed laparoscopically. In addition, hand-assisted laparoscopy is used in some centers for comprehensive surgery of advanced disease using a limited abdominal incisions.
    • Laparoscopic reassessment or second-look operation or rule out recurrence: The role of second-look surgery in the management of advanced epithelial ovarian cancer is controversial. High recurrence rates after negative histological findings, lack of consistently effective salvage therapy, and absence of data showing improved survival benefits have diminished acceptance of the routine use of second-look surgery. Nevertheless, patients with suboptimal initial cytoreductive surgery for stage III ovarian cancer who have a complete clinical response to platinum-based combination chemotherapy appear to achieve a distinct survival benefit from second-look surgical procedures. The management of advanced epithelial ovarian cancer includes surgical staging and aggressive debulking by laparotomy followed by intravenous chemotherapy. Nevertheless, even in cases of a good response after optimal debulking surgery and intravenous chemotherapy, 50% of the patients with no clinical evidence of residual disease will suffer a recurrence because of the presence of microscopic peritoneal implants. In those patients the failure of second-line intravenous chemotherapy to control residual disease has led to the use of intraperitoneal chemotherapies for small microscopic residual disease. Until recently, second-look procedures and insertion of intraperitoneal catheters were almost always carried out by laparotomy or "blind" surgical technique. With the improvement of instrumentation and surgical techniques, we are now able to perform these procedures by laparoscopy.
  • MINIMAL ACCESS CANCER SURGERY (MACS) FOR ovarian CANCER

    Laparoscopy has been described as a method for surgical reassessment in patients with ovarian cancer since the early 1970s; however, these early reports were received with limited acceptance of laparoscopy as a replacement for laparotomy. The initial limitations of laparoscopic practice as described included inadequate visualization in up to 12% of patients, a high false-negative rate and a high complication rate, mainly bowel injury. In addition, there were limitations in performing extensive laparoscopic sampling of areas of tumor persistence including retroperitoneal lymph nodes. However, with time several authors have pointed out advantages to the laparoscopic approach including a reduction in the need for laparotomy in upto 50% of cases, a reduction in operating time, blood loss, hospital stay, and total hospital charges.

    The safety of the laparoscopic approach has also been documented with minimal intraoperative and postoperative complications in more recent reports. With advanced laparoscopic techniques, adhesions can usually be released to improve visualization of peritoneal surfaces, allowing suspicious lesions to be biopsied and areas of tumor persistence, including the pelvic and periaortic lymph nodes, to be sampled. Peritoneal washings can be obtained and intraperitoneal catheters can be inserted under direct visualization. There are, however, potential limitations to laparoscopy; mainly, the inability to palpate unvisualized areas and possible limited exposure to the posterior diaphragm mainly behind the liver, where disease may be missed.

    The GOG study to determine the feasibility of laparoscopic completion staging in patients with incompletely staged gynecologic cancers concluded that interval laparoscopic staging of gynecologic malignancies can be successfully undertaken in selected patients, but laparotomy for adhesions or metastatic disease and risk of visceral injury should be anticipated.

  • References
    • Quinn MA, Bishop GJ, Campbell JJ, et al. Laparoscopic follow-up of patients with ovarian cancer. Br J Obstet Gynaecol 1980;87:1132-9.
    • Ozols RF, Fisher RI, Anderson T, et al. Peritoneoscopy in the management of ovarian cancer. Am J Obstet Gynecol 1981;140:611-9.
    • Berek JS, Griffiths CT, Leventhal JM. Laparoscopy for second-look evaluation in ovarian cancer. Obstet Gynecol 1981;58:192-8.
    • Piver MS, Shashikant BL, Barlow JJ, et al. Second-look laparoscopy prior to proposed second-look laparotomy. Obstet Gynecol 1980;55:571-3.
    • Abu-Rustum NR, Barakat RR, Siegel PL, Venkatraman E, Curtin JP, Hoskins WJ. Second-look operation for epithelial ovarian cancer: Laparoscopy or laparotomy? Obstet Gynecol 1996;88:549-53.
    • Husain A, Chi DS, Prasad M, Abu-Rustum N, Barakat RR, Brown CL, Poynor EA, Hoskins WJ, Curtin JP. The role of laparoscopy in second-look evaluations for ovarian cancer. Gynecol Oncol 2001 Jan;80(1):44-7.
    • Moore DH. Primary surgical management of early epithelial ovarian carcinoma. In: S.C. Rubin and G.P. Sutton, Editors, Ovarian cancer (2nd edition), Lippincott Williams & Wilkins, Philadelphia (2001), pp. 201–218.
    • Querleu D and Leblanc E. Laparoscopic infrarenal para-aortic lymph node dissection for restaging of carcinoma of the ovary or fallopian tube. Cancer. 1994; 73:1467–71.
    • Spirtos NM, Eisekop SM, Boike G, Schlaerth JB, Cappellari JO. Laparoscopic staging in patients with incompletely staged cancers of the uterus, ovary, fallopian tube, and primary peritoneum: a Gynecologic Oncology Group (GOG) study. Am J Obstet Gynecol. 2005;193:1645-9.
    • Rahaman J, Dottino P, Jennings TS, Holland J, Cohen CJ. The second-look operation improves survival in suboptimally debulked stage III ovarian cancer patients. Int J Gynecol Cancer. 2005;15:19-25.
    • Nagarsheth NP, Rahaman J, Cohen CJ, Gretz H, Nezhat F. The incidence of port-site metastases in gynecologic cancers. JSLS. 2004;8:133-9.
    • Abu-Rustum NR, Sonoda Y, Chi DS, Teoman H, Dizon DS, Venkatraman E, Barakat RR. The effects of CO2 pneumoperitoneum on the survival of women with persistent metastatic ovarian cancer. Gynecol Oncol. 2003;90:431-4.
    • Vaisbuch E, Dgani R, Ben-Arie A, Hagay Z. The role of laparoscopy in ovarian tumors of low malignant potential and early-stage ovarian cancer. Obstet Gynecol Surv. 2005;60:326-30.
    • Chi DS, Curtin JP. Gynecologic cancer and laparoscopy. Obstet Gynecol Clin North Am. 1999;26:201-15
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