To the Editor
The American Cancer Society estimates that more than 21,000 women will be diagnosed with ovarian cancer and more than 15,500 will die of the disease in 2012.1 The role of minimally invasive surgery in gynecologic oncology has been continuously expanding. Overall, the potential role of laparoscopy in ovarian cancer surgery may be divided into the following categories:
- (1) Laparoscopic evaluation, diagnosis, and staging of apparent early ovarian cancer;
- (2) Laparoscopic diagnosis and assessment to determine whether the patient is suitable for upfront debulking surgery or for neoadjuvant chemotherapy in advanced ovarian cancer;
- (3) Laparoscopic upfront cytoreductive surgery or postneoadjuvant chemotherapy in selected advanced ovarian cancer cases; and
- (4) Laparoscopic reassessment or second-look operation and resection of the isolated recurrences
LAPAROSCOPIC EVALUATION, DIAGNOSIS, AND STAGING OF APPARENT EARLY AND ADVANCED OVARIAN CANCER
Several retrospective and case series reports have demonstrated the feasibility and safety of a laparoscopic approach to the management of early-stage ovarian cancers.2–6 These studies show laparoscopy to be associated with several perioperative benefits such as decreased blood loss, shorter hospital stay, and faster return of bowel function without compromising safety. Importantly, retrospective evidence in early ovarian cancer also suggests similar recurrence rates after laparoscopic and open staging procedure, suggesting that the laparoscopic technique does not compromise the outcome of early-stage ovarian carcinoma.5,6
LAPAROSCOPIC DIAGNOSIS AND ASSESSMENT TO DETERMINE WHETHER THE PATIENT IS SUITABLE FOR UPFRONT DEBULKING SURGERY OR NEOADJUVANT CHEMOTHERAPY
The mainstay of treatment for advanced-stage invasive epithelial ovarian cancer is optimal cytoreduction, followed by platinum-based combination chemotherapy.7 Optimal cytoreduction, to microscopic disease, is associated with best survival.8–11 To assess the resectability of advanced ovarian cancer, patient selection should be done with a view to either optimal primary cytoreductive surgery, preferable to microscopical disease, or neoadjuvant chemotherapy. Fagotti et al12 assessed 7 parameters of respectability in laparoscopy For a Fagotti score under 4, a complete cytoreduction could be obtained in 78% of patients. The Fagotti index may still require validation, yet it had been already proposed, in a setting of a clinical trial, to introduce laparoscopy at the start of surgical treatment to determine respectability and avoid unsuccessful laparotomic debulking surgery.13
LAPAROSCOPIC UPFRONT CYTOREDUCTIVE SURGERY OR POSTNEOADJUVANT CHEMOTHERAPY IN SELECTED ADVANCED OVARIAN CANCER CASES
Over the last few years, several authors have performed and described complex laparoscopic procedure for debulking of advanced ovarian cancer to suggest that minimally invasive laparoscopic or robot-assisted, alone or combined with minilaparotomy, surgery for selected ovarian cancer debulking, is feasible, effective, and comparable to debulking laparotomy in selected cases, with advanced disease.14–17 In the era where neoadjuvant chemotherapy with interval cytoreduction has emerged as an alternative to primary surgical debulking,18 we believe that in selected cases, in which the neoadjuvant triage will be offered to the patients, the disease after initiation of chemotherapy will be less extensive and will therefore encourage many gynecological oncologists to perform laparoscopic debulking surgery for these patients.
LAPAROSCOPIC REASSESSMENT, OR SECOND-LOOK OPERATION AND RESECTION OF THE ISOLATED RECURRENCES
In the past, second look operation was suggested as part of the therapeutic triage of patients with advanced ovarian cancer. Nowadays, this procedure is performed mainly in clinical trials or in selected cases with uncertain clinical response of these patients. Similar results have been reported regarding the efficacy of laparoscopy compared to laparotomy in assessing the pelvic and upper abdomen in these cases.19 The role of secondary cytoreduction surgery for advanced ovarian carcinoma is debatable. Recently, several authors suggested some criteria such as isolated recurrence, the lack of ascites, and optimal debulking on the primary surgery as indications for secondary debulking.20,21 In these selected cases, laparoscopic secondary cytoreduction has been reported with acceptable results with regard to the efficacy and the outcomes.22–25
The promise of minimal incisions and shorter recovery time, coupled with increased number of skilled laparoscopic surgeons and team approach in well-equipped operating rooms, add to potential temptation of introducing these approaches to ovarian cancer treatment without the context of clinical trial.
Farr R. Nezhat, MD
Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
St. Luke’s and Roosevelt Hospitals
Academic Affiliates of Columbia University
College of Physicians and Surgeons
New York, NY
Ofer Lavie, MD
Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
Carmel Medical Center
Academic Affiliate of Rappaport Faculty of Medicine
the National Technion
1. American Cancer Society. Cancer Facts & Figures, 2011
. Atlanta, GA: ACS; 2011.
2. Childers JM, Lang J, Surwit EA, et al. Laparoscopic surgical staging of ovarian cancer. Gynecol Oncol
. 1995; 59: 25–33.
3. Angioli R, Muzii L, Battista C, et al. The role of laparoscopy in ovarian carcinoma. Minerva Ginecol
. 2009; 61: 35–43.
4. Tozzi R, Schneider A. Laparoscopic treatment of early ovarian cancer. Curr Opin Obstet Gynecol
. 2005; 17: 354–358.
5. Weber S, McCann CK, Boruta DM, et al. Laparoscopic surgical staging of early ovarian cancer. Rev Obstet Gynecol
. 2011; 4: 117–122.
6. Nezhat FR, Ezzati M, Chuang L, et al. Laparoscopic management of early ovarian and fallopian tube cancers: surgical and survival outcome. Am J Obstet Gynecol
. 2009; 200: 83–85.
7. Katz VL, Lentz GM, Lobo RA, et al. Comprehensive Gynecology
.5th ed. Philadelphia, PA: Mosby Elsevier; 2007.
8. Bristow RE, Tomacruz SR, Armstrong DK, et al. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta analysis, J Clin Oncol
. 2002; 20: 1248–1259.
9. Winter WE III, Maxwell GL, Tian C, et al. Gynecologic Oncology Group Study. Prognostic factors for stage III epithelial ovarian cancer: a Gynecologic Oncology Group Study. J Clin Oncol
. 2007; 25: 3621–3627.
10. Winter WE III, Maxwell GL, Tian C, et al. Tumor residual after surgical cytoreduction in prediction of clinical outcome in stage IV epithelial ovarian cancer: a Gynecologic Oncology Group Study. J Clin Oncol
. 2008; 26: 83–89.
11. Du Bois A, Reuss A, Pujade-Lauraine E, et al. Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: a combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials: by the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and the Groupe d’ Investigateurs Nationaux Pour les Etudes des Cancers l’Ovaire (GINECO). Cancer
. 2009; 115: 1234–1244.
12. Fagotti A, Ferrandina G, Fanfani F, et al. A laparoscopy-based score to predict surgical outcome in patients with advanced ovarian carcinoma: a pilot study. Annal Surg Oncol
. 2006; 13: 1156–1161.
13. Rutten MJ, Gaarenstroom KN, Van Gorp T, et al. Laparoscopy to predict the result of primary cytoreductive surgery in advanced ovarian cancer patients (LapOvCa-trial): a multicentre randomized controlled study. BMC Cancer
. 2012; 12: 31.
14. Nezhat FR, DeNoble SM, Liu CS, et al. The safety and efficacy of laparoscopic surgical staging and debulking of apparent advanced stage ovarian, fallopian tube, and primary peritoneal cancers. JSLS
. 2010; 14: 155–168.
15. Magrina JF, Zanagnolo V, Noble BN, et al. Robotic approach for ovarian cancer: perioperative and survival results and comparison with laparoscopy and laparotomy. Gynecol Oncol
. 2011; 121: 100–105.
16. Fanning J, Yacoub E, Hojat R. Laparoscopic-assisted cytoreduction for primary ovarian cancer: success, morbidity and survival. Gynecol Oncol
. 2011; 123: 47–49.
17. Krivak TC, Elkas JC, Rose GS, et al. The utility of hand-assisted laparoscopy in ovarian cancer. Gynecol Oncol
. 2005; 96: 72–76.
18. Vergote I, Tropé CG, Amant F, et al.; (European Organization for Research and Treatment of Cancer-Gynaecological Cancer Group; NCIC Clinical Trials Group). Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer. N Engl J Med
. 2010; 363: 943–953.
19. Abu-Rustum NR, Barakat RR, Siegel PL, et al. Second-look operation for epithelial ovarian cancer: laparoscopy or laparotomy? Obstet Gynecol
. 1996; 88: 549–553.
20. Schorge JO, Wingo SN, Bhore R, et al. Secondary cytoreductive surgery for recurrent platinum-sensitive ovarian cancer. Int J Gynaecol Obstet
. 2010; 108: 123–127.
21. Frederick PJ, McQuinn L, Milam MR, et al. Preoperative factors predicting survival after secondary cytoreduction for recurrent ovarian cancer. Int J Gynecol Cancer
. 2011; 21: 831–836.
22. Amara DP, Nezhat C, Teng N, et al. Operative laparoscopy in the management of ovarian cancer. Surg Laparosc Endosc
. 1996; 6: 38–45.
23. Chi DS, Abu-Rustum NR, Sonoda Y, et al. Laparoscopic and hand-assisted laparoscopic splenectomy for recurrent and persistent ovarian cancer. Gynecol Oncol
. 2006; 101: 224–227.
24. Trinh H, Ott C, Fanning J. Feasibility of laparoscopic debulking with electrosurgical loop excision procedure and argon beam coagulator at recurrence in patients with previous laparotomy debulking. Am J Obstet Gynecol
. 2004; 190: 1394–1397.
25. Nezhat FR, Denoble SM, Cho JE, et al. The safety and efficacy of video laparoscopic surgical debulking of recurrent ovarian, fallopian tube, and primary peritoneal cancers. JSLS
. 2010; 14: 155–168.