she wants laparoscopy. yes or no?
Maria is a 57-year-old mother of 4 who presents to a gynecologic oncologist with pelvic pain and ultrasonographic evidence of a 7-cm complex mass at the right adnexa. She has an enlarged fibroid uterus (12-week size), a preoperative CA125 level of 21 U/mL, and she says she wants laparoscopic management.
Is minimally invasive surgery an acceptable choice?
This large, complex mass is possibly malignant. Until now, laparoscopy has played only a small role in the management of ovarian cancer, although it has greatly changed treatment of other gynecologic malignancies. Since women with ovarian cancer tend to be older and have coexisting diseases, laparoscopy could confer many benefits, provided surgical staging is comprehensive, and timely diagnosis and patient outcomes are not compromised.1
The utility of laparoscopy in ovarian borderline tumors and cancer is increasing. This article surveys current applications and concerns, including
- when to refer,
- predicting malignancy,
- effects of carbon dioxide (CO2) peritoneum,
- risk of port-site recurrences,
- hand-assisted laparoscopy,
- comprehensive staging, and
- assessing resectability.
Conventional staging by laparotomy with a vertical incision from above the umbilicus to the symphysis pubis is still the gold standard; however, laparoscopy can be used in the management of selected cases of ovarian cancer:
- to manage and stage apparent early-stage ovarian cancer,
- to determine the extent of advanced disease and potential resectability,
- to resect disease via hand-assisted laparoscopy in selected women with advanced disease, and
- to obtain a “second look,” or reassess the patient for disease recurrence and placement of intraperitoneal catheters.
Benefits of laparoscopy for benign masses
The benefits of laparoscopy over laparotomy in the management of benign adnexal masses are well defined:2
- less postoperative morbidity,
- less postoperative pain,
- less analgesia required,
- shorter hospitalizations, and
- shorter recovery time.
When to refer. Referral of at-risk patients to a gynecologic oncologist should be based on personal and family history, physical, imaging, and tumor markers.
When to get a consult: ASAP. General gynecologists may encounter malignancy unexpectedly. When they do, it is of paramount importance to obtain gynecologic oncology consultation intraoperatively, if possible, or as soon as possible postoperatively.
How common is cancer in laparoscopically managed masses?
Consider a complex ovarian mass potentially malignant until proven otherwise. Why? Because it remains difficult to rule out malignancy preoperatively, even with strict patient selection.
For example, a study involving 292 laparoscopically managed women found a 3.8% malignancy rate.3 These women had undergone preoperative vaginal ultrasound, CA125 measurement, and pelvic examination, but malignancy was not detected until surgery.
The incidence of malignancy at laparoscopy for a pelvic mass varies widely due to different guidelines for patient selection. In 1 series of 757 patients,4 the rate of unanticipated malignancy was 2.5%. This included 7 invasive cancers and 12 borderline tumors. Preoperative evaluation entailed routine clinical and ultrasound examinations. At laparoscopy, peritoneal cytology was obtained, the ovaries and peritoneum were inspected, and any cysts were punctured so their contents could be examined. If a malignant mass was encountered or suspected, the woman in question was treated by immediate laparotomy using a vertical midline incision.4
History of nongynecologic cancer heightens risk of malignancy
For example, of 31 women with stage IV breast cancer and a new adnexal mass, 3 (10%) were found to have primary ovarian cancer, and 21 (68%) had metastatic breast cancer.5
In a study at our institution,6 51 of 264 patients (19%) with a history of nongynecologic cancer and a new adnexal mass were found to have a malignancy. Of these women, 22 (43%) had primary ovarian cancer; the rest had metastatic disease. Most patients had laparoscopy even when malignancy was encountered.
Utility of frozen section
Frozen-section analysis speeds diagnosis of the adnexal mass, allowing the necessary surgery to be performed immediately.The overall accuracy of frozen-section analysis is high, reported at 92.7% in 1 study.7 It is less accurate in borderline tumors because of the extensive sampling required.