Laparoscopy versus laparotomy for the surgical management of apparent early stage ovarian cancer
Introduction
Ovarian cancer accounts for approximately a quarter of all genital tract malignancies but is responsible for half the deaths from gynecological cancer, primarily due to its late presentation. Only 19% of the patients are diagnosed with stage I disease [1] and early diagnosis is frequently incidental during procedure for supposed benign adnexal masses. When the disease is limited to the ovaries, 5-year survival rates are excellent approaching 90%, but it has been demonstrated that nearly 30% of patients with an apparent early ovarian cancer (EOC) actually harbour microscopic metastatic disease [2], [3]. Disease upstaging has not only implications in providing the most accurate prognostic information, but it affects indications for adjuvant therapy and may ultimately result in an improved disease-free and overall survival [4], [5]. Therefore, an optimal surgical staging of women without gross evidence of extra-ovarian disease is of utmost importance, particularly when considering only clinical observation without adjuvant treatment for patients with stage I ovarian cancer.
Traditional approach to ovarian cancer is surgical comprehensive staging including peritoneal washing, total abdominal hysterectomy, bilateral salpingo-oophorectomy, multiple random biopsies of the peritoneal surface, omentectomy, and pelvic and paraaortic lymphadenectomy, performed through a generous longitudinal midline laparotomy. Laparoscopic approach for the surgical staging or restaging of EOC was first reported in the mid 1990s [6]. However, since stage I ovarian cancer is a rare condition, only limited case series addressing the technical feasibility and safety of laparoscopic staging of presumed EOC have been published so far [7], [8], [9], [10], [11], [12], [13], [14]. In the absence of large-scale randomized controlled trials to validate the benefits of laparoscopy over open surgery for the management of EOC, we must rely only on a small non-randomized case-control study [15] and a retrospective multicenter comparative survey [16] in the recent literature.
This study was designed to compare the results of laparoscopic staging of apparent EOC with those obtained with comprehensive surgical staging via laparotomy in terms of feasibility, adequacy and mid-term outcome.
Section snippets
Materials and methods
Laparoscopic approach for the management of early stage ovarian cancer was introduced at the Department of Obstetric and Gynecology of University of Insubria in January 2003. Consecutive women diagnosed with an apparent stage I ovarian cancer on frozen-section analysis at the time of primary surgery at our institution as well as patients who had previous adnexal surgery elsewhere and referred to our Oncologic Unit for restaging, underwent comprehensive surgical staging by laparoscopy (LPS
Results
The study group consisted of 15 women undergoing comprehensive laparoscopic surgical staging or restaging for EOC. The control group included 19 women who underwent surgical staging by traditional abdominal surgery. There was no difference in demographics and preoperative variables between the two groups (Table 1). In the subgroup of patients referred for restaging the mean interval between the initial surgery and the comprehensive staging was 8 days (range: 5–14). Histological types, tumor
Discussion
The findings of our study suggest that laparoscopy is feasible, safe, and adequate for the staging of EOC when compared with the gold standard laparotomic approach. In 1994 Querleu and Leblanc [6] first demonstrated in a series of 8 patients referred for restaging that laparoscopic surgery could be used to adequately stage ovarian malignancy. Since then several investigators from pioneering centers reported small case series of comprehensive laparoscopic surgical staging of EOC, showing
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