Role in Evaluation of Gynecological Malignancy

Courtesy of FIGO

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Professor Denis Querleu:  "I will talk about the role of laparoscopy in the staging of gynecologic cancers, and this role needs evaluation because a poor laparoscopic surgeon or an unskilled gynecologic surgeon could do a very inadequate job, which is not acceptable in this field. You can contaminate the abdominal wall and peritoneal, another drawback could be the overuse of the technique - just because the technique exists you use it, but the patients don't get any benefit from that. Staging surgery can also induce complications, especially unintended laparotomy, which is in contradiction with the goal of laparoscopic surgery, and finally, laparoscopic surgery can add costs to the treatment. We have to evaluate the role of laparoscopy in gynecologic cancer, some experimental data, and also some clinical data. 

The first issue is a question of contamination and increasing tumor deposits or tumor growths because of CO2 laparoscopy. There has been a lot of research work in the literature and the results in this field are conflicting and totally different but no data is available about the survival of animals, only the question of grafts has been addressed. We have carried out an experimental study in my group randomizing mice between the control group, the laparotomy group, the CO2 laparoscopy group, and the helium laparoscopy group. We assessed just like other investigators; we assessed peritoneal dissemination, which is not different between the four groups. We assessed the scar implants, which are less after CO2 laparoscopy than after laparotomy, and we also assessed hepatic metastasis and subcutaneous implants with no difference between the techniques. In addition, we gave chemotherapy to help all the animals but have no very significant difference but in hepatic metastases. The most important information of this research work is that there is absolutely no difference between the groups of animals whether you have a control mouse who underwent a laparotomy, a CO2 laparoscopy, or helium laparoscopy. So to my mind the question of abdominal implants is important but it's not relevant to the survival of animals and we can extrapolate that to patients if it's possible. 

We have another group of work concerning comparisons of pelvic and aortic dissection between laparoscopy and laparotomy, and this work had been published three years ago. We compared transperitoneal laparoscopy to laparotomy in pigs, and you can see from this picture that the nodule is the same between the techniques and that laparoscopy takes more time. It takes twice the time of dissection by laparotomy but the adhesion score after laparoscopy is significantly less than after laparotomy which is evidence that laparoscopy is efficient and creates less surgical trauma for the patient. We have also compared the now classical transperitoneal laparoscopy with the new technique, which is the extraperitoneal laparoscopy for aortic dissection. This paper will be published this year, and I was actually impressed. We have compared this new technique to the old technique in pigs, and you can also see that the nodule is the same whether you have performed an extra- or transperitoneal laparoscopy and that the duration of the operation is the same but that the extraperitoneal laparoscopy induces even less adhesions than the transperitoneal laparoscopy. Even more interesting in patients who will have radiation therapy is that the adhesions in the irradiation field for extended field radiation therapy, the adhesion score is much less in the extraperitoneal group. You can see that adhesions in the irradiated field are significantly less in this group, and we feel that it is a very important experimental data. 

The techniques have evolved with time, and we started no more than ten years ago with pelvic lymphadenectomies and with aortic lymphadenectomies, and starting only two years ago with the extraperitoneal aortic dissection, and I will talk about this experience. We have updated our data in 1998 just because it was a ten-year experience, and you can see that we performed in gynecologic cancers more than 300 lymph node dissections, a lot of pelvic node dissections which we call interiliac dissection, and almost 100 aortic dissections and, of course, we have done more since. The reasons concerning the complication rate and the efficiency of this technique are known - for pelvic dissection no laparotomy was performed for complications, we only had 6 symptomatic lymphoceles, and in no negative patients, 5 lateral pelvic recurrences which means that we had no more lateral pelvic recurrences which means a missed diseased node, not more than after laparotomy. As far as aortic dissection is concerned, more recent results concerned 150 patients. You see that we have performed only 1 laparotomy for complications and 1 injury to the inferior mesenteric artery that we managed laparoscopically, and observed only 1 recurrence in the aortic area and this recurrence was in the inferior area which means that in front of the aortic dissection is not enough in gynecology cancers. The number of nodes in the interiliac area has increased with experience, and you see that since 1996 we removed approximately 19-20 nodes from both sides on the pelvis, which is exactly the same number of nodes that was retrieved by experienced laparotomy surgeons from Austria and Italy who published their results in the early 1990s. 

The role of laparoscopic surgery in staging is different between the three main tumor localizations - endometrial cancer, cervical cancer, and ovarian cancer, and I will address these three topics. Starting with endometrial cancer, I won't talk about surgery, you have used laparoscopic staging and a general vaginal hysterectomy in a number of patients but I would like only to make the point of staging. As we have used laparoscopic lymphadenectomy and vaginal hysterectomy in endometrial cancer, we have been able to compare this group of 100 patients that I mentioned here with a group of 114 having had laparotomy for the same diagnosis by surgeons in my institution because not all surgeons in my teaching did laparoscopy at the beginning. You can see that the survival curve of the two groups of patients are exactly the same which means that staging with laparoscopy is not detrimental to the patient as far as endometrial cancer is concerned. In carcinoma of the cervix, there are two main groups of patients in which we used laparoscopic surgery - early cervical cancer and advanced cervical cancer. The rationale of lymphadenectomy in early cervical cancer is that it spares an external extended node dissection when the sentinel area - we now use the sentinel nodes and it will be addressed later - but when the nodes are negative in what we call the sentinel area, it's not necessary to use high node dissection in no node-negative patients. In the same patients we used vaginal surgery which means that we spare laparotomy to these patients, on the other hand, when the patients are not node-positive, we do not operate on this patient and we send them for radiation therapy only which means that we spare them surgery. 

In this context of cervical cancer, we have demonstrated that laparoscopic staging is quite efficient. You see here that the positivity rate at laparoscopy is exactly in the range of what is observed in the literature with laparotomy. You see in these slides that the survival of the patients are managed with laparoscopic lymphadenectomy and are exactly the same done after laparotomy. This is a case control study using two groups - a group of laparoscopy patients was a group that we published ten years ago and that we have reassessed after almost ten years now of follow-up and we compared these cases with a control group of matched patients with laparotomy, and you again see that the survival is the same. As far as node positive patients are concerned, it's extremely important to compare the complication rate of radiation therapy. You know that the combination of surgery - staging surgery or surgical management with radiotherapy, induces a lot of complications and, again, we have carried out a case control study between 26 patients managed with laparoscopy followed by radiation therapy comparing these patients to open pelvic lymphadenectomy. You can see in this study that the survival of patients is the same but the radiation therapy complications are significantly less in the laparoscopy group which is the goal of laparoscopy. In advanced cervical cancer, we use aortic staging; it is another group of patients and the goal is to avoid surgery in patients with high positive nodes. On the other hand, to avoid extended field irradiation is now a in node-negative patient and in a selected group of patients to avoid an aborted exenteration if there is a contraindication. 

In this field of advanced cervical cancer, we use a new technique of extraperitoneal dissection, which we have found to be better in an experimental setting, and you see on this picture how we use the three ports for extraperitoneal dissection. One is for the endoscope, the second for the ancillary instrument, and using this technique we can assess the aortic nodes. In the series that we published together this year, we have found only a 5% failure rate of this technique, a duration of two hours, and a nodule of 20 nodes on average which is absolutely satisfactory for staging procedure. We found that the positivity rate for this technique is, again, consistent with the known data in the literature concerning node involvement in cervical cancer with a yield of 32% of positive nodes with this technique. The prognostic information given by the aortic dissection was extremely important for the patient knowing that in the node positive most of the patients died very early with distal metastases, and in the node negative group, only a few patients died with distal metastases and, of course, much less died and the two differences are significant. So we now do use aortic staging with the extraperitoneal endoscopic technique to decide whether the patient needs pelvic radiation therapy only or extended field radiation therapy concurrent with chemotherapy. In ovarian cancer, we do use laparoscopy in early staging and in advanced staging as well, of course, with firm indication. For early ovarian cancer, we use laparoscopy only in apparent stage 1A that are referred to us after a first laparotomy or laparoscopy with unsatisfactory staging of therapy. It's a concept of re-staging of inadequately managed patients. We did this operation in 44 cases with more than a two-year follow-up for all patients. You see as a result of this study the operative time including therapy was four hours. We did perform peritoneal and node dissection staging and perioperative data is shown on this slide with upstaging of a significant number of patients - 4 with positive nodes, 6 with positive peritoneum, and we gave chemotherapy to all of these patients. Only one post-operative complication occurred which was an abscess of the pouch of Douglas after an appendectomy, not a complication of staging by itself. The patient stayed only two days in the hospital and hemorrhaged on average. We could spare 34 patients with true stage1A chemotherapy, and we followed-up these 34 patients and found only 2 intraperitoneal recurrences in this group of patients - one after four years, another one after two and half years so we feel that laparoscopic re-staging of ovarian cancer is a cure rate accurate. We also use laparoscopy in advanced stage patients. 

I will finish quickly because we have a third speaker. We have used decision laparoscopy in advanced stages of ovarian cancer to decide whether the patient was operable or not, and patients that were not operable have adjuvant chemotherapy. You see in this series with more than two-years of follow-up we deferred surgery in approximately one-third of the patients and performed secondarily in 9 of 11 patients a complete optimal surgery, and 2 patients evaluated under chemotherapy. We performed surgery the same day in 20 patients and found that operability was adequately appreciated in 18 patients, 2 patients had palliative surgery, and you see that 14 patients are optimal or complete surgery which means that in this series more than 90% of cases were correctly predicted as operable and 90% of patients had complete or optimal resection immediately or after three cycles of chemotherapy, and a significant number of patients had optimal or complete resection without maximal surgical effort, especially without a total resection. In this group, a survival of 30% was noted after two years. I have only a small short comment about port site recurrences in this series. The incidence is 1%, that's the message, and I will shorten the message - all the cases were umbilical in this series and all three cases were associated with extensive peritonal metastases. Lastly concerning training, I've done the work on the evaluation of training and this is a learning curve of a fellow with laparoscopic aortic dissection. You see that the percent percentage of remaining nodes checked by laparotomy decreases with experience and that you need 50 cases of experience to be a reliable laparoscopic surgeon. To do that, you have to train on pigs, you have to see live surgery demonstration, and I fortunately can take the opportunity to advertise the course that we have now carried out with Daniel Dargent for seven years and we'll be in our eighth year this year. 

Thank you very much."