TheRole of Operative Laparoscopy in Gynecologic Oncologydownloads.hindawi.com/journals/dte/1996/892478.pdflaparoscopy to oncology was the development oftech- niques for...

Diagnostic and Therapeutic Endoscopy, 1996, Vol. 2, pp. 185-I 88Reprints available directly from the publisherPhotocopying permitted by license only

(C) 1996 OPA (Overseas Publishers Association)Amsterdam B. V. Published in The Netherlands

by Harwood Academic Publishers GmbHPrinted in Singapore

The Role of Operative Laparoscopy in Gynecologic Oncology

E. M. HARTENBACH and J. M. FOWLER

Women’s Cancer Center, Department of Obstetrics and Gynecology, University ofMinnesota Hospitaland Clinics, Minneapolis, Minnesota

(Received July 19, 1995; infinalform November 27, 1995)

The potential applications of operative laparoscopy have expanded with improvements in technol-ogy and instrumentation. With newly developed techniques to complete both pelvic and paraaotticlymph node dissection, the use of the laparoscope has increased in patients with pelvic malignancies.Gynecologic oncologists are currently incorporating the techniques of operative laparoscopy in themanagement ofpatients with cervical, endometxial, and ovarian cancer. Multicenter prospective clin-ical trials are necessary to further define the role of laparoscopy in gynecologic oncology.

KEY WORDS: Laparoscopy, gynecologic malignancies, laparoscopic lymphadenectomy, laparoscopicsurgical staging

Historically, the laparoscope has been used for diagnos-tic purposes and for sterilization procedures. Due to tech-nologic advances, operative laparoscopy now plays a rolein the management of a wide variety of benign gyneco-logical conditions including ectopic pregnancy, en-dometriosis, pelvic pain, leiomyomata, and adnexalmasses. Similarly, the role of operative laparoscopy inthe management of malignant disease has expanded.With newly developed techniques to complete bothpelvic and paraaortic lymph node dissection, the use ofthe laparoscope has increased in patients with pelvic ma-lignancies. Gynecologic oncologists are currently incor-porating the techniques of operative laparoscopy in themanagement of patients with cervical, endometrial, andovarian cancer.The main role for operative laparoscopy in women with

gynecologic neoplasms is in surgical staging. The tech-nique of laparoscopic pelvic lymph node dissection wasfirst described in women with cervical carcinoma byQuerleu et al. in 1991 (1). Subsequently, other investiga-tors have reported on the safety and efficacy of this pro-cedure in patients with cancers of the cervix,endometrium, and ovary (2-4). Critical to the addition of

Address for correspondence: Jeffrey M. Fowler, M.D., Division ofGynecologic Oncology, Box 395, Mayo Memorial Building, 420Delaware Street Southeast, Minneapolis, MN 55455. Tel: 612-626-4338; 612-626-0665.

185

laparoscopy to oncology was the development of tech-niques forparaaortic lymphadenectomy. For surgical stag-ing to be complete, access to bilateral paraaortic nodaltissue is imperative (Fig. 1). Nezhat et al. (5) first pub-lished acase report ofa laparoscopic radical hysterectomythat included a low fight paraaortic nodal dissection in1992. Others had previously begun to develop strategiesfor laparoscopic paraaortic lymph node sampling in ani-mal models (6). Currently, there are a number of seriesthat confirm the feasibility ofremoving bilateral paraaor-tic lymph nodes laparoscopically (2,4,7).The most significant experience to date with laparo-

scopic lymphadenectomy is in women with cervical car-cinoma. Cervical carcinoma remains a clinically stageddisease as recommended by the International Federationof Gynecology and Obstetrics (FIGO). However, clinicalstaging is inadequate in estimating tumor spread. The dis-crepancy between clinical and surgical staging rangesfrom 20 to 48% depending on the clinical stage (8). Theprimary benefit of surgical staging is the ability to iden-tify patients who may benefit from extended field irradi-ation. Although the value of surgical staging remainscontroversial, management decisions based on the infor-mation result in an improvement in survival in 2.5 to 7%of women whose cancer is surgically staged (8,9). Otheradvantages of surgical staging include the removal ofbulky lymph nodes, removal of diseased adnexae, andovarian transposition.

186 E.M. HARTENBACH AND J. M. FOWLER

Figure I Left-sided paraaortic lymph node dissection accomplished via laparoscopy.

Laparoscopic lymphadenectomy in cervical cancer pa-tients is utilized in two clinical settings (10). In patientswith early stage disease (FIGO IA-IIA) that is suitable forradical hysterectomy, lymph node sampling is carried outbefore radical hysterectomy. Lymph nodes are assessed byfrozen section and radical hysterectomy is performed ifthey are negative for malignancy. In patients with FIGOIB-IIA disease as many as 5 to 10% will have positivecommon iliac and paraaortic lymph nodes (11). Therefore,laparoscopic sampling can save these patients from un-dergoing a laparotomy. If the lymph nodes are positive,the surgical staging is completed laparoscopically, and thepatient is then treated with radiation therapy. In contrast,patients with advanced disease (FIGO lIB-IV) are surgi-cally staged with laparoscopic pelvic and paraaortic lym-phadenectomy. Removal of bulky, grossly positive lymphnodes can be carried out in the majority of these patients.L.vmth node yield is adequate and compares with that ofstaging laparotomies (3,10). Radiation can then be tailoredto disease extent. There is some concern that transperi-toneal laparoscopic lymphadenectomy techniques may in-crease radiation-related enteric morbidity. However,animal studies indicate that transperitoneal laparoscopic

procedures may not produce any more surgical adhesionsthan extraperitoneal procedures (12). In addition, to theuse of the laparoscope for surgical staging, there are casereports of laparoscopic radical hysterectomy and laparo-scopically assisted radical vaginal hysterectomy(5,13,14). It remains to be seen whether these procedureswill be incorporated into current clinical practice.

Operative laparoscopy is also useful in the managementof patients with malignancies of the uterine corpus. In1988, endometrial cancer became a surgically staged ma-lignancy according to FIGO. The importance ofpelvic andparaaortic lymph node status documented by a largeGynecologic Oncology Group (GOG) study was instru-mental in motivating the change to surgical staging (15).In 1992, Childers and Surwit (16) reported the use of acombined laparoscopic and vaginal approach in the man-agement of two cases of stage adenocarcinoma ofthe en-dometrium. The lymph node dissection, mobilization ofthe adnexae, and procurement ofperitoneal cytology wereperformed laparoscopically and then the uterus, tubes, andovaries were removed vaginally. The subsequent larger se-ries published by Childers et al. (2) documented that theapproach is feasible and has an acceptable complication

LAPAROSCOPY IN FEMALE CANCERS 187

rate. The main advantage is a shortened hospital stay andrecovery time. A recent abstract presented data on a com-parison between laparoscopic managementand traditionalmanagement in patients with endometrial cancer (17).Patients managed with a laparoscopic approach had thesame number of lymph nodes removed, but had less com-plications, a shorter hospital stay, and quicker recoverythan the laparotomy group.

In addition to surgical staging in the primary manage-ment ofendometrial carcinoma patients, the technique canbe utilized in patients with incomplete staging of diseaseat their primary surgery. Childers et al. (18) reported on13 ofthese patients with presumed stage I disease referredafter hysterectomy. Laparoscopic lymphadenectomy wascompleted in all patients and residual disease was notedin three. Laparoscopic restaging is an alternative for pa-tients referred after incomplete staging ofa variety ofma-lignancies including uterine sarcomas, epithelial ovariancarcinomas, sex cord stromal ovarian tumors, and germcell tumors of the ovary.The use of laparoscopy or peritoneoscopy in the man-

agement of epithelial ovarian cancer was first describedin 1973 by Bagley et al. (19). The laparoscope was usedto evaluate patients before and after a chemotherapy pro-tocol. This initial report highlighted the ability of the la-paroscope to visualize subdiaphragmatic metastasis likelyto be undetected by conventional laparotomy. Subsequentstudies confirmed that laparoscopy can be used for dis-ease assessment or "second-look" surgery (20,21).However, in 1981, Ozols et al. (21) reported that in pa-tients with a negative second look laparoscopy, immedi-ate laparotomy revealed residual disease in 55%. Manygynecologic oncologists concluded that a laparotomy wasrequired in all cases to confirm the absence of disease.These results were reported before modern advances in la-paroscopic surgery, and many laparoscopic surgeons nowbelieve that second-look procedures can be carded outwith the same false-negative rate as laparotomy. Currenttechniques of adhesiolysis and lymphadenectomy con-tribute to disease reassessment surgery in these patients.Childers et al. (22) recently reported on 44 laparoscopicsecond-look procedures with complication rates similar tosurgery via laparotomy. Similarly, the accuracy in detect-ing disease (56%)compared favorably with laparotomy.As mentioned above, another group of patients with

ovarian malignancies that have benefited from laparo-scopic advances are those patients referred after incom-plete staging. Patients who have undergone a totalabdominal hysterectomy and bilateral salpingo-oophorec-tomy without lymphadenectomy can have a laparoscopicpelvic and paraaortic lymphadenectomy performed. Thisis particularly important for early-stage disease, for which

as many as 22% ofstage I malignancies are upstagedbasedon lymph node involvement.Quedeu et al. (23) performed laparoscopic restaging on

nine patients with apparent early-stage carcinoma of theovary or fallopian tube, but with incomplete staging dur-ing a previous surgical procedure. The authors were ableto complete staging in all nine patients including in-frarenal, paraaortic lymphnode dissections. They reportedno major complications related to the procedure.Alternatively, patients can be treated with chemotherapy,and then a second-look laparoscopy procedure with lym-phadenectomy can be performed for reassessmentand sur-gical staging.

It is clear that laparoscopic approaches to the manage-ment of gynecologic malignancies are feasible and pro-vide exciting alternatives. However, the safety andefficacyof operative laparoscopy compared to laparotomy in thissetting has not been carefully studied. Potential advan-tages include shorter operative time for some procedures,shorterrecovery times, and less adhesion formation. Thesenew surgical techniques need to be evaluated critically andcompared to more traditional approaches. Currently, theGOG, a multicentercooperative group, is conducting stud-ies to evaluate the use ofoperative laparoscopy in the man-agement of cervical, endometrial, and ovarian cancerpatients. Multicenter prospective clinical trials like theseare necessary to further define the role of laparoscopy ingynecologic oncology.

REFERENCES

I. Querleu D, LeBlanc E, Castelain B. Laparoscopic pelvic lym-phadenectomy in the staging of early carcinoma of the cervix. AmJ Obstet Gynecol 1994; 164:579.

2. Childers JM, Brzechffa PR, Hatch KD, et al. Laparoscopically-as-sisted surgical staging (LASS) of endometrial cancer. GynecolOncol 1993;51:33.

3. Fowler JM, Carter JR, Carlson JW, et al. Lymph node yield fromlaparoscopic lymphadenectomy in cervical cancer: a comparativestudy. Gynecol Oncol 1993;51:187.

4. Childers JM, Hatch KD, Tran A, et al. Laparoscopic paraaortic lym-phadenectomy in gynecological malignancies. Obstet Gynecol1993;82:741.

5. Nezhat CR, Burrell MO, Nezhat FR, et al. Laparoscopic radical hys-terectomy with paraaortic and pelvic node dissection. Am J ObstetGynecol 1992; 166:864.

6. Herd J, FowlerJM, Shenson D, et al. Laparoscopic paraaortic lymphnode sampling: development of a technique. Gynecol Oncol1992;44:271.

7. Querleu D. Laparoscopic paraaortic node sampling in gynecologyoncology: a preliminary experience. Gynecol Oncol 1993;49:24.

8. LaPolla JP, Schlaerth JB, Gaddis O, et al. Influence ofsurgical stag-ing on the evaluation and treatment of patients with cervical carci-noma. Gynecol Oncol 1986;24:194.

9. Potish RA, Twiggs LB, Okagaki T, et al. Therapeutic implicationsof the natural history of advanced cervical cancer as defined by pre-treatment surgical staging.

188 E.M. HARTENBACH AND J. M. FOWLER

10. Hallum A, Childers J. Laparoscopy in the treatment of early cervi-cal carcinoma diagnostic and therapeutic endoscopy. Diagn TherEndosc 1994; 1:19.

11. Morrow CP. Synopsis of gynecological oncology. In: Morrow CP,Curtin JP, Townsend DE, eds. New York: Churchill Livingstone,1993:111.

12. Fowler JM, Hartenbach EM, Reynolds HT, et al. Pelvic adhesionformation after pelvic lymphadenectomy: comparison betweentransperitoneal laparoscopy and extraperitoneal laparotomy in aporcine model. Gynecol Oncol 1994;55:25.

13. Querleu D. Laparoscopically-assisted radical vaginal hysterectomy.Gynecol Oncol 1993;51:248.

14. Dargent D, Roy M, Kelka N, et al. The Schauta operation: its placein the management of cervical cancer in 1993. Abstract presentedat the 24th Annual Meeting of The Society of GynecologicOncologists, 1993.

15. Creasman WT, Morrow CP, Bundy BN, et al. Surgico pathologicalspread pattern of endometrial carcinoma: a gynecological oncologygroup study. Cancer 1987;60:2035.

16. Childers JM, Surwit EA. Combined laparoscopic and vaginal

surgery for the management oftwo cases ofstage endometrial can-cer. Gynecol Oncol 1992;45:46.

17. Boike G, Lurain J, Burke J. A comparison of laparoscopic man-agementofendometrial cancerwith traditional laparotomy. GynecolOncol 1994;52:105.

18. Childers JM, Spiritos NM, Brainard P, et al. Laparoscopic stagingofthe patient with incompletely staged early adenocarcinoma oftheendometrium. Obstet Gynecol 1994;83:597.

19. Bagley CM, Young RC, Schein PS, et al. Ovarian carcinomametastatic to the diaphragmmfrequently undiagnosed at la-paroscopy. Am J Obstet Gynecol 1973;110:397.

20. Berek JS, Griffiths CT, Leventhal JM. Laparoscopy for second-lookevaluation in ovarian cancer. Obstet Gynecol 1981 ;58:192.

21. Ozol RF, Fisher RI, Anderson T, et al. Peritoneoscopy in the man-agement of ovarian cancer. Am J Obstet Gynecol 1981; 140:611.

22. Childers JM, Lang J, Surwit EA, Hatch KD. Laparoscopic surgicalstaging of ovarian cancer. Gynecol Oncol, in press.

23. Querleu D, LeBlanc E. Laparoscopic Infrarenal paraaortic lymphnode dissection for restaging of carcinoma of the ovary or fallopiantube. Cancer 1994;73:1467.

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