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1 The role of laparoscopic surgery in gynaecological oncology
1 The role of laparoscopic surgery in gynaecological oncology J O H N M. M O N A G H A N
The role of laparoscopic surgery in gynaecological oncology has still not been fully defined. It is clear that during the last 3-5 years, as laparoscopic minimal access surgery has developed, we have seen a marked expansion in applications. A number of groups, including Dargent et al (1993), Querleu (1991), Bruhat (1994) and Childers et al (1992), have shown that by utilizing highly skilled techniques laparoscopic minimal access surgery can be very successfully applied within a wide range of gynaecological oncology. Gynaecological oncology is essentially a surgical subject. The primary management of the vast majority of cancer patients remains surgical and it is inevitable that with the development of minimal access surgery attempts should be made to use these skills as much as possible in oncology. The significant advantages of minimal access surgery are obvious and discussed elsewhere. Until recently the main principles of good surgical practice, i.e. wide exposure and good access have been looked upon as contraindications to the use of laparoscopic techniques. However, the rapid development of video camera technology combined with the use of multi-port access have demonstrated the ease of performing complex procedures with minimal traumatic impact upon the patient. The extensive anatomical dissections which were traditionally part of oncology surgery are now seen to be feasible and successful in the hands of surgeons trained in both gynaecological oncology and minimal access surgery. Laparoscopic minimal access surgery can be applied to the following clinical areas. CERVICAL I N T R A E P I T H E L I A L NEOPLASIA Although the vast majority of patients found to have cervical intraepithelial neoplasia (CIN) will be treated using out-patient conservative therapy such as laser vaporization or loop diathermy excision, there will always remain a small percentage (3-5%) who have persistent cytological or colposcoPic abnormalities who will require further definitive therapy. Another small group suffering from incidental gynaecological problems such as fibroids or menorrhagia will also be best treated by hysterectomy. BailliOre's Clinical Obstetrics and Gynaecology-639 Vol. 9, No. 4, December 1995 ISBN 0-7020-2008-7
Copyright © 1995, by Baillirre Tindall All rights of reproduction in any form reserved
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For the patient requiting hysterectomy there is little doubt that the optimal therapy is to use a minimal access technique; either vaginal hysterectomy or laparoscopic assisted vaginal hysterectomy (LAVH). Using the latter technique accurate identification and delineation of these abnormal areas reduces the risk of leaving a residue of pre-cancer behind. This is of particular value for the patient who has a lesion which extends from the cervix onto the fornices of the vagina, which is found in 2.4% of women (Nwabinelli and Monaghan, 1991). The treatment of patients with persistent cytological abnormalities using standard abdominal procedures is marred by a significant risk of leaving behind slivers of the cervix and vagina which harbour areas of CIN and may go on to develop invasive lesions at a later date. A further advantage of LAVH is the freedom given to the surgeon to remove the ovaries in those patients where it is appropriate to do so.
M I C R O I N V A S I V E C A N C E R OF T H E CERVIX Over the years there has been a confusing series of minor changes in the definition of microinvasive cancer of the cervix. The condition is simply part of the spectrum of disease which flows from cervical intraepithelial neoplasia through to late stage invasive cancer of the cervix. The difficulties experienced in defining the entity of 'microinvasive cancer' have revolved around the drawing of lines which will most closely relate to the prognosis o f the disease and also to the various techniques of management. The n e w F I G O classification for microinvasive cancer of the cervix
As of late 1994, FIGO has recommended that the terms microinvasive carcinoma and early stromal invasion be removed and two new stages be used in their place.
Stage IA 1 Stage IAlwhere invasion from the basement membrane extends down to no more than 3 mm into the stroma and the lateral extension extends to no further than 7 mm.
Stage IA2 Stage IA2 where the depth of invasion lies between 3 and 5 mm. Again the lateral extension should be no more than 7 mm. FIGO has requested that pathologists should comment on lymphatic channel involvement, lymphocytic reaction and degree of differentiation of the tumour. These separate comments should be recorded for future assessment and possible modification of the staging criteria.
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Techniques of management For stage IA1 (less than 3 mm of invasion) the risks of lymph node metastases are very close to zero. Thus for these patients it is usually found that if the diagnostic cone biopsy has completely resected the lesion then no further therapy is necessary. However, where the patient has other gynaecological problems which suggest that a hysterectomy is appropriate then a laparoscopic procedure is optimal. Where excision of the stage IA1 lesion is incomplete then further assessment is necessary. This may take the form of colposcopic assessment with loop diathermy biopsy or cone biopsy so that the excision margins can be reviewed. Often these margins have in fact been effectively dealt with by the initial procedure. It is vital, however, to eliminate the risk of a larger invasive cancer lying beyond the initial diagnostic biopsy, the so-called 'tip of the iceberg phenomenon'. Where the lesion has invaded between 3 and 5 mm the risk of lymph node metastases rises to low single figure percentages. Where the lesion has been completely excised the laparoscopic assisted vaginal hysterectomy with assessment of the pelvic lymph nodes will give considerable information and will effectively deal with this early invasive carcinoma of the cervix. In addition the procedure allows accurate delineation of any extension of disease onto the outer cervix or vagina, thus decreasing the risk of persistent abnormal smears. Early invasive cancer spreads by lymphatic channel embolization rather than by permeation, thus leaving tissue between the primary tumour and the primary lymph nodes free of disease. Therefore leaving this tissue in situ does not jeopardize the prognosis. It is suggested that for the patient requiring hysterectomy with stage IA1 cancer an LAVH with or without ovarian removal (depending on the wishes of the patient) is the recommended course of action. For stage IA2 an LAVH with or without removal of the ovaries is appropriate and node sampling or lymphadenectomy is recommended. The question of whether node sampling or attempts at a comprehensive lymphadenectomy should be made remains unresolved. This dilemma was present long before the arrival of minimal access surgery.
A D E N O C A R C I N O M A IN SITU AND EARLY INVASIVE ADENOCARCINOMA OF THE CERVIX These conditions, once thought to be relatively rare, now present with marked frequency in large colposcopy clinics particularly since the return to the widespread use of excisional methods of assessment and management (loop diathermy cone and excision biopsy). The recommended role of minimal access surgery in these conditions is very similar to the applications for microinvasive squamous cancer. The role of conservative therapy has been shown by Cullimore et al (1992) for adenocarcinoma in situ. Most patients will be effectively treated
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by the loop diathermy cone biopsy which has established the diagnosis. The only caveat to this recommendation is the more disparate nature of the condition when compared to the confluent nature of CIN. In spite of these reservations it is now generally recommended that adenocarcinoma in situ be managed as for CIN. Similarly the patient for whom an LAVH would be appropriate would be the same as for CIN, i.e. the patient with other additional reasons for performing a hysterectomy. Early invasive adenocarcinoma of the cervix presents difficult management problems. We do not have a clear definition of a 'microinvasive disease' for this type of cancer. Many clinicians are uncomfortable about the disparate nature of the condition and its tendency to develop deep in the substance of the cervix resulting in large tumours before clinical diagnosis can be made. If a deep diagnostic cone is not performed then there is a significant danger of under diagnosis of the true extent of the disease with a consequent under treatment if an abdominal hysterectomy or LAVH is employed. There is also some uncertainty about the true risk of metastases to the ovaries and thus the question of ovarian conservation is unresolved. Fears of the use of hormone replacement therapy (HRT) following treatment including oophorectomy are unfounded thus assisting the decision to remove ovaries as part of the definitive management. STAGE IB C A N C E R OF THE CERVIX For stage IB disease, because of the higher risk of local spread and lymph node metastases (15-25%), a more comprehensive local radical therapy is necessary together with a full lymphadenectomy. As has been demonstrated in other oncology disciplines, most notably in urology (Schuessler et al, 1991), pelvic lymphadenectomy can be carried out using minimal access techniques. Daniel Dargent has demonstrated the combination of a Schauta radical vaginal hysterectomy together with extraperitoneal dissection of the lymph nodes (see Chapter 4). More recently the radical Schauta hysterectomy with the addition of the transperitoneal resection of the pelvic and para-aortic lymph nodes has been demonstrated (Kadar and Reich, 1993; see Chapter 2). Bruhat (1994) and Querleu (1991) have also shown that the performance of a laparoscopic radical hysterectomy combined with laparoscopic pelvic and para-aortic lymph node dissection can be performed comprehensively and satisfactorily. Nezhat et al (1992) showed the feasibility of laparoscopic radical hysterectomy with pelvic and para-aortic lymphadenectomy. Childers et al (1992) has shown the elegant use of mono-polar diathermy for the removal of all pelvic and para-aortic lymph nodes. It is fascinating to see how reintroducing radical vaginal surgery such as the Schauta and adding modem minimal access surgery in the form of laparoscopic lymphadenectomy has countered many of the old arguments about the limited value of radical vaginal surgery in cancer care. Delgado (1994) has shown that using a combination of the Mitra approach to the pelvic nodes carried deep into the pelvis so as to allow the
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lateral parts of the cardinal ligaments to be stapled, he can then simplify the performance of a Schauta procedure and significantly limit intraperitoneal contamination. MORE ADVANCED CANCER OF THE CERVIX The ability to assess the lymph node status prior to definitive radiotherapeutic treatment is of enormous value. The significant limitations of lymphangiography, ultrasound, computerized tomography (CT) and magnetic resonance imaging (MRI) scanning have demonstrated frequently that although these techniques have a role where there is massive enlargement of the nodes, their accuracy is far from certain when there is smaller volume disease. The use of retroperitoneal and more recently transperitoneal minimal access techniques to assess and remove pelvic and para-aortic lymph nodes will add considerably to the information prior to the planning of radiation therapy. Between 30% and 40% of patients with stage IIIB disease will have involved pelvic and paraaortic lymph nodes. If these involved lymph nodes are not brought within the radiation field the therapy is worthless. At the present time the coordination between radiotherapists and minimal access surgeons still has to be improved and developed. CANCER OF THE UTERINE CORPUS Cancer of the uterine corpus, which in the West is becoming more common than cancer of the cervix, predominantly affects peri-menopausal and postmenopausal women. It is a disease of poor surgical risk patients, affecting the obese, diabetic, hypertensive and the elderly. The advantages of minimal access surgery in this group of higher risk patients are obvious. Although operating times may be extended, post-operative recovery with the reduction in morbidity is markedly enhanced. The majority of cancers of the corpus are well differentiated stage I tumours; for these patients laparoscopic vaginal hysterectomy with the performance of peritoneal washings and assessment of lymph nodes is a perfect technique which should become standard (Phipps and Monaghan, 1993). Unfortunately, the vast majority of cancer of the corpus in the Western world is dealt with by the first gynaecologist who sees the patient and as a consequence the transfer of surgical management from the general gynaecologist with limited interest or skill in the area of minimal access surgery to the gynaecological oncologist with surgical skills in this area has been slow to develop. It is also surprising that after an initial rush of enthusiasm for minimal access surgery there has developed a marked polarization in its use. Skilled and very enthusiastic gynaecologists see more and more applications for minimal access procedures, whereas the majority of gynaecologists, certainly in the UK, have not taken up these new techniques with any great enthusiasm.
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Risks of complications Vault recurrence will occur in a tiny minority of patients with well differentiated cancer of the corpus (< 2%). This figure rises with poorer degrees of differentiation. It has been demonstrated that the removal of a small cuff of vagina will reduce this low, but significant risk of vaginal vault recurrence in cancer of the corpus. This technique can readily be applied in combination with minimal access surgery thus improving the long-term prognosis of these patients.
CANCER OF THE OVARY The role of minimal access surgery in cancer of the ovary at the present time remains controversial. There has been considerable concern expressed about the risk of managing ovarian cysts which although thought to be benign may later demonstrate themselves to be malignant. The risk of spillage, inadequate removal and tumour implantation in port sites has been stressed on a number of occasions. It is difficult to be categoric about the level of risk as only a small number of centres have any significant experience of the management of ovarian cysts using minimal access techniques. The likelihood of inadequate removal of an ovarian invasive lesion arises when the clinician's judgement is flawed or where an apparently benign cystic lesion is found to contain a focus of malignancy. Because of the size of ovarian cysts measures have to be taken to reduce them for removal either via the ports or the vagina. Following conventional management of ovarian carcinoma implantation of tumour will commonly occur in drain tracks and paracentesis tracks, resulting in the development of worrying masses in the abdominal wall. It is therefore considered important that repeated small volume paracentesis and the use of abdominal drains be avoided. It is because of this experience that oncology surgeons have a significant concern about the removal of ovarian structures whether complete or morcellized through the ports. Contamination may be reduced using retrieval bags but their value in oncology has not been demonstrated in large studies. Although there remains no convincing evidence that the spillage of contents of malignant cysts alters survival, aesthetically, spillage is not acceptable and every effort must be made to avoid it.
Assessment of lymph node metastases Lymph node metastases occur with alarming frequency in ovarian cancel: In stage I disease involvement levels of 10-20% have been reported whereas for the most common stages of presentation, stage III, node positivity is noted in 60-80% of patients. Clearly the primary management of such patients with invasive cancer of the ovary will involve a standard laparotomy with removal of all visible turnout where possible. The
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advantage of removing the lymph nodes in terms of survival awaits the results of trials but initial results of treatment protocols outwith a trial have suggested advantages to patients. Unfortunately the vast majority of patients who present with ovarian cancer are operated on by general gynaecologists or surgeons. As a result very few of these patients have lymphadenectomies performed with a clear risk of leaving significant volumes of tumour behind in the lymph nodes. Following chemotherapy it is frequently found that patients still have evidence of tumour presence as shown by persistently elevated tumour markers. In recent times considerable doubts have been expressed about the pivotal role of tumour markers, and thoughts have turned to the possible role of laparoscopic techniques for the further assessment of such patients.
SECOND L O O K PROCEDURES Second look procedures were utilized very extensively in the 1970s for the assessment of progress during prolonged chemotherapy courses but fell into disuse with the advent of platinum drugs in the 1980s. It became generally accepted that 'second look procedures' should only be performed as part of a trial protocol. During this time there was also considerable doubt expressed about the role of interval debulking which was occasionally performed if the persistent disease was resectable.
TUMOUR MARKER ELEVATION
For the patient with persistently elevated or new elevations of tumour markers without any clinical or radiological evidence of disease the clinician is at a disadvantage. 1. Should the patient be re-treated with chemotherapy? 2. Should a laparotomy be performed? 3. Should the clinician await solid evidence of recurrence before taking action? There may be a useful alternative in the form of minimal invasive surgical techniques. The major concern in using laparoscopic techniques is the knowledge that the patient has had major disease with a previous laparotomy. The surgery involved has often been extensive with large abdominal scars and a high risk of adhesion formation. Standard techniques for achieving a pneumoperitoneum and for trochar placement are therefore fraught with danger and are thought by many clinicians to be unacceptably dangerous. The use of open laparoscopic techniques whereby a tiny incision is made in the abdominal wall, usually periumbilically, allows visual access to the abdominal cavity with a massive reduction in risk. A similar technique has been described by Hassan (1971). In recent times the introduction of the
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'Visiport' (Auto Suture, Ascot, UK) has further reduced the risk of inadvertent entry into an intra-abdominal viscus. This simple trochar with a curved shallow cutting blade which can be used under direct vision by the operator allows progressive safe entry into the abdominal cavity for fluid and solid tissue sampling, for release of adhesions and if appropriate the removal of pelvic and para-aortic lymph nodes for both diagnosis and therapy. THE REASSESSMENT OF PATIENTS There may be a role for laparoscopic techniques in a selected subgroup of those patients who are known to have received incomplete surgical resection which has been followed by an apparently successful course of chemotherapy, for example where the uterus or omentum has been left behind or lymph nodes not assessed. A preliminary laparoscopy carried out with the patient's consent for a full laparotomy may reveal the possibility of completing the surgery using minimal access techniques without jeopardizing the completeness of resection. For a patient who has had a stage I cancer of the ovary diagnosed inadvertently as part of a procedure for 'benign' disease, laparoscopic reassessment may provide useful information, such as peritoneal washings status, so that correct staging can be performed. VULVA CANCER The role of laparoscopy in vulva cancer would appear initially to be minuscule. However, for those patients with large tumours a laparoscopic assessment of nodal assessment of the pelvic lymph nodes and possible removal may be of enormous value. At the present time the general recommendation is that where two or more groin nodes are involved or a single node is completely replaced or there is nodal capsular rupture (Palidini et al, 1994) then post-operative adjuvant radiotherapy should be performed to the groins and the external iliac lymph nodes. It is likely however that a large proportion of these patients will in fact have negative pelvic lymph nodes and therefore do not need to be treated in this way. If a laparoscopic assessment could be performed then the opportunity to reduce therapy further would be increased. Because of the rarity of vulva cancer and the difficulty of centralizing treatment it is not feasible to establish a prospective trial for this tiny subgroup of patients, but it is likely that as a treatment method it may be attempted in the near future. GENERAL ASSESSMENT OF THE GYNAECOLOGICAL O N C O L O G Y PATIENTS For the gynaecological oncologists who utilize minimal access techniques it will increasingly be found that the laparoscope may be used for the pre-
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laparotomy or pre-definitive therapy assessment of tumour masses. Recently the author has assessed a tumour lying in the paracolpos in a 13year-old child. The assistance of the laparoscopic assessment prior to definitive therapy was very helpful in planning what eventually became conservative therapy maintaining the uterus, tubes and ovaries and a significant part of the vagina. This patient had a rare tumour of the paracolpos, probably arising in the Wolffian duct remnant.
THE MANAGEMENT OF LYMPHOCYSTS Lymphocysts are an occasional problem for patients who have had radical pelvic surgery. They are most commonly encountered in urological practice but ale also commonly seen following radical gynaecological oncological procedures, particularly radical hysterectomy (Ilancheran and Monaghan, 1988). They most commonly occur when attempts have been made to close the pelvic peritoneum, leaving a retroperitoneal space which can seal off. This fills with lymphatic fluid causing discomfort and pressure symptoms or severe malaise if the lymphocyst becomes infected. Attempts to reduce the risk of development of lymphocysts have been made using drainage of the pelvis in a variety of ways. It was felt until recently that a combination of suction drainage and leaving the pelvic peritoneum open would be the most effective way of reducing the risk of development. In a randomized study in patients where the pelvic peritoneum was left open, either drained or not drained, the clinical identification of lymphocysts was identical and minimal (6%) (Lopes et al, 1995). However, in 15.6-17.4% of patients, lymphocysts were identifed by pelvic ultrasound at 8 weeks post-operatively.
Treatment of lymphocysts The standard therapy for asymptomatic lymphocysts has been conservative with observation using diagnostic ultrasound to confirm non-recurrence. Where the lymphocyst had become infected, antibiotics, with an expectant policy was recommended. For the lymphocyst causing pressure or obstructive symptoms, laparotorny with marsupialization of the cyst was usually carried out. Minimal access surgery has allowed marsupialization without the need for laparotomy. The cysts generally lie close to the pelvic brim and are easily accessed for drainage and deroofing, sometimes omentum can be sewn into the defect to improve drainage (Ancona et al, 1991). It is important to remember that the cyst wall is often extremely thick and strong being up to 1 cm in thickness in extreme cases.
SUMMARY Minimal access surgery is here to stay in gynaecological oncology. Within the last three years, rapid strides have been made in applying minimal
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access surgical techniques to a wide range of gynaecological oncology procedures. The re-assessment of radical vaginal surgery has come largely because of the ease of accessing the pelvic lymph nodes using retroperitoneal and intraperitoneal techniques. An ability to assess the lymph nodes of the pelvis and the para-aortic region prior to definitive therapy is making management of many oncological conditions more logical. Question marks still arise over the place of minimal access surgery in ovarian cancer. A recent study by Professor Gunther Kinderman (Munich) in which, following a postal questionnaire, he identified an unacceptably high rate of laparoscopic interventions in invasive cancer with a parallel unacceptably high rate of metastatic disease, particularly in the port sites, has demonstrated a need for constant vigilance and careful assessment of the application of minimal access surgery in certain areas of oncology. Even while this chapter was in press, Professor Daniel Dargent has shown the possibility of carrying out assessment laparoscopically of the groin lymph nodes using a combination of minimal access surgery and plastic surgical techniques to remove fat. This technique when applied to sentinel node identification may revolutionize our assessment of the groin. Clearly this is an exciting time in gynaecological oncology and many and new inventive applications are being visualized by surgeons throughout the word. When this chapter is rewritten in two years time, inevitably, a considerable part of it will be altered. A glimpse of the future has been seen and we await the full vision with bated breath.
REFERENCES Ancona E, Rogotti P, Zaninotto G e t al (t991) Treatment of lymphocele following renal transplantation by laparoscopic smgery. International Surgery 76: 261-263. Bruhat /VIA (I994) Laparoscopic radical hysterectomy and node dissection (video presentation). London: Royal College of Obstetricians and Gynaecologists. Childers JM, Hatch K & Surwit EA (1992) The role of laparoscopic lymphadenectomy in the management of cervical carcinoma. Gynecologic Oncology 47: 38-43. Cullimore J, Luesley D, Rollason T et al (1992) A prospective study of conization of the cervix in the management of cervical intraepithelial glandular neoplasia--a preliminary report. British Journal of Obstetrics and Gynaecology 99: 314-318. Dargent D, Roy M, Keita N e t al (1993) The Schauta operation--its place in the management of cervical cancer. Gynecologic Oncology 49:109-110 (abstract). Delgado G (1994) Radical vaginal hysterectomy with Mitra extraperitoneal lymph node dissection. Video presentation at the Felix Rutledge Society Meeting April, Bologna, Italy. Hassan HM (1971) A modified instrument and method for laparoscopy. American Journal of Obstetrics and Gynecology 110: 886-889. Ilancheran A & Monaghan J (1988) Pelvic lymphocyst--a 10 year experience. GynecologicOncology 29: 333-336. Kadar N & Reich H (1993) Laparoscopically assisted radical Schauta hysterectomy and bilateral pelvic lymphadenectomy for the treatment of bulky stage Ib carcinoma of the cervix. Gynaecological Endoscopy 2: 135-142. Lopes A de B, Hall JR & Monaghan JM (1995) Drainage following radical hysterectomy and pelvic lymphadenectomy: dogma or need. Obstetricsand Gynecology 86: (in press). Nezhat C, Nezhat F & Welander C (1992) Laparoscopic radical hysterectomy and pelvic and paraaortic lymphadenectomy in the treatment of carcinoma of the cervix. American Journal of Obstetrics and Gynecology 166: 864-865.
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Nwabinelli J & Monaghan J (1991) Vaginal epithelial abnormalities in patients with CIN: Clinical and pathological features and management. British Journal of Obstetrics and Gynaecology 98: 25-29. Paladini D, Cross P, Lopes T & Monaghan J (1994) Prognostic significance of lymph node variables in squamous cell carcinoma of the vulva. Cancer 74: 249t-2496. Phipps J & Monaghan JM (1993) Laparoscopic hysterectomy and cancer. Surgical Oncology 2 (supplement 1): 67-72. Quedeu D (1991) Hysterectomies enlargies de Schauta-Amreich et Schauta-Stoekel assistees par coelioscopie. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 20: 747-748. Schuessler WW, Vancaille TG, Reich H & Griffith DP (1991) Transperitoneal endosnrgical lymphadenectomy in patients with localised prostate cancer. Journal of Urology 145:988-991.
The role of laparoscopic surgery in gynaecological oncology has still not been fully defined. It is clear that during the last 3-5 years, as laparoscopic minimal access surgery has developed, we have seen a marked expansion in applications. A number of groups, including Dargent et al (1993), Querleu (1991), Bruhat (1994) and Childers et al (1992), have shown that by utilizing highly skilled techniques laparoscopic minimal access surgery can be very successfully applied within a wide range of gynaecological oncology. Gynaecological oncology is essentially a surgical subject. The primary management of the vast majority of cancer patients remains surgical and it is inevitable that with the development of minimal access surgery attempts should be made to use these skills as much as possible in oncology. The significant advantages of minimal access surgery are obvious and discussed elsewhere. Until recently the main principles of good surgical practice, i.e. wide exposure and good access have been looked upon as contraindications to the use of laparoscopic techniques. However, the rapid development of video camera technology combined with the use of multi-port access have demonstrated the ease of performing complex procedures with minimal traumatic impact upon the patient. The extensive anatomical dissections which were traditionally part of oncology surgery are now seen to be feasible and successful in the hands of surgeons trained in both gynaecological oncology and minimal access surgery. Laparoscopic minimal access surgery can be applied to the following clinical areas. CERVICAL I N T R A E P I T H E L I A L NEOPLASIA Although the vast majority of patients found to have cervical intraepithelial neoplasia (CIN) will be treated using out-patient conservative therapy such as laser vaporization or loop diathermy excision, there will always remain a small percentage (3-5%) who have persistent cytological or colposcoPic abnormalities who will require further definitive therapy. Another small group suffering from incidental gynaecological problems such as fibroids or menorrhagia will also be best treated by hysterectomy. BailliOre's Clinical Obstetrics and Gynaecology-639 Vol. 9, No. 4, December 1995 ISBN 0-7020-2008-7
Copyright © 1995, by Baillirre Tindall All rights of reproduction in any form reserved
640
J. M O N A G H A N
For the patient requiting hysterectomy there is little doubt that the optimal therapy is to use a minimal access technique; either vaginal hysterectomy or laparoscopic assisted vaginal hysterectomy (LAVH). Using the latter technique accurate identification and delineation of these abnormal areas reduces the risk of leaving a residue of pre-cancer behind. This is of particular value for the patient who has a lesion which extends from the cervix onto the fornices of the vagina, which is found in 2.4% of women (Nwabinelli and Monaghan, 1991). The treatment of patients with persistent cytological abnormalities using standard abdominal procedures is marred by a significant risk of leaving behind slivers of the cervix and vagina which harbour areas of CIN and may go on to develop invasive lesions at a later date. A further advantage of LAVH is the freedom given to the surgeon to remove the ovaries in those patients where it is appropriate to do so.
M I C R O I N V A S I V E C A N C E R OF T H E CERVIX Over the years there has been a confusing series of minor changes in the definition of microinvasive cancer of the cervix. The condition is simply part of the spectrum of disease which flows from cervical intraepithelial neoplasia through to late stage invasive cancer of the cervix. The difficulties experienced in defining the entity of 'microinvasive cancer' have revolved around the drawing of lines which will most closely relate to the prognosis o f the disease and also to the various techniques of management. The n e w F I G O classification for microinvasive cancer of the cervix
As of late 1994, FIGO has recommended that the terms microinvasive carcinoma and early stromal invasion be removed and two new stages be used in their place.
Stage IA 1 Stage IAlwhere invasion from the basement membrane extends down to no more than 3 mm into the stroma and the lateral extension extends to no further than 7 mm.
Stage IA2 Stage IA2 where the depth of invasion lies between 3 and 5 mm. Again the lateral extension should be no more than 7 mm. FIGO has requested that pathologists should comment on lymphatic channel involvement, lymphocytic reaction and degree of differentiation of the tumour. These separate comments should be recorded for future assessment and possible modification of the staging criteria.
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Techniques of management For stage IA1 (less than 3 mm of invasion) the risks of lymph node metastases are very close to zero. Thus for these patients it is usually found that if the diagnostic cone biopsy has completely resected the lesion then no further therapy is necessary. However, where the patient has other gynaecological problems which suggest that a hysterectomy is appropriate then a laparoscopic procedure is optimal. Where excision of the stage IA1 lesion is incomplete then further assessment is necessary. This may take the form of colposcopic assessment with loop diathermy biopsy or cone biopsy so that the excision margins can be reviewed. Often these margins have in fact been effectively dealt with by the initial procedure. It is vital, however, to eliminate the risk of a larger invasive cancer lying beyond the initial diagnostic biopsy, the so-called 'tip of the iceberg phenomenon'. Where the lesion has invaded between 3 and 5 mm the risk of lymph node metastases rises to low single figure percentages. Where the lesion has been completely excised the laparoscopic assisted vaginal hysterectomy with assessment of the pelvic lymph nodes will give considerable information and will effectively deal with this early invasive carcinoma of the cervix. In addition the procedure allows accurate delineation of any extension of disease onto the outer cervix or vagina, thus decreasing the risk of persistent abnormal smears. Early invasive cancer spreads by lymphatic channel embolization rather than by permeation, thus leaving tissue between the primary tumour and the primary lymph nodes free of disease. Therefore leaving this tissue in situ does not jeopardize the prognosis. It is suggested that for the patient requiring hysterectomy with stage IA1 cancer an LAVH with or without ovarian removal (depending on the wishes of the patient) is the recommended course of action. For stage IA2 an LAVH with or without removal of the ovaries is appropriate and node sampling or lymphadenectomy is recommended. The question of whether node sampling or attempts at a comprehensive lymphadenectomy should be made remains unresolved. This dilemma was present long before the arrival of minimal access surgery.
A D E N O C A R C I N O M A IN SITU AND EARLY INVASIVE ADENOCARCINOMA OF THE CERVIX These conditions, once thought to be relatively rare, now present with marked frequency in large colposcopy clinics particularly since the return to the widespread use of excisional methods of assessment and management (loop diathermy cone and excision biopsy). The recommended role of minimal access surgery in these conditions is very similar to the applications for microinvasive squamous cancer. The role of conservative therapy has been shown by Cullimore et al (1992) for adenocarcinoma in situ. Most patients will be effectively treated
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by the loop diathermy cone biopsy which has established the diagnosis. The only caveat to this recommendation is the more disparate nature of the condition when compared to the confluent nature of CIN. In spite of these reservations it is now generally recommended that adenocarcinoma in situ be managed as for CIN. Similarly the patient for whom an LAVH would be appropriate would be the same as for CIN, i.e. the patient with other additional reasons for performing a hysterectomy. Early invasive adenocarcinoma of the cervix presents difficult management problems. We do not have a clear definition of a 'microinvasive disease' for this type of cancer. Many clinicians are uncomfortable about the disparate nature of the condition and its tendency to develop deep in the substance of the cervix resulting in large tumours before clinical diagnosis can be made. If a deep diagnostic cone is not performed then there is a significant danger of under diagnosis of the true extent of the disease with a consequent under treatment if an abdominal hysterectomy or LAVH is employed. There is also some uncertainty about the true risk of metastases to the ovaries and thus the question of ovarian conservation is unresolved. Fears of the use of hormone replacement therapy (HRT) following treatment including oophorectomy are unfounded thus assisting the decision to remove ovaries as part of the definitive management. STAGE IB C A N C E R OF THE CERVIX For stage IB disease, because of the higher risk of local spread and lymph node metastases (15-25%), a more comprehensive local radical therapy is necessary together with a full lymphadenectomy. As has been demonstrated in other oncology disciplines, most notably in urology (Schuessler et al, 1991), pelvic lymphadenectomy can be carried out using minimal access techniques. Daniel Dargent has demonstrated the combination of a Schauta radical vaginal hysterectomy together with extraperitoneal dissection of the lymph nodes (see Chapter 4). More recently the radical Schauta hysterectomy with the addition of the transperitoneal resection of the pelvic and para-aortic lymph nodes has been demonstrated (Kadar and Reich, 1993; see Chapter 2). Bruhat (1994) and Querleu (1991) have also shown that the performance of a laparoscopic radical hysterectomy combined with laparoscopic pelvic and para-aortic lymph node dissection can be performed comprehensively and satisfactorily. Nezhat et al (1992) showed the feasibility of laparoscopic radical hysterectomy with pelvic and para-aortic lymphadenectomy. Childers et al (1992) has shown the elegant use of mono-polar diathermy for the removal of all pelvic and para-aortic lymph nodes. It is fascinating to see how reintroducing radical vaginal surgery such as the Schauta and adding modem minimal access surgery in the form of laparoscopic lymphadenectomy has countered many of the old arguments about the limited value of radical vaginal surgery in cancer care. Delgado (1994) has shown that using a combination of the Mitra approach to the pelvic nodes carried deep into the pelvis so as to allow the
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lateral parts of the cardinal ligaments to be stapled, he can then simplify the performance of a Schauta procedure and significantly limit intraperitoneal contamination. MORE ADVANCED CANCER OF THE CERVIX The ability to assess the lymph node status prior to definitive radiotherapeutic treatment is of enormous value. The significant limitations of lymphangiography, ultrasound, computerized tomography (CT) and magnetic resonance imaging (MRI) scanning have demonstrated frequently that although these techniques have a role where there is massive enlargement of the nodes, their accuracy is far from certain when there is smaller volume disease. The use of retroperitoneal and more recently transperitoneal minimal access techniques to assess and remove pelvic and para-aortic lymph nodes will add considerably to the information prior to the planning of radiation therapy. Between 30% and 40% of patients with stage IIIB disease will have involved pelvic and paraaortic lymph nodes. If these involved lymph nodes are not brought within the radiation field the therapy is worthless. At the present time the coordination between radiotherapists and minimal access surgeons still has to be improved and developed. CANCER OF THE UTERINE CORPUS Cancer of the uterine corpus, which in the West is becoming more common than cancer of the cervix, predominantly affects peri-menopausal and postmenopausal women. It is a disease of poor surgical risk patients, affecting the obese, diabetic, hypertensive and the elderly. The advantages of minimal access surgery in this group of higher risk patients are obvious. Although operating times may be extended, post-operative recovery with the reduction in morbidity is markedly enhanced. The majority of cancers of the corpus are well differentiated stage I tumours; for these patients laparoscopic vaginal hysterectomy with the performance of peritoneal washings and assessment of lymph nodes is a perfect technique which should become standard (Phipps and Monaghan, 1993). Unfortunately, the vast majority of cancer of the corpus in the Western world is dealt with by the first gynaecologist who sees the patient and as a consequence the transfer of surgical management from the general gynaecologist with limited interest or skill in the area of minimal access surgery to the gynaecological oncologist with surgical skills in this area has been slow to develop. It is also surprising that after an initial rush of enthusiasm for minimal access surgery there has developed a marked polarization in its use. Skilled and very enthusiastic gynaecologists see more and more applications for minimal access procedures, whereas the majority of gynaecologists, certainly in the UK, have not taken up these new techniques with any great enthusiasm.
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Risks of complications Vault recurrence will occur in a tiny minority of patients with well differentiated cancer of the corpus (< 2%). This figure rises with poorer degrees of differentiation. It has been demonstrated that the removal of a small cuff of vagina will reduce this low, but significant risk of vaginal vault recurrence in cancer of the corpus. This technique can readily be applied in combination with minimal access surgery thus improving the long-term prognosis of these patients.
CANCER OF THE OVARY The role of minimal access surgery in cancer of the ovary at the present time remains controversial. There has been considerable concern expressed about the risk of managing ovarian cysts which although thought to be benign may later demonstrate themselves to be malignant. The risk of spillage, inadequate removal and tumour implantation in port sites has been stressed on a number of occasions. It is difficult to be categoric about the level of risk as only a small number of centres have any significant experience of the management of ovarian cysts using minimal access techniques. The likelihood of inadequate removal of an ovarian invasive lesion arises when the clinician's judgement is flawed or where an apparently benign cystic lesion is found to contain a focus of malignancy. Because of the size of ovarian cysts measures have to be taken to reduce them for removal either via the ports or the vagina. Following conventional management of ovarian carcinoma implantation of tumour will commonly occur in drain tracks and paracentesis tracks, resulting in the development of worrying masses in the abdominal wall. It is therefore considered important that repeated small volume paracentesis and the use of abdominal drains be avoided. It is because of this experience that oncology surgeons have a significant concern about the removal of ovarian structures whether complete or morcellized through the ports. Contamination may be reduced using retrieval bags but their value in oncology has not been demonstrated in large studies. Although there remains no convincing evidence that the spillage of contents of malignant cysts alters survival, aesthetically, spillage is not acceptable and every effort must be made to avoid it.
Assessment of lymph node metastases Lymph node metastases occur with alarming frequency in ovarian cancel: In stage I disease involvement levels of 10-20% have been reported whereas for the most common stages of presentation, stage III, node positivity is noted in 60-80% of patients. Clearly the primary management of such patients with invasive cancer of the ovary will involve a standard laparotomy with removal of all visible turnout where possible. The
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advantage of removing the lymph nodes in terms of survival awaits the results of trials but initial results of treatment protocols outwith a trial have suggested advantages to patients. Unfortunately the vast majority of patients who present with ovarian cancer are operated on by general gynaecologists or surgeons. As a result very few of these patients have lymphadenectomies performed with a clear risk of leaving significant volumes of tumour behind in the lymph nodes. Following chemotherapy it is frequently found that patients still have evidence of tumour presence as shown by persistently elevated tumour markers. In recent times considerable doubts have been expressed about the pivotal role of tumour markers, and thoughts have turned to the possible role of laparoscopic techniques for the further assessment of such patients.
SECOND L O O K PROCEDURES Second look procedures were utilized very extensively in the 1970s for the assessment of progress during prolonged chemotherapy courses but fell into disuse with the advent of platinum drugs in the 1980s. It became generally accepted that 'second look procedures' should only be performed as part of a trial protocol. During this time there was also considerable doubt expressed about the role of interval debulking which was occasionally performed if the persistent disease was resectable.
TUMOUR MARKER ELEVATION
For the patient with persistently elevated or new elevations of tumour markers without any clinical or radiological evidence of disease the clinician is at a disadvantage. 1. Should the patient be re-treated with chemotherapy? 2. Should a laparotomy be performed? 3. Should the clinician await solid evidence of recurrence before taking action? There may be a useful alternative in the form of minimal invasive surgical techniques. The major concern in using laparoscopic techniques is the knowledge that the patient has had major disease with a previous laparotomy. The surgery involved has often been extensive with large abdominal scars and a high risk of adhesion formation. Standard techniques for achieving a pneumoperitoneum and for trochar placement are therefore fraught with danger and are thought by many clinicians to be unacceptably dangerous. The use of open laparoscopic techniques whereby a tiny incision is made in the abdominal wall, usually periumbilically, allows visual access to the abdominal cavity with a massive reduction in risk. A similar technique has been described by Hassan (1971). In recent times the introduction of the
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'Visiport' (Auto Suture, Ascot, UK) has further reduced the risk of inadvertent entry into an intra-abdominal viscus. This simple trochar with a curved shallow cutting blade which can be used under direct vision by the operator allows progressive safe entry into the abdominal cavity for fluid and solid tissue sampling, for release of adhesions and if appropriate the removal of pelvic and para-aortic lymph nodes for both diagnosis and therapy. THE REASSESSMENT OF PATIENTS There may be a role for laparoscopic techniques in a selected subgroup of those patients who are known to have received incomplete surgical resection which has been followed by an apparently successful course of chemotherapy, for example where the uterus or omentum has been left behind or lymph nodes not assessed. A preliminary laparoscopy carried out with the patient's consent for a full laparotomy may reveal the possibility of completing the surgery using minimal access techniques without jeopardizing the completeness of resection. For a patient who has had a stage I cancer of the ovary diagnosed inadvertently as part of a procedure for 'benign' disease, laparoscopic reassessment may provide useful information, such as peritoneal washings status, so that correct staging can be performed. VULVA CANCER The role of laparoscopy in vulva cancer would appear initially to be minuscule. However, for those patients with large tumours a laparoscopic assessment of nodal assessment of the pelvic lymph nodes and possible removal may be of enormous value. At the present time the general recommendation is that where two or more groin nodes are involved or a single node is completely replaced or there is nodal capsular rupture (Palidini et al, 1994) then post-operative adjuvant radiotherapy should be performed to the groins and the external iliac lymph nodes. It is likely however that a large proportion of these patients will in fact have negative pelvic lymph nodes and therefore do not need to be treated in this way. If a laparoscopic assessment could be performed then the opportunity to reduce therapy further would be increased. Because of the rarity of vulva cancer and the difficulty of centralizing treatment it is not feasible to establish a prospective trial for this tiny subgroup of patients, but it is likely that as a treatment method it may be attempted in the near future. GENERAL ASSESSMENT OF THE GYNAECOLOGICAL O N C O L O G Y PATIENTS For the gynaecological oncologists who utilize minimal access techniques it will increasingly be found that the laparoscope may be used for the pre-
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laparotomy or pre-definitive therapy assessment of tumour masses. Recently the author has assessed a tumour lying in the paracolpos in a 13year-old child. The assistance of the laparoscopic assessment prior to definitive therapy was very helpful in planning what eventually became conservative therapy maintaining the uterus, tubes and ovaries and a significant part of the vagina. This patient had a rare tumour of the paracolpos, probably arising in the Wolffian duct remnant.
THE MANAGEMENT OF LYMPHOCYSTS Lymphocysts are an occasional problem for patients who have had radical pelvic surgery. They are most commonly encountered in urological practice but ale also commonly seen following radical gynaecological oncological procedures, particularly radical hysterectomy (Ilancheran and Monaghan, 1988). They most commonly occur when attempts have been made to close the pelvic peritoneum, leaving a retroperitoneal space which can seal off. This fills with lymphatic fluid causing discomfort and pressure symptoms or severe malaise if the lymphocyst becomes infected. Attempts to reduce the risk of development of lymphocysts have been made using drainage of the pelvis in a variety of ways. It was felt until recently that a combination of suction drainage and leaving the pelvic peritoneum open would be the most effective way of reducing the risk of development. In a randomized study in patients where the pelvic peritoneum was left open, either drained or not drained, the clinical identification of lymphocysts was identical and minimal (6%) (Lopes et al, 1995). However, in 15.6-17.4% of patients, lymphocysts were identifed by pelvic ultrasound at 8 weeks post-operatively.
Treatment of lymphocysts The standard therapy for asymptomatic lymphocysts has been conservative with observation using diagnostic ultrasound to confirm non-recurrence. Where the lymphocyst had become infected, antibiotics, with an expectant policy was recommended. For the lymphocyst causing pressure or obstructive symptoms, laparotorny with marsupialization of the cyst was usually carried out. Minimal access surgery has allowed marsupialization without the need for laparotomy. The cysts generally lie close to the pelvic brim and are easily accessed for drainage and deroofing, sometimes omentum can be sewn into the defect to improve drainage (Ancona et al, 1991). It is important to remember that the cyst wall is often extremely thick and strong being up to 1 cm in thickness in extreme cases.
SUMMARY Minimal access surgery is here to stay in gynaecological oncology. Within the last three years, rapid strides have been made in applying minimal
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access surgical techniques to a wide range of gynaecological oncology procedures. The re-assessment of radical vaginal surgery has come largely because of the ease of accessing the pelvic lymph nodes using retroperitoneal and intraperitoneal techniques. An ability to assess the lymph nodes of the pelvis and the para-aortic region prior to definitive therapy is making management of many oncological conditions more logical. Question marks still arise over the place of minimal access surgery in ovarian cancer. A recent study by Professor Gunther Kinderman (Munich) in which, following a postal questionnaire, he identified an unacceptably high rate of laparoscopic interventions in invasive cancer with a parallel unacceptably high rate of metastatic disease, particularly in the port sites, has demonstrated a need for constant vigilance and careful assessment of the application of minimal access surgery in certain areas of oncology. Even while this chapter was in press, Professor Daniel Dargent has shown the possibility of carrying out assessment laparoscopically of the groin lymph nodes using a combination of minimal access surgery and plastic surgical techniques to remove fat. This technique when applied to sentinel node identification may revolutionize our assessment of the groin. Clearly this is an exciting time in gynaecological oncology and many and new inventive applications are being visualized by surgeons throughout the word. When this chapter is rewritten in two years time, inevitably, a considerable part of it will be altered. A glimpse of the future has been seen and we await the full vision with bated breath.
REFERENCES Ancona E, Rogotti P, Zaninotto G e t al (t991) Treatment of lymphocele following renal transplantation by laparoscopic smgery. International Surgery 76: 261-263. Bruhat /VIA (I994) Laparoscopic radical hysterectomy and node dissection (video presentation). London: Royal College of Obstetricians and Gynaecologists. Childers JM, Hatch K & Surwit EA (1992) The role of laparoscopic lymphadenectomy in the management of cervical carcinoma. Gynecologic Oncology 47: 38-43. Cullimore J, Luesley D, Rollason T et al (1992) A prospective study of conization of the cervix in the management of cervical intraepithelial glandular neoplasia--a preliminary report. British Journal of Obstetrics and Gynaecology 99: 314-318. Dargent D, Roy M, Keita N e t al (1993) The Schauta operation--its place in the management of cervical cancer. Gynecologic Oncology 49:109-110 (abstract). Delgado G (1994) Radical vaginal hysterectomy with Mitra extraperitoneal lymph node dissection. Video presentation at the Felix Rutledge Society Meeting April, Bologna, Italy. Hassan HM (1971) A modified instrument and method for laparoscopy. American Journal of Obstetrics and Gynecology 110: 886-889. Ilancheran A & Monaghan J (1988) Pelvic lymphocyst--a 10 year experience. GynecologicOncology 29: 333-336. Kadar N & Reich H (1993) Laparoscopically assisted radical Schauta hysterectomy and bilateral pelvic lymphadenectomy for the treatment of bulky stage Ib carcinoma of the cervix. Gynaecological Endoscopy 2: 135-142. Lopes A de B, Hall JR & Monaghan JM (1995) Drainage following radical hysterectomy and pelvic lymphadenectomy: dogma or need. Obstetricsand Gynecology 86: (in press). Nezhat C, Nezhat F & Welander C (1992) Laparoscopic radical hysterectomy and pelvic and paraaortic lymphadenectomy in the treatment of carcinoma of the cervix. American Journal of Obstetrics and Gynecology 166: 864-865.
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Nwabinelli J & Monaghan J (1991) Vaginal epithelial abnormalities in patients with CIN: Clinical and pathological features and management. British Journal of Obstetrics and Gynaecology 98: 25-29. Paladini D, Cross P, Lopes T & Monaghan J (1994) Prognostic significance of lymph node variables in squamous cell carcinoma of the vulva. Cancer 74: 249t-2496. Phipps J & Monaghan JM (1993) Laparoscopic hysterectomy and cancer. Surgical Oncology 2 (supplement 1): 67-72. Quedeu D (1991) Hysterectomies enlargies de Schauta-Amreich et Schauta-Stoekel assistees par coelioscopie. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 20: 747-748. Schuessler WW, Vancaille TG, Reich H & Griffith DP (1991) Transperitoneal endosnrgical lymphadenectomy in patients with localised prostate cancer. Journal of Urology 145:988-991.