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Laparoscopic omentectomy in the staging of ovarian low malignant potential neoplasms
August 2003, Vol. 10, No. 3 Supplement
The Journal of the American Association of Gynecologic Laparoscopists
Results. The blue dye technique alone identified at least one SN in 61 (87%) of patients. The rate of SN detection by side of dissection was 70% on the left side and 77% on the right side. Bilateral SN were identified in 60% of cases. In the subgroup of patients who had the combined technique (n=29), the SN detection rate increased to 93% and the bilateral SN detection rate reached 72%. In the last 15 cases of the series, the SN detection rate reached 97%. A total of 135 SN were identified, with the majority (88%) being located at 3 main sites: external iliac, obturator and bifurcation. Thirty-six patients (51%) had 2 SN identified, and 16 (24%) had 3 SN or more. Twelve (17%) patients had positive lymph nodes. The false-negative rate was zero. The negative predictive value of the SN mapping was 100 % and the sensitivity was 93 % with the combined technique. Two patients had allergic reaction to the blue dye (3%). Corzclusiorz. The SN mapping with the combined blue dye technique and lymphoscintigraphy in patients with cervical cancer is laparoscopically feasible and highly accurate. The SN detection rate improves significantly with experience and with the use of lymphoscintigraphy.
26. Hysteroscopic Injection of Tracers in the Detection of Sentinel Node in Endometrial Cancer, Preliminary Study E Solima. National Cancer Institute, Milan, Italy.
Objectives. To evaluate the feasibility of hysteroscopic injection of blue dye and technetium 99m (Tc) in the detection of sentinel node (SN) in endometrial cancer patients by lymphoscintigraphy and radio-guided surgery. Settirzg. Tertiary level oncologic research hospital. Patierzts. A consecutive series of 18 patients with endometrial cancer were submitted to hysteroscopic injection of 111 MBq of Tc and 8 ml of patent blue dye. Subsequently lymphoscintigraphic scans were taken. After hysterectomy and frozen section assessment of surgical specimen, a handheld gamma-ray detector probe was used to locate and remove the sentinel lymph node. Nodal blue dye uptake was visualized. Systematic pelvic lymphadenectomy was further carried out when appropriate. Results. In all the cases at least one sentinel node was detected using radio-guided surgery. In only 5 cases at least one node with blue dye uptake was recognized only after being dissected and isolated. In all the cases more than one site was positive to Tc and in 9 cases SN were detected bilaterally in the pelvis. In 5 cases one SN was detected in the para-aortic area. In 3 cases the SN was positive to the tumor. CorzHusiorz. The hysteroscopic injection of Tc99 labeled human albumin colloid particles in the detection of sentinel node(s) in endometrial cancer is a feasible technique. The neoplastic lymphatic spread has been shown to be extremely variable. The development of this method for SN detection should be further evaluated whether is an alternative to systematic lymph node dissection which carries a significant morbidity.
27. Long Term Follow-up after Laparoscopic Management of Low Malignant Potential Ovarian Tumors M Canis. Centre Hospitalier Universitaire, Clermont Ferrand, France.
Objective. To study the long term survival rate after laparoscopic management of low malignant potential ovarian tumors. Desigrz. Retrospective study. Patierzts. Between December 1991 and January 2002, 47 low malignant potential tumors were managed in our department. In 28 cases the initial surgical procedure was performed after the diagnosis, and 7 patients were managed by laparotomy. Results. The 5 and 10 year survival rates were 93%. One patient died 30 months after the laparoscopic procedure. She was diagnosed with a peritoneal carcinomatosis with invasive peritoneal implants, 1 year after the management of a stage Ic serous low malignant potential tumor. A multivariate analysis confirmed that the prognosis was not influenced by the surgical procedure. CorzHusiorz. The survival rate after laparoscopic management of low malignancy potential tumor is similar to that reported after laparotomy. To design a prospective randomized study on this problem appears unrealistic. Large prospective international survey would be necessary to confirm our data.
28. Laparoscopic Omentectomy in the Staging of Ovarian Low Malignant Potential Neoplasms E Solima. National Cancer Institute, Milan, Italy.
Objectives. To evaluate the feasibility of laparoscopic omentectomy in the staging of patients with low malignant potential (LMP) ovarian neoplasms. Settirzg. Tertiary level oncologic research hospital. Patierzts. From October 2001 to April 2003 12 patients underwent laparoscopic staging of ovarian neoplasm of LMP. The mean age was 36 years (range 16-73 years). Mean BMI was 23 (range: 20-27). Seven patients underwent ovarian cystectomy or adnexectomy or hysterectomy and adnexectomy and subsequent staging. Five patients were inadequately treated elsewhere and were referred for staging. Four 5 mm trocars were positioned in the Palmer point, into the umbilicus and in the lateral lower abdominal quadrants respectively; one 10 mm port was placed infranmbilically on the midline. After adhesiolysis, peritoneal washing and biopsies when indicated, infracolic omentectomy was carried out from right to left along the inferior margin of the transverse colon. Results. The mean operating time was 23 minutes (range 15-48). Mean postoperative hospital stay was 1.5 days. No intraoperatory and postoperatory complications were recorded. No patients presented peritoneal carcinomatosis hampering the feasibility of the procedure. Ten patients had stage I disease and 2 stage IIIa disease (due to microscopic peritoneal metastasis).
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Oral Presentations
COFzclusioFz.Laparoscopic approach to omentectomy in the staging of LMP ovarian tumours is a safe and feasible alternative to conventional laparotomy. The widespread use of laparoscopy in the treatment of ovarian epithelial tumors warrants the definition of a well-defined indication of the procedure, including staging in selected cases to avoid unnecessary laparotomies.
29. Long Term Follow-up after Laparoscopic Management of Invasive Ovarian Cancer M Canis, G Mage. Centre Hospitalier Universitaire, Clermont Ferrand, France.
Objective. To study the long term survival rate after laparoscopic management of invasive ovarian cancer. DesigFz. Retrospective study. PatieFzts. Between December 1991 and January 2002, 54 invasive ovarian cancers were managed in our department. In 11 cases the initial surgical procedure was performed only by laparoscopy, in 31 cases a conversion to laparotomy was performed after the diagnosis, and 12 patients were managed by laparotomy. According to the FIGO classification, 19 patients had a stage I, 5 patients a stage II and 27 a stage III and 2 a stage IV. Results. The overall 5 and 10-year survival rates were respectively 66.8% and 50.1% in stage II. The 5 and 10year survival rates in stage I were respectively 90.2% and 90.2%. A multivariate analysis confirmed that the prognosis was not influenced by the surgical procedure. CoFzclusioFz. The survival rate after laparoscopic management of invasive ovarian cancer is similar to that reported after laparotomy. Large prospective studies would be necessary to confirm our data, to propose laparoscopy as a safe alternative to laparotomy in the surgical diagnosis of ovarian cancer.
Plenary 7--Endometriosis 30. Association Rate Between Deep Peritoneal Endometriosis and Other Forms of the Disease: Etiopathogenetic Implications 1M Busacca, 2E Somigliana, 2M Ordorizzi, 2S Rocca, 1A Borgna, 1A Stimilli, 1M Vignali. 1University of Milan, M. Melloni Hospital, Milan, Italy; 2Clinica Mangiagalli, Milan, Italy.
BackgrouFzd. It has been recently suggested that deep endometriosis and the other forms of the disease do not share a common etiopathogenetic mechanism. Objective. In this study, we hypothesize that, if this is true, deep peritoneal endometriosis and the other forms should not be significantly associated. Sett#zg. Tertiary care center for endometriosis. Methods. Clinical and surgical records of all women who referred to the II Department of Obstetrics and Gynecology, Clinica "L. Mangiagalli" between January 1995 and June 2002 and who were diagnosed deep peritoneal pelvic endo-
metriosis at the time of surgery were retrieved. The concomitant presence of superficial endometriotic implants, endometriomas and pelvic adhesions was evaluated. A binomial probability distribution model was used to calculate the 95% Confidence Interval (95% CI) of the association rates. Results. Ninety-three women with deep peritoneal endometriosis were identified. The presence of superficial endometriotic implants, endometriomas and pelvic adhesions was documented in 61.3% (95% CI: 51.4%-71.2%), 50.5% (95% CI: 40.3%-60.7%) and 74.2% (95% CI: 65.3 %-83.1%) of patients with deep endometriotic nodules, respectively. Overall, deep peritoneal endometriosis was the only form of the disease in only 6.5% (95% CI: 3.6%12.3%) of cases. No relevant differences regarding these associations were observed according to the location and the size of the deep endometriotic nodules. CoFzclusioFz. Results from this study do not support the hypothesis that deep endometriosis should be considered a distinct entity of the disease.
31. A Study of Usefulness of MRI Jerry Method in Preoperative Diagnosis of Rectovaginal Endometriosis M Kitade, H Takeuchi, J. Kumakiri, I Kikuchi, S Takase, H Shimanuki. Juntendo University School of Medicine, Bunkyo-Ku, Tokyo, Japan.
Objective. To assess the usefulness of MRI jerry method in preoperative diagnosis of rectovaginal endometriosis (RVE). Material arm Me#zods. Thirteen patients with suspected RVE underwent preoperative diagnosis by MRI jerry method before laparoscopic surgery. After colon-cleaning for three days, ultrasonographic jelly was injected into vagina and rectum of patients and T2-weighted MRI (axial and sagital) images were taken. Laparoscopy revealed CCDSO (complete cul-de-sac obliteration) in patients with established RVE. Laparoscopic procedures consisted of adhesiotomy with a needle like monopolar and Kelly forceps to open CCDSO and removal of the deep lesion with a monopolar. Patients were divided into three groups based on laparoscopic findings; those with normal pelvic findings without CCDSO (N group), those only showing CCDSO and without any deep nodular lesion (A group), and those with hypertrophic or nodular deep lesions (D group). It was examined retrospectively whether this classification was possible or not in preoperative diagnosis by MRI jerry method. Results. Among 13 patients undergoing preoperative diagnosis with MRI jerry method, preoperative MRI findings were consistent with laparoscopic findings in 11 patients (84.6%). The correct diagnosis rates were 85.6% (6/7), 50% (1/2) and 100% (4/4) in N, A and D groups, respectively. CoFzclusioFz. These results suggest that MRI jerry method is useful for preoperative diagnosis of RVE.
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The Journal of the American Association of Gynecologic Laparoscopists
Results. The blue dye technique alone identified at least one SN in 61 (87%) of patients. The rate of SN detection by side of dissection was 70% on the left side and 77% on the right side. Bilateral SN were identified in 60% of cases. In the subgroup of patients who had the combined technique (n=29), the SN detection rate increased to 93% and the bilateral SN detection rate reached 72%. In the last 15 cases of the series, the SN detection rate reached 97%. A total of 135 SN were identified, with the majority (88%) being located at 3 main sites: external iliac, obturator and bifurcation. Thirty-six patients (51%) had 2 SN identified, and 16 (24%) had 3 SN or more. Twelve (17%) patients had positive lymph nodes. The false-negative rate was zero. The negative predictive value of the SN mapping was 100 % and the sensitivity was 93 % with the combined technique. Two patients had allergic reaction to the blue dye (3%). Corzclusiorz. The SN mapping with the combined blue dye technique and lymphoscintigraphy in patients with cervical cancer is laparoscopically feasible and highly accurate. The SN detection rate improves significantly with experience and with the use of lymphoscintigraphy.
26. Hysteroscopic Injection of Tracers in the Detection of Sentinel Node in Endometrial Cancer, Preliminary Study E Solima. National Cancer Institute, Milan, Italy.
Objectives. To evaluate the feasibility of hysteroscopic injection of blue dye and technetium 99m (Tc) in the detection of sentinel node (SN) in endometrial cancer patients by lymphoscintigraphy and radio-guided surgery. Settirzg. Tertiary level oncologic research hospital. Patierzts. A consecutive series of 18 patients with endometrial cancer were submitted to hysteroscopic injection of 111 MBq of Tc and 8 ml of patent blue dye. Subsequently lymphoscintigraphic scans were taken. After hysterectomy and frozen section assessment of surgical specimen, a handheld gamma-ray detector probe was used to locate and remove the sentinel lymph node. Nodal blue dye uptake was visualized. Systematic pelvic lymphadenectomy was further carried out when appropriate. Results. In all the cases at least one sentinel node was detected using radio-guided surgery. In only 5 cases at least one node with blue dye uptake was recognized only after being dissected and isolated. In all the cases more than one site was positive to Tc and in 9 cases SN were detected bilaterally in the pelvis. In 5 cases one SN was detected in the para-aortic area. In 3 cases the SN was positive to the tumor. CorzHusiorz. The hysteroscopic injection of Tc99 labeled human albumin colloid particles in the detection of sentinel node(s) in endometrial cancer is a feasible technique. The neoplastic lymphatic spread has been shown to be extremely variable. The development of this method for SN detection should be further evaluated whether is an alternative to systematic lymph node dissection which carries a significant morbidity.
27. Long Term Follow-up after Laparoscopic Management of Low Malignant Potential Ovarian Tumors M Canis. Centre Hospitalier Universitaire, Clermont Ferrand, France.
Objective. To study the long term survival rate after laparoscopic management of low malignant potential ovarian tumors. Desigrz. Retrospective study. Patierzts. Between December 1991 and January 2002, 47 low malignant potential tumors were managed in our department. In 28 cases the initial surgical procedure was performed after the diagnosis, and 7 patients were managed by laparotomy. Results. The 5 and 10 year survival rates were 93%. One patient died 30 months after the laparoscopic procedure. She was diagnosed with a peritoneal carcinomatosis with invasive peritoneal implants, 1 year after the management of a stage Ic serous low malignant potential tumor. A multivariate analysis confirmed that the prognosis was not influenced by the surgical procedure. CorzHusiorz. The survival rate after laparoscopic management of low malignancy potential tumor is similar to that reported after laparotomy. To design a prospective randomized study on this problem appears unrealistic. Large prospective international survey would be necessary to confirm our data.
28. Laparoscopic Omentectomy in the Staging of Ovarian Low Malignant Potential Neoplasms E Solima. National Cancer Institute, Milan, Italy.
Objectives. To evaluate the feasibility of laparoscopic omentectomy in the staging of patients with low malignant potential (LMP) ovarian neoplasms. Settirzg. Tertiary level oncologic research hospital. Patierzts. From October 2001 to April 2003 12 patients underwent laparoscopic staging of ovarian neoplasm of LMP. The mean age was 36 years (range 16-73 years). Mean BMI was 23 (range: 20-27). Seven patients underwent ovarian cystectomy or adnexectomy or hysterectomy and adnexectomy and subsequent staging. Five patients were inadequately treated elsewhere and were referred for staging. Four 5 mm trocars were positioned in the Palmer point, into the umbilicus and in the lateral lower abdominal quadrants respectively; one 10 mm port was placed infranmbilically on the midline. After adhesiolysis, peritoneal washing and biopsies when indicated, infracolic omentectomy was carried out from right to left along the inferior margin of the transverse colon. Results. The mean operating time was 23 minutes (range 15-48). Mean postoperative hospital stay was 1.5 days. No intraoperatory and postoperatory complications were recorded. No patients presented peritoneal carcinomatosis hampering the feasibility of the procedure. Ten patients had stage I disease and 2 stage IIIa disease (due to microscopic peritoneal metastasis).
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Oral Presentations
COFzclusioFz.Laparoscopic approach to omentectomy in the staging of LMP ovarian tumours is a safe and feasible alternative to conventional laparotomy. The widespread use of laparoscopy in the treatment of ovarian epithelial tumors warrants the definition of a well-defined indication of the procedure, including staging in selected cases to avoid unnecessary laparotomies.
29. Long Term Follow-up after Laparoscopic Management of Invasive Ovarian Cancer M Canis, G Mage. Centre Hospitalier Universitaire, Clermont Ferrand, France.
Objective. To study the long term survival rate after laparoscopic management of invasive ovarian cancer. DesigFz. Retrospective study. PatieFzts. Between December 1991 and January 2002, 54 invasive ovarian cancers were managed in our department. In 11 cases the initial surgical procedure was performed only by laparoscopy, in 31 cases a conversion to laparotomy was performed after the diagnosis, and 12 patients were managed by laparotomy. According to the FIGO classification, 19 patients had a stage I, 5 patients a stage II and 27 a stage III and 2 a stage IV. Results. The overall 5 and 10-year survival rates were respectively 66.8% and 50.1% in stage II. The 5 and 10year survival rates in stage I were respectively 90.2% and 90.2%. A multivariate analysis confirmed that the prognosis was not influenced by the surgical procedure. CoFzclusioFz. The survival rate after laparoscopic management of invasive ovarian cancer is similar to that reported after laparotomy. Large prospective studies would be necessary to confirm our data, to propose laparoscopy as a safe alternative to laparotomy in the surgical diagnosis of ovarian cancer.
Plenary 7--Endometriosis 30. Association Rate Between Deep Peritoneal Endometriosis and Other Forms of the Disease: Etiopathogenetic Implications 1M Busacca, 2E Somigliana, 2M Ordorizzi, 2S Rocca, 1A Borgna, 1A Stimilli, 1M Vignali. 1University of Milan, M. Melloni Hospital, Milan, Italy; 2Clinica Mangiagalli, Milan, Italy.
BackgrouFzd. It has been recently suggested that deep endometriosis and the other forms of the disease do not share a common etiopathogenetic mechanism. Objective. In this study, we hypothesize that, if this is true, deep peritoneal endometriosis and the other forms should not be significantly associated. Sett#zg. Tertiary care center for endometriosis. Methods. Clinical and surgical records of all women who referred to the II Department of Obstetrics and Gynecology, Clinica "L. Mangiagalli" between January 1995 and June 2002 and who were diagnosed deep peritoneal pelvic endo-
metriosis at the time of surgery were retrieved. The concomitant presence of superficial endometriotic implants, endometriomas and pelvic adhesions was evaluated. A binomial probability distribution model was used to calculate the 95% Confidence Interval (95% CI) of the association rates. Results. Ninety-three women with deep peritoneal endometriosis were identified. The presence of superficial endometriotic implants, endometriomas and pelvic adhesions was documented in 61.3% (95% CI: 51.4%-71.2%), 50.5% (95% CI: 40.3%-60.7%) and 74.2% (95% CI: 65.3 %-83.1%) of patients with deep endometriotic nodules, respectively. Overall, deep peritoneal endometriosis was the only form of the disease in only 6.5% (95% CI: 3.6%12.3%) of cases. No relevant differences regarding these associations were observed according to the location and the size of the deep endometriotic nodules. CoFzclusioFz. Results from this study do not support the hypothesis that deep endometriosis should be considered a distinct entity of the disease.
31. A Study of Usefulness of MRI Jerry Method in Preoperative Diagnosis of Rectovaginal Endometriosis M Kitade, H Takeuchi, J. Kumakiri, I Kikuchi, S Takase, H Shimanuki. Juntendo University School of Medicine, Bunkyo-Ku, Tokyo, Japan.
Objective. To assess the usefulness of MRI jerry method in preoperative diagnosis of rectovaginal endometriosis (RVE). Material arm Me#zods. Thirteen patients with suspected RVE underwent preoperative diagnosis by MRI jerry method before laparoscopic surgery. After colon-cleaning for three days, ultrasonographic jelly was injected into vagina and rectum of patients and T2-weighted MRI (axial and sagital) images were taken. Laparoscopy revealed CCDSO (complete cul-de-sac obliteration) in patients with established RVE. Laparoscopic procedures consisted of adhesiotomy with a needle like monopolar and Kelly forceps to open CCDSO and removal of the deep lesion with a monopolar. Patients were divided into three groups based on laparoscopic findings; those with normal pelvic findings without CCDSO (N group), those only showing CCDSO and without any deep nodular lesion (A group), and those with hypertrophic or nodular deep lesions (D group). It was examined retrospectively whether this classification was possible or not in preoperative diagnosis by MRI jerry method. Results. Among 13 patients undergoing preoperative diagnosis with MRI jerry method, preoperative MRI findings were consistent with laparoscopic findings in 11 patients (84.6%). The correct diagnosis rates were 85.6% (6/7), 50% (1/2) and 100% (4/4) in N, A and D groups, respectively. CoFzclusioFz. These results suggest that MRI jerry method is useful for preoperative diagnosis of RVE.
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