Oncologic Concerns regarding Laparoscopic Cytoreductive Surgery in Patients with Advanced Ovarian Cancer Submitted to Neoadjuvant Chemotherapy

Abstract

Background: Presently, the use of laparoscopy in advanced ovarian cancer (AOC) is extremely controversial. In the era of neoadjuvant chemotherapy (NACT), endoscopic debulking surgery could be a reasonable alternative for selected patients with primarily unresectable disease. Objectives: To evaluate the feasibility as well as the operative and oncologic safety of laparoscopic debulking surgery in patients with AOC submitted to NACT. Methods: This is a pilot observational study on initially unresectable, high-grade serous ovarian cancer treated with a sequence of 6 cycles of carboplatin and paclitaxel followed by debulking surgery performed by laparoscopy (group 1) or laparotomy (group 2). The inclusion criteria were clinical complete response, CA-125 normalization, imaging without disease in critical areas, and optimal cytoreduction. Results: From January 2011 to March 2014, 21 patients were included. Ten women underwent laparoscopy and 11 laparotomy. No epidemiological or oncologic differences were observed between the groups. No surgery-related casualties, intraoperative complications, conversion to laparotomy, or excessive blood loss or transfusion was detected in the laparoscopic procedures. The mean time of operation was 292 min. The length of hospital stay averaged 3.6 days. Two women in group 1 developed relevant complications. After a mean follow-up of 20 months, the recurrence rates were similar, i.e. 80% in group 1 versus 88% in group 2. Although statistical significance was not reached, the mortality related to cancer was considerably higher (20 vs. 0%; p = 0.086) and the mean chemotherapy-free interval was markedly shorter in group 1 (13.3 vs. 20.5 months; p = 0.288). Conclusion: Laparoscopic optimal debulking surgery after NACT is feasible and effective in selected patients. Nevertheless, laparoscopy was substantially associated with inferior oncologic results. Endoscopic cytoreduction in AOC should be cautiously suggested until larger prospective trials confirm the observed results.

Oncologic Safety of Laparoscopy in the Surgical Treatment of Type II Endometrial Cancer

“…Uncertainties regarding potential iatrogenic peritoneal cancer cell dissemination and, consequently, negative impact on prognosis are frequent cause of fierce debate among specialists worldwide. 16 In fact, endoscopic procedures introduce new components in the abdominal cavity such as increased abdominal pressure, carbon dioxide, lower temperatures, and intense illumination that led to important alterations in peritoneal integrity and physiology. 22 The final consequence of this process is a considerable attenuation of the inflammatory response.…”

“…23 Certainly, impaired immune function of the peritoneum creates a more favorable environment for tumor cell implantation. 16 Differently from other pathologies, the peritoneal organ has a supreme importance in the clinical course of ovarian and fallopian tube carcinoma. The biological similarities between serous ovarian/tube and EC allied to the absence of data specifically concerning utilization of laparoscopy in type II uterine body cancer have inspired us to study the oncologic safety of the method.…”

“…The use of laparoscopy is extremely controversial in the surgical treatment of ovarian malignancies basically due to its potential negative effect on peritoneal immunology. 16 Most of the studies addressing the oncologic safety of endoscopy in the treatment of EC have focused on patients with early stage or low-risk disease and few on patients with high risk. Besides, data specifically regarding long-term survival outcomes about laparoscopic surgery in type II EC remain lacking.…”

The role of minimally invasive interval debulking surgery in advanced epithelial ovarian cancer

“…The current literature contains only a few studies related to the role of MIS at the time of IDS, and no RCTs exist to clarify the oncologic impact of minimally invasive IDS (MI-IDS) in terms of survival [9]. In a retrospective review of data from 30 patients undergoing laparoscopic cytoreduction after NACT, Corrado et al reported better perioperative outcomes, including median blood loss, median hospital stay, and intraoperative complications, than those who underwent the same procedures via laparotomy [23].…”

“…In a pilot observational study on initially unresectable, high-grade serous ovarian cancer, Favero et al evaluated the feasibility as well as the operative and oncologic safety of laparoscopic IDS [9]. Patients were treated with a sequence of six cycles of carboplatin and paclitaxel followed by debulking surgery performed by laparoscopy (group 1) or laparotomy (group 2).…”