Laparoscopy in Patients with Advanced Ovarian Cancer
Abstract & commentary
Synopsis: Laparoscopy with careful closure of the peritoneum, rectus sheath, and skin, followed by chemotherapy or cytoreductive surgery with excision of the trocar trajectories within one week, is safe in patients with advanced ovarian cancer.
Source: van Dam PA, et al. Am J Obstet Gynecol 1999; 181:536-541.
Van dam and colleagues have reported their experience with 83 women with primary, advanced ovarian cancer and 21 women with recurrent ovarian cancer undergoing laparoscopy for tissue diagnosis and for assessment of operability. The purpose of the study was to determine risk factors for trocar implantation metastasis after diagnostic laparoscopy in this patient population. A recurrence developed at the trocar site in seven of 12 (58%) patients undergoing a laparoscopy in which only the skin was closed at the end of the procedure, and in two of 92 (2%) patients undergoing a laparoscopy with closure of all layers. The stage, histologic type, histologic grade, maximal tumor diameter, estimated weight of metastatic tumor, residual tumor diameter, surgical characteristics, and type of chemotherapy were well balanced between both groups. Patients with implantation metastasis had significantly more ascites and a longer interval between the start of platinum-based chemotherapy or cytoreductive surgery compared with patients without abdominal wall recurrence. A palpable abdominal wall metastasis developed in none of the patients undergoing a laparoscopy within one week after the laparoscopy. Patients with abdominal wall implantation metastasis had a survival rate similar to that of the other patients. van Dam et al concluded that laparoscopy with careful closure of the peritoneum, rectus sheath, and skin followed by chemotherapy or cytoreductive surgery with excision of the trocar trajectories within one week is safe in patients with advanced ovarian cancer.
Comment by David M. Gershenson, MD
For the past decade, we have witnessed a resurgence in the use of operative laparoscopy in gynecologic surgery in general, and also within the subspecialty of gynecologic oncology. Most worrisome is the fact that there are an escalating number of case reports and small series detailing tumor implantation in abdominal wall trocar sites after laparoscopy in patients with ovarian, endometrial, and cervical cancers. Many gynecologic oncologists are obviously concerned about this phenomenon and question the safety of laparoscopy in patients with clinical findings diagnostic of, or suspicious for a gynecologic malignancy. Although they do occur, tumor implantation sites in laparotomy incisions of patients with gynecologic cancers are rare. Several theories exist regarding the pathophysiology of this entity—oxygen content, gas turbulence, contamination by ascites, etc. We currently do not completely understand this phenomenon. Of course, gynecologic oncologists have known for years that patients who undergo paracentesis for massive ascites may subsequently develop tumor implantation in the paracentesis site. This flies in the face of previous reports. Importantly, van Dam et al found a lower incidence of trocar site implantation if all layers of the abdominal wall were closed separately. However, even with a sample size of 104 patients, the numbers are small. Furthermore, all of the patients in this study had either advanced stage disease or recurrent disease. The most disturbing variation on this theme is trocar site implantation in a patient with stage I disease, converting a potentially curable situation to one that may not be curable. I agree with van Dam et al that, if chemotherapy is administered soon after laparoscopy, any microscopic implantation is probably not a serious threat. The other related issue regarding laparoscopy in patients with known or suspected malignancy is its abuse and unnecessary use prior to definitive treatment. But that is a subject for a future discussion. Clearly, more study is needed in this area before we can fully embrace laparoscopy in a patient with a gynecologic malignancy.
The incidence of trocar site implantation after laparoscopy in patients with ovarian cancer is: