Epithelial Ovarian Carcinoma with role of laparoscopy

1. Malignant Ovarian mass
Dr Ajay Aggarwal
MD obs & Gynae
(PGI, Chandigarh)

2. Ovarian masses approach
• The overall incidence of a symptomatic ovarian cyst in a
premenopausal female being malignant is approximately
1:1000 increasing to 3:1000 at the age of 50.

3. Premenopausal women
• A serum CA-125 assay is not necessary in all premenopausal
women when a clear USG diagnosis of a simple ovarian cyst
has been made.
• If CA-125 assay is 35-200 units/ml then exclude/treat the
common differential diagnoses
• If serum CA-125 assay more than 200 units/ml, discussion
with a gynaecological oncologist is recommended
• When CA-125 is raised, serial monitoring of CA-125 may be
helpful as rapidly rising levels are more likely to be associated
with malignancy than high levels which remain static.

4. • A pelvic ultrasound is the most effective way to evaluate an
ovarian mass with TVS being preferred due to its increased
sensitivity.
• Combined use of colour flow mapping and 3D imaging may
improve sensitivity, particularly in complex cases.
• Repeating ultrasound assessment in the postmenstrual
phase may be helpful in cases of doubt and endometrial
views may contribute to diagnosis in cases of estrogen-
secreting tumours of the ovary.

5. • The NICE guideline recommends that for women with
suspected ovarian malignancy the RMI I score should be
calculated and used to guide the woman’s management.
• RMI = U x M x CA-125.
• RMI I sensitivity 78% (95% CI 71-85%), specificity 87% (95% CI
83-91%)

6. • There are simple ultrasound rules derived from the IOTA
(International ovarian tumor analysis) Group. The use of
specific ultrasound morphological findings without CA-125
has been shown to have high sensitivity and specificity.
• Ultrasound rules- benign (B-rules) or malignant (M-Rules).
• Reported sensitivity was 95%, specificity 91%

7. IOTA Group ultrasound ‘rules’ to classify masses as
benign (B-rules) or malignant (M-rules)
B-rules M-rules
Unilocular cysts Irregular solid tumor
Presence of solid component where the
largest solid component <7mm
Ascites
Acoustic Shadowing At least four papillary structures
Smooth multilocular tumor with a largest
diameter <10cm
Irregular multilocular solid tumor with
largest diameter > or equal to 10cm
No blood flow Very strong blood flow

8. Management
• Women with small (less than 50 mm diameter) simple ovarian
cysts generally do not require follow-up as these cysts are
very likely to be physiological and almost always resolve
within 3 menstrual cycles.
• Women with simple ovarian cysts of 50–70 mm in diameter
should have yearly ultrasound follow-up and those with larger
simple cysts should be considered for either further imaging
(MRI) or surgical intervention.

9. • Ovarian cysts that persist or increase in size are unlikely to be
functional and may warrant surgical management.
• The use of the combined oral contraceptive pill does not
promote the resolution of functional ovarian cysts
RCOG, Cochrane

10. • Aspiration of ovarian cysts- less effective, high recurrence
rate, spillage of malignancy
• Laparoscopy- Spillage of cyst contents should be avoided
where possible as preoperative and intraoperative
assessment cannot absolutely preclude malignancy.
• Consideration should be given to the use of a tissue bag to
avoid peritoneal spill of cystic contents. Any solid content
should be removed using an appropriate bag.

11. • Where possible removal of benign ovarian masses should be
via the umbilical port. This results in less postoperative pain
and a quicker retrieval time than when using lateral ports of
the same size.

12. Postmenopausal
• It is recommended that ovarian cysts in postmenopausal
women should be assessed using CA125 and TVS.
• It is recommended that a ‘risk of malignancy index’ should be
used to select those women who require primary surgery in a
cancer centre by a gynaecological oncologist.

15. Ovarian Cancer
• Fifth most common cancer in women
• Lifetime risk of about 2%
• Overall 5-year survival rate of less than 35%
• Patients have advanced disease at diagnosis in more than two
thirds of the cases
• About 30% of ovarian neoplasms in postmenopausal women
are malignant
• Only about 7% of ovarian epithelial tumors in premenopausal
patients are frankly malignant

16. • Epithelial cancers are the most common ovarian malignancies.
• Peak incidence-56 to 60 years of age
• Types-
– serous 75%
– mucinous (20%)
– endometrioid (2%)
– clear cell
– Brenner
– undifferentiated carcinomas

17. Clinical Approach
• History (Symptoms) and examination
• Investigation- CA-125; AFP & hCG & LDH (<40yrs), CEA
• USG features
• If the ultrasound, serum CA125 and clinical status suggest
ovarian cancer, perform a CT scan of the pelvis and abdomen
to establish the extent of disease. Include the thorax if
clinically indicated.
• Do not use MRI routinely for assessing women with suspected
ovarian cancer
• Risk assessment- RMI 1, OVA1, ROMA

18. OVA 1
• OVA1 is an FDA-approved test for the evaluation of an
ovarian mass.
• This new test combines the results of five immunoassays
(CA-125, transthyretin, apolipoprotein A1, b2-microglobulin
and transferrin).
• Using a unique proprietary algorithm to produce a single
numerical score, OVA1 indicates a woman’s likelihood of
malignancy.
• It is not a screening test for ovarian cancer, nor is it a
replacement for conventional clinical and diagnostic
assessments. But OVA1 will improve the accuracy of
diagnosis prior to surgery or referral to a gynecologic
oncologist.

19. ROMA
• The Risk of Ovarian Malignancy Algorithm (ROMA) stratifies
women at high or low risk for epithelial ovarian cancer based
on menopausal status and preoperative serum levels of HE4
and CA-125.
• ROMA had sensitivity 94.3%, vs. 83.7% for RMI
(Gynecol. Oncol. 2009;112:40-6)
• HE4 has sensitivity similar to CA-125 in detecting late-stage
disease but greater specificity than CA-125 in diagnosing early
ovarian cancer. Validation of HE4 as a diagnostic biomarker in
detecting ovarian cancer at early stages is currently ongoing.

20. CT SCAN
• Role in :
– intra-abdominal disease
– hepatic metastases
– pelvic sidewall ds.
– lymphnode enlargement
– obstructive uropathy,
– possibly an alternate primary cancer site
– role in assessing operability of the tumor.

21. PET CT scan
• Positron emission tomography (PET) scanning does not have
an established role in the diagnosis of primary ovarian
malignancy. Its use is still being evaluated, but the PET scan
plays a useful role in some patients by detecting the pattern
and sites of recurrent disease.

22. FNAC
• Poor sensitivity
• Spillage and seeding of cancer cells into the peritoneal cavity,
thereby changing the stage and prognosis
• ONLY INDICATION :advanced ovarian cancer pts. who are
medically unfit to undergo surgery. In these women,
malignant cytology confirmed in this fashion will establish a
cancer diagnosis, thereby permitting initiation of neoadjuvant
chemotherapy

23. Other modalities in suspected 2⁰ ovarian cancer
• Exclude other primary cancers metastatic to the ovary.
• A barium enema or colonoscopy if symptoms and signs
suspicious for colon cancer.
• Stool for occult blood
• Upper gastrointestinal endoscopy if nausea, vomiting, or
hematemesis .
• Mammography is indicated if there is any breast mass
• Endometrial biopsy and endocervical curettage if irregular
menses or postmenopausal bleeding

24. Staging

25. Management of Stage 1
• TAH + BSO with optimal surgical staging - Peritoneal cytology,
exploration of pelvis, peritoneal surface, diaphragm,
omentum, lymph nodes, biopsy from suspected areas,
random biopsies of the pelvic and abdominal peritoneum;
and retroperitoneal lymph node assessment , Infracolic
omentectomy
• Lymph nodes may be involved in 10 – 20% cases of stage 1
• Perform retroperitoneal lymph node assessment- Lymph node
assessment involves sampling of retroperitoneal lymphatic
tissue from the paraaortic area and pelvic side walls if there is
a palpable abnormality, or random sampling if there is no
palpable abnormality.

26. • Do not include systematic retroperitoneal lymphadenectomy
(block dissection of lymph nodes from the pelvic side walls to
the level of the renal veins) as part of standard surgical
treatment in women with suspected ovarian cancer whose
disease appears to be confined to the ovaries (that is, who
appear to have stage I disease).
• Do not offer adjuvant chemotherapy to women who have had
optimal surgical staging and have low-risk stage I disease
(grade 1 or 2, stage Ia or 1b).

27. • Offer women with high-risk stage I disease (grade 3 or stage
Ic) adjuvant chemotherapy consisting of six cycles of
carboplatin.
• Discuss the possible benefits and side effects of adjuvant
chemotherapy with women who have had suboptimal surgical
staging and appear to have stage I disease.

28. Fertility sparing surgery
• The uterus and the contralateral ovary can be preserved in
women with stage Ia, grade 1 to 2 disease who desire to
preserve fertility.
• The conditions of the women should be monitored carefully
with routine periodic pelvic examinations and determinations
of serum CA125 levels.
• Generally, the other ovary and the uterus are removed at the
completion of childbearing.

29. Management of advanced (stage II–IV)
ovarian cancer
• Maximal cytoreduction is the most significant predictor of
survival.
• If performing surgery for women with ovarian cancer, whether
before chemotherapy or after neoadjuvant chemotherapy,
the objective should be complete resection of all macroscopic
disease.
• The definition of “optimal” debulking is defined as the
removal of bulky disease such that the largest single tumor
nodule is ≤ 1 cm at the closure of the procedure. ACOG
• Do not offer intraperitoneal chemotherapy to women with
ovarian cancer, except as part of a clinical trial.

30. Interval Debulking Procedures
• Interval debulking surgery is defined as cytoreductive or
debulking surgery performed after a course of induction
chemotherapy.
– A second surgical attempt, following several rounds of
adjuvant chemotherapy, after a suboptimal primary
surgery
– Surgery performed after several rounds of neoadjuvant
chemotherapy

31. Role of NACT
• Neoadjuvant Chemotherapy (NACT) followed by primary
debulking surgery is an approach that is taken with patients
who are considered high-risk surgical candidates.
• The rationale is that giving 2-3 cycles of chemotherapy will
reduce the tumor burden and make subsequent surgery more
feasible. However, the potential for resistant clones of
malignant cells to develop during exposure to NACT remains a
concern.

32. • Prior to giving NACT, the pathologic diagnosis should be
confirmed by either fine needle aspiration, CT-guided biopsy.
consider laparoscopic biopsy if percutaneous image-guided
biopsy is not feasible or has not produced an adequate
sample.
• Use cytology if histology is not appropriate
• The advantages of using NACT include:
– Shorter operative times
– Less blood loss
– Reduced time in the ICU
– Shorter hospital stays

33. Second-Look Surgery
• Second-look surgery either by laparotomy or laparoscopy has
been used to reassess the disease status in patients who have
completed initial cytoreductive surgery and adjuvant
chemotherapy and appear to have had a complete clinical
response to treatment (asymptomatic, no radiographic
evidence of disease,normal CA 125).
• Surgical reassessment includes examination of both the
peritoneal cavity and the retroperitoneal space. Up to 50% of
patients with advanced ovarian cancer have evidence of
residual disease during surgery despite an apparent clinical
remission.

34. • The presence of disease is associated with a poorer prognosis.
• However, a significant percentage of patients with negative
findings will also develop recurrence.
• A clear survival advantage has not been demonstrated for this
procedure.
• Routine use of second-look surgery is not recommended and
this procedure should therefore generally be reserved for
clinical trials.

35. Epithelial Ovarian Cancer - Prognosis and
Recurrent Disease
Five-year survival rates for epithelial ovarian carcinoma by FIGO stage :
• Stage IA - 87%
• Stage IB - 71%
• Stage IC - 79%
• Stage IIA - 67%
• Stage IIB - 55%
• Stage IIC - 57%
• Stage IIIA - 41%
• Stage IIIB - 25%
• Stage IIIC - 23%
• Stage IV - 11%
• Overall survival rate- 35-40%

36. Recurrent disease
• Approximately 50-60% of women treated for advanced
ovarian cancer will experience a relapse of their disease at
some point after initial therapy, usually within two years.
• The choice of treatment for recurrent disease is not as clear
due to heterogeneity of the:
– Time to disease recurrence
– Extent and distribution of recurrent disease
– Performance status of the patient
– Cumulative toxicity from prior treatment
• Chemotherapy: 2nd line agents
• Surgery
• Radiation

37. Role of frozen section
• The accuracy of frozen-section diagnosis varies from 72% to
88.7%
• Diagnostic accuracy has been shown to be lower in masses
greater than 10 cm (74%) and tumors of low malignant
potential (78%) ACOG 2007

38. Role of laparoscopy
Potential role of minimally invasive surgery in ovarian cancer is in
the following categories:
i) laparoscopic evaluation, diagnosis, and staging of apparent
early ovarian cancer
ii) laparoscopic debulking of advanced ovarian cancer
iii) laparoscopic assessment of feasibility of upfront optimal
surgical cytoreduction
iv) laparoscopic reassessment in patients with complete
remission after primary treatment
v) laparoscopic assessment and cytoreduction of recurrent
disease.

39. laparoscopic evaluation, diagnosis, and staging
of apparent early ovarian cancer
• Laparoscopic perioperative benefits- decreased blood loss,
faster return of bowel function and shorter hospital stay.
• Laparoscopy may offer an advantage in management of early-
stage ovarian cancer by enabling better visualization of
difficult areas such as the anterior abdominal wall,
subdiaphragmatic areas, peritoneal surfaces, obturator spaces
and anterior and posterior cul-de-sacs, as well as
magnification and detection of smaller lesions that may be
missed at perioperative imaging and even during laparotomy

40. • Recurrence rates are similar after laparoscopic and open
staging procedures, suggesting that the laparoscopic
technique does not compromise the outcome of early-stage
ovarian carcinoma.
• At present, efforts should be made to reduce the incidence of
tumor contamination of the abdominal cavity, including liberal
use of a laparoscopic bag and controlled aspiration, and
minimizing the risk of cyst rupture.

41. Minimally Invasive Surgery for Cytoreduction of
Advanced Ovarian Cancer
• laparoscopic cytoreduction for primary advanced ovarian
cancer can be successful and result in minimal morbidity and
acceptable survival
• In 2010, Nezhat et al reported a series of 32 patients with
advanced ovarian, fallopian tube, or primary peritoneal
cancer who underwent laparoscopic debulking. In 17 of the 32
patients, the disease was successfully debulked at
laparoscopy, with 88% of optimal cytoreduction. At mean
follow up of 19.2 months, 9 patients were without evidence of
the disease. Compared with the group who underwent
laparotomy, the laparoscopic approach had resulted in
minimal blood loss and a shorter hospital stay. No patients
developed port-site metastasis, and time to disease
recurrence in the laparoscopic group was not inferior to that
in the laparotomy group.

42. • In another retrospective series of 25 patients with presumed
stage III/IV primary ovarian cancer undergoing laparoscopic
assisted cytoreduction, Fanning et al (2011) reported
successful cytoreduction in 23 patients (92%). Two procedures
were converted to laparotomy because of extensive omental
disease and bulky metastasis surrounding the rectosigmoid
colon, respectively. In all 25 patients, the lesion was
cytoreduced to <2 cm, and 36% had no residual disease.
Median operative time was 2.3 hours, and blood loss was 340
mL. Median length of stay was 1 day. Median visual analog
scale pain score was 4, which was discomforting. Six patients
(24%) had postoperative complications; however, none were
grade 3 or 4. Median overall survival was 3.5 years.

43. Retrospective case-control study
Magrina et al [2011]
Robotic surgery Laparoscopy laparotomy
Number of subjects 25 27 119
stage 3&4 Ca ovary 60% 75% 87%
Mean Blood Loss
P<0.001
164 mL 267 mL 1307 mL
length of hospital
stay p <.001
4 days 3 9
Node counts same
Operative time
(p 5 .009)
315minutes 254 261
Survival
P=.08 same
67.1% 75.6% 66.0%
Complications same

44. • The authors concluded that in patients undergoing primary
tumor excision of epithelial ovarian cancer alone or with 1
additional major surgery, robotic-assisted and laparoscopy are
preferable to laparotomy. overall survival is not influenced by
the type of surgical approach but by the extent of debulking
(complete vs incomplete)

45. Laparoscopic Assessment of Feasibility of
Upfront Optimal Surgical Cytoreduction
• In selected cases in which neoadjuvant triage is offered to
patients and the disease after completion of chemotherapy is
less extensive, laparoscopic debulking surgery may be
performed.

47. Laparoscopic Reassessment or Second-
Look Surgery
• Today this procedure is performed primarily in clinical trials or
in selected cases with uncertain clinical response of patients.
• Disease recurrence after negative second-look surgery was
reported to be similar for laparoscopy and laparotomy

48. Laparoscopic Assessment and Cytoreduction of
Recurrent Disease
• The role of secondary cytoreduction surgery to treat recurrent
ovarian carcinoma is debatable.
• several authors have suggested some criteria including
isolated recurrence, lack of ascites and optimal debulking at
the primary surgery as indications for secondary debulking.
• In these selected cases, laparoscopic secondary cytoreduction
has been reported in case reports and series, with acceptable
results insofar as efficacy and outcomes are concerned.

49. • laparoscopic debulking using the loop electrosurgical excision
procedure and argon beam coagulation seems feasible (94%),
successful (94%), and safe (complications in 6%)
Trinh et al 2004
• In a well-selected population, laparoscopy is technically
feasible and can be used for optimal cytoreduction in patients
with recurrent ovarian, fallopian, or primary peritoneal cancer
Nezhat et al 2012

50. Specific points
• Any suspect growth is biopsied.
• In the case of normal visual exploration, random peritoneal
biopsies are performed in the pouch of Douglas, pelvic and
abdominal parietal peritoneum, paracolic gutters,
hemidiaphragms and mesentery.
• When conservative treatment is considered, biopsy of the
contralateral ovary is performed only in the case of suspect
growth on imaging studies or at laparoscopy. Dilation and
curettage are performed so as not to miss a possible
endometrial spread or a synchronous tumor
• Removal of the specimen exclusively using a laparoscopic bag
and control of the bag integrity once extracted

51. Thanks

52. • This powerpoint presentation was presented by Dr
Ajay Aggarwal under moderation of Dr Nikita Trehan
on 04/03/2015 at 12:30pm indian time and 11am
Dubai time. It was a video conference between
Sunrise Hospital, Delhi and International modern
Hospital, Dubai. There was a discussion after
presentation and few points were highlighted.

53. • Management of simple and complex adnexal mass
was discussed. And guidelines were explained.
• For risk assessment, role of RMI and ROMA scores
were discussed and utility of ROMA score with high
sensitivity and equal efficacy was explained.
• Ultrasound findings to differentiate benign from
malignant masses as suggested by IOTA group were
also explained.

54. • FIGO staging of ovarian cancer was changed in 2014
and it was discussed during the presentation. Role of
new staging is in prognosis.

55. FIGO Ovarian Cancer Staging
Effective Jan. 1, 2014

56. FIGO Ovarian Cancer Staging
Effective Jan. 1, 2014

57. FIGO Ovarian Cancer Staging
Effective Jan. 1, 2014
• Other major recommendations are as follows:
• Histologic type including grading should be
designated at staging
• Primary site (ovary, Fallopian tube or peritoneum)
should be designated where possible
• Tumors that may otherwise qualify for stage I but
involved with dense adhesions justify upgrading to
stage II if tumor cells are histologically proven to be
present in the adhesions

58. • Role of chemotherapy, lymph node assessment
versus lymphadenectomy and role of fertility sparing
surgery were discussed with respect to different
stages of ovarian cancer.
• The session was finished with discussion of role of
minimal invasive surgery (laparoscopic surgery) in
early and advanced ovarian cancer and recurrence
cases as well.