European Journal of Obstetrics & Gynecology and Reproductive Biology 61 (1995) 147-150

Laparoscopic management of malignant ovarian cysts: a 7%case national survey. Part 2: Follow-up and final treatment

Bernard Blanc*, Claude D’Ercole, Eric Nicoloso, LCon Boubli

Service de GynPcologie ObstPtrique B, H6pital de la Conception. I3385 Marseille Cedex 5, France

Accepted 10 May 1994

Abstract

This paper reports a retrospective multi-institutional French survey carried out in 1992 to determine the incidence of laparoscopic management of malignant ovarian cysts. Of 5307 ovarian lesions treated endoscopically, 78 were malignant (1.47%) including 60 borderline tumours (77%) and 18 ovarian cancers (23%). Laparoscopic treatment was puncture in 23% of cases, partial exeresis in 51% and total removal in 26%. Laparotomy was immediately performed in 25% of the cases and as a second stage procedure in 58% (mean delay: 78 days). Laparotomy was not performed in 16% of the cases. Our findings suggest that laparoscopic manage- ment of ovarian lesions that subsequently prove to be malignant is not uncommon. To prevent the risk of metastasis, thorough pre-operative and per-operative evaluation is mandatory. In 22.4% of the patients presenting lesions in this study, laparoscopic tampering resulted in an upgrading of FIG0 stage.

Keywords: Laparoscopy; Ovarian cancer; Borderline lesion; Surgical management; FIG0 staging

1. Introduction

This paper reports a retrospective multi-institutional French survey, carried out from April to October 1992, to determine the incidence of laparoscopic management of malignant ovarian cysts. A total of 7122 ovarian lesions were examined laparoscopically and 5307 of

these were treated, including 78 malignant tumors (1.47%) (60 borderline tumors and 18 ovarian cancers).

Table 1 summarizes the laparoscopic procedures per- formed. In 41 cases (52.3%), the cystic lesions were punctured. In 18 patients (23.08%), puncture was the only laparoscopic procedure. In 40 cases (56.3%), partial exeresis limited to the cystic lesion was performed. In 20

Table 1 Laparoscopic treatment of 78 ovarian cysts subsequently found to be malignant

Procedure Borderline Neoplastic Total

Puncture only 12 6 18 Intraperitoneal cystectomy 19 1 20 Transparietal cystectomy 16 4 20 Intraperitoneal annexectomy 5 1 6 Intraperitoneal ovariectomy 3 2 5 Transparietal ovarectomy 5 4 9 Total 60 18 78

%

23.08 25.64 25.64

7.69 6.41

11.54

* Corresponding author, Tel.: +33 91 383786; Fax: +33 91 480940.

0301-2115/95/$09.50 0 1995 Elsevier Science Ireland Ltd. All rights reserved SSDI 0301-2115(95)0211 l-5

148 B. Blanc et al. /European Journal of Obstetrics & Gynecology and Reproductive Biology 61 (1995) 147-150

Table 2 Overall management of 78 adnexal masses subsequently found to be malignant

Ovarian disease

Laparoscopy only Immediate laparotomy Immediate laparotomy

+ second stage laparotomy Delayed laparotomy Lost to follow-up Total

Borderline lesion Cancer Total

12 0 12 11 5 16 2 2 4

34 II 45 I 0 1

60 18 78

%

15.4 20.5

5.1

57.7 1.28

cases (25.6%), the ovary or the whole adnexal was com- copy. This patient, who presented a borderline lesion, pletely removed. underwent transparietal cystectomy.

Frozen sections were studied preoperatively in 23 cases (29.5%). Findings were concordant with the final diagnosis in 16 cases (69.6%) and discordant in three cases (13%), i.e. three borderline lesions. In four cases (17.4%), frozen sections were doubtful, i.e. three borderline lesions and one cancer. In 11 cases (47.8%), frozen section findings led to immediate laparotomy during the same surgical procedure. However, in 10 cases (43.5%) surgery was postponed for a mean dura- tion of 75 days (range: 2-380 days) despite a positive frozen section. In two cases, frozen sections were nega- tive and only laparoscopic treatment was performed. Follow-up in these two patients is currently 6 and 72 months. The recovery period after laparoscopy was uneventful in 77 cases (98.8%), the only complication mentioned being parietal infection.

Tables 2 and 3 present a summary of surgical manage- ment in the 78 patients. Twelve patients (15.4%) with borderline lesions were treated by laparoscopy alone. Twenty patients (25.6%) underwent immediate laparot- omy. Of these patients, 19 presented suspicious laparo- scopic findings and four required repeat laparotomy. Forty-five patients (57.7%) underwent delayed laparoto- my. Of these patients, 11 had ovarian cancer. One foreign patient was lost to follow-up after the laparos-

An upgrade in FIG0 stage was observed in 11 cases (22.4%), including eight within the first month after lap- aroscopy. Upgrading was noted in live out of 60 patients presenting borderline lesions (8.3%) and six out of 18 patients with ovarian cancer (30%). Of the 11 patients, whose histories are exhaustively presented in Table 4, 10 did not undergo immediate laparotomy. In three of these cases, frozen section was positive and correlated with the final diagnosis. In the patient (no. 3) that underwent immediate laparotomy, frozen section was not performed but the decision to open the abdomen was taken because pyosalpinx was suspected. The final diagnosis in this patient was a cystadenocarcinoma and repeat laparotomy was performed. Case no. 9 involved a 34-year-old woman in whom intraperitoneal cystec- tomy yielded suspicious findings. Two months after lap- aroscopy, the cyst recurred and a transparietal cystectomy was performed demonstrating a stage IA borderline tumor. Three and half years later this patient presented a second recurrence and laparotomy was per- formed demonstrating stage IIIC cystadenocarcinoma. Tumor implantation was noted along the pathway of transparietal cystectomy needle. This patient is currently undergoing chemotherapy.

Follow-up data is presented in Table 5. The mean

Table 3 Correlation between ultrasonographic findings, laparoscopic appearance and decision to perform laparotomy during the laparoscopy

Laparoscopic aspect US findings

No suspicion Suspicion

n Immediate laparotomy ” Immediate laparotomy

Liquid Septation Solid Both solid/liquid Vegetations No echo Total

US, Ultrasonographic.

15 1 8 4 11 0 5 3

2 0 I 1 8 0 8 5 9 0 9 5 I 0 1 I

46 1 (2.17%) 32 19 (58.06%)

B. Blanc et al. /European Journal of Obstetrics & Gynecology and Reproductive Biology 61 (1995) 147-150 149

Table 4 Exhaustive presentation of 11 cases in which an upgrade in FIG0 stage was noted between laparoscopy and laparotomy

CaSe Laparoscopic Second-stage Histology FIG0 Macroscopic Microscopic Histology Duration of Current treatment laparotomy upgrading implants implants type follow-up status

delay a (months)

1 2 3 4 5 6 I 8 9

IO

OTPb KIP PctO+LI KIP Pct”Bb

ATP KIP KIPlb, KIP2 OTP

8 K IA-HA 15 K ICI11 15 K IA-IC 16 BL IA-IC 21 BL IC-III 21 BL IA-III 21 BL IA-WC 25 K IA-II

380 BL IA-WC 440 K IA-III

X X X

X

? ? X X X

11 KIP 120 BL IA-IV X ?

Serous Clear cell Serous Serous Serous Serous Serous ? Serous Andro- blastoma Mutinous

21 K breast 9 Died tumor 6 NED

20 NED 6 NED

50 NED 9 NED

12 NED I NED

23 NED

38 Died tumor

Pet, puncture; LI, imediate laparotomy; Pct”B, puncture and biopsy; NED, no evidence of disease. ‘Delay between laparoscopic treatment and second stage laparotomy. bFrozen section examination.

duration of follow-up in all 78 patients is 14.6 months. Three (3.8%) are dead including two from lesion-related causes. Fifty-nine patients (75.6%) are alive with no evi- dence of complication. Fourteen patients (17.9%) have been lost to follow-up. Laparoscopy was considered as the sole treatment in all these patients, one of whom had ovarian cancer. It is noteworthy that regular surveil- lance was possible in only 66 patients and that in 37 of these 66 patients (56.1%), the duration of follow-up is less than 1 year.

Table 6 Comparison of macroscopic findings in the American and present French studies

Tumor aspect American study French study

W) W)

<8C 61 66.10 Cystic 62 96 Unilocular 48 39.10 Unilateral 81 96 No suspicious findings 31 33

2. Discussion

Table I Comparison of laparoscopic procedures used in the American and present French studies

Our perusal of the literature turned up one study, very similar to this one, performed by Maiman in the United States [ 11. It included 42 cases involving laparoscopic excision of ovarian neoplasms subsequently found to be malignant. Like our study, the American experience indicates that laparoscopic management of malignant

Procedure

Puncture Partial exeresis Total exeresis

American study French study

W) (%)

38 23.10 33 51.28 29 25.60

Table 5 Follow-up of 18 patients who underwent laparoscopic management of adnexal cystic masses subsequently found to be malignant

Current status n % Table 8 Comparison of overall surgical management in the American and present French studies

NED Died

Tumor-related No precision

Complications Cancer of the contralateral ovary Breast cancer

No precision

59 15.65 3 3.84

(2) (1) (:, 2.56

(1) 14 11.95

Procedure American study French study

Immediate laparotomy 41% 20.5% Delayed laparotomy 11% 62.82% No laparotomy 12% 15.38% Lost to follow-up 0% 15.38% Mean delay to repeat 36 days 18 days

NED, no evidence of disease.

150 B. Blanc et al. /European Journal of Obstetrics & Gynecology and Reproductive Biology 61 (1995) 147-150

Table 9 Comparison of histology in the American and present French studies

Procedure

Borderline Cancer Germ. cell tumors Stromal tumors Stages II-IV

American study French study

(“/I (“Q

29 14.36 57 20.51

9.5 1.28 4.1 3.85

50 11.54

adnexal masses is not uncommon. In fact it seems likely that both studies underestimate the incidence of laparo- scopic tampering since we addressed our questionnaire only to surgical teams whose practices include routine laparoscopy and Maiman included only members of Oncologic Gynecology Society.

Tables 6, 7, 8, and 9, summarize the results of these two studies. The laparoscopic and macroscopic aspects of the lesions, as well as therapeutic procedures used, were quite similar in the two studies. In contrast, histologic findings were different. Maiman reported more invasive lesions (57% vs. 20.51%). Furthermore, initial staging revealed > 50% of lesions to be stage II or more in the American survey as compared to only 11.5% in our study.

Recurrence or transformation into real cancer has been documented after laparoscopic management of borderline tumors [2-51. In the present study, up- grading of FIG0 staging was observed in five laparoscopically treated borderline tumors (Table 4). In four of these cases, frank cancer was noted with parietal implants (two cases) and/or peritoneal implants (four cases). In the fifth case, intraperitoneal cystectomy led to an upgrade from stage IA to IC. It is noteworthy that in three cases, the upgrade was documented by repeat laparoscopy within 1 month after tampering. In the other two cases, repeat laparoscopy was performed much later (380 and 780 days). In this study the average age in patients with borderline tumors was 5 years lower than in those with ovarian cancer. In a previous report, a lo-year difference was reported [6]. The fact that many of these women still want children underscores the need for careful selection to avoid upgrading of a borderline tumor.

This study also documented spreading of cancer after laparoscopic treatment of ovarian cancer (see Table 4). In six cases, further invasion was noted between the laparoscopy and laparotomy. Prognosis is not changed by either intraperitoneal rupture or perlaparoscopic puncture of the cyst change the prognosis or by peroperative handling or traumatism [7,8].

When malignancy is ascertained, surgical treatment should be undertaken immediately, if possible on the day of the laparoscopy. In our survey no spreading was noted when the surgery was performed immediately after the laparoscopy. Our data showing a mean delay of >8 weeks between diagnostic laparoscopic and sur- gery indicates that treatment is often postponed.

Our findings confirm the following previous recom- mendations for laparoscopy management of adnexal cystic masses: (a) Patients must be careful selected (ultrasonography). Blind application of laparoscopic treatment is hazardous. (b) During laparoscopy strict guidelines should be followed to rule out malignancy (complete investigation of the abdominal cavity and routine analysis of peritoneal liquid) and malignant seeding (single-use of puncture needles, complete empty- ing of the cyst, per-operative cystoscopy, and abdominal cavity irrigation and wrapping of the resection specimen before extraction). (c) If suspicious lesions are noted outside the ovary or inside the cyst, laparotomy should be performed to remove the ovary for frozen section study. Further study is needed to assess the risk of malignant transformation of borderline lesions.

Acknowledgments

We would like to thank all the responding surgeons without whose cooperation this survey would not have been possible.

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