European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 106–110
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Surgical management of non-epithelial ovarian malignancies: advantages and limitations of laparoscopy Anne-Sophie Gremeau a,b,*, Nicolas Bourdel a,b, Kris Jardon a,b, Benoit Rabischong a,b, Ge´rard Mage a,b, Jean-Luc Pouly a,b, Michel Canis a,b a CHU Clermont-Ferrand, CHU Estaing, Department of Obstetrics, Gynecology and Reproductive Medicine, 1 place Lucie Aubrac, 63003 Clermont-Ferrand cedex 1, France b CICE (International Center for Endoscopic Surgery), Faculty of Medicine, Bat 3C, 28 place Henri Dunand, 63000 Clermont-Ferrand, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 May 2013 Received in revised form 22 September 2013 Accepted 15 October 2013
Objective: To compare open and laparoscopic surgery in the management of non-epithelial ovarian malignancies. Study design: Retrospective study from University Hospital of Clermont-Ferrand, France, of 20 patients undergoing surgery for non-epithelial ovarian malignancies. We compared the outcome of 13 open surgeries and 7 laparoscopic surgeries. The main outcome measures were stage and size of the tumor, surgical procedure, hospital stay, adjuvant treatment, follow-up and fertility. Results: The mean age of the patients and the type of tumor at the time of diagnosis were similar in the two groups but the tumor size was significantly larger in the laparotomy group (14.0 cm vs. 6.7 cm; p < 0.05). Treatment was conservative in 85.6% vs. 61.5% in the laparoscopy and laparotomy groups respectively. Tumor stages were not statistically different in the two groups. The hospital stay was shorter in the laparoscopy group (3.1 days vs. 6.9 days p = 0.03) and there were no differences in terms of complications, surgical procedures, number of lymph nodes removed and adjuvant treatment. Conclusions: Laparoscopy respecting the usual oncologic principles appears to be a good alternative to laparotomy for the initial management of non-epithelial ovarian malignancies. The limiting factors of this technique remain the tumor size, the tumor stages and the surgeon’s experience. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Non-epithelial ovarian malignancies Laparoscopy
1. Introduction Non epithelial ovarian malignancies represent approximately 10% of ovarian cancers [1–3]. Two groups have been described in our study: ovarian sex cord-stromal tumors (OSCTs), including granulosa and Sertoli Leydig tumors, and malignant ovarian germ cell tumors (MOGCTs), including dysgerminoma, yolk sac tumors, choriocarcinoma, embryonal carcinoma, immature teratoma and mixed germ cell tumors [4]. Due to their low incidence, no prospective randomized studies have been published, and management of these tumors is based on the results of retrospective studies. Certain specific points need to be highlighted for management of these tumors: firstly, especially for germinal tumors, they are neoplasms with rapid
* Corresponding author at: Gyne´cologie Obste´trique Reproduction Humaine, CHU Estaing, 1 place Lucie Aubrac, 63003 Clermont-Ferrand cedex 1, France. Tel.: +33 4 73 755 042; fax: +33 4 73 750 152. E-mail addresses: [email protected], [email protected] (A.-S. Gremeau). 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.10.023
growth and they can reach voluminous dimensions rapidly. Secondly, the first operation is sometimes carried out in an emergency context (torsion or rupture) by a surgeon not always qualified in oncology. Lastly, they occur most often in young women and it is important to try to preserve these patients’ fertility. In young women, conservative surgery (unilateral adnexectomy, exploration of the pelvis and abdominal cavity, peritoneal cytology and biopsies) is usually performed in association with platinum-based chemotherapy [5,6]. Initial surgery is essential since it allows diagnosis, staging and the first treatment [7]. Usually the first oncologic surgery is performed by laparotomy, but for these rare tumors affecting young patients we wondered if laparoscopy could be an alternative to open surgery. In addition to its traditional advantages (painless, cosmetic result, fewer complications, faster return to normal activities, shorter hospital stay), laparoscopy could create fewer post-operative adhesions, which could be essential in this population [8,9]. The aim of the study is to assess the feasibility of the laparoscopic approach and to compare the outcomes of patients treated initially by laparoscopy or by laparotomy.
A.-S. Gremeau et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 106–110
2. Materials and methods This is a retrospective study including all non-epithelial ovarian malignancies, such as ovarian sex cord-stromal tumors (OSCTs) and malignant ovarian germ cell tumors (MOGCTs), indexed in the database of the pathology unit at Clermont-Ferrand University Hospital, France, between 1989 and 2009. Patients were treated in two different units: the Gynecology Unit, and the Children’s Surgery Unit. For each patient the following items were manually recorded from their notes: age, symptoms, investigations (imagery and markers), tumor location and size, surgical management (laparotomy or laparoscopy, peritoneal cytology or biopsy, surgical procedure, conservative or radical treatment, lymphadenectomy, omentectomy, FIGO stage), duration of hospital stay, adjuvant treatments (chemotherapy, second look surgery), survey and fertility (menstruation and pregnancy rate). Radical treatment was defined as hysterectomy and bilateral salpingo-oophorectomy and conservative treatment as unilateral salpingo-oophorectomy in order to preserve fertility. Twenty-two patients were listed, two of whom were excluded for the following reasons: one with lost notes, and a case of gonadoblastoma with 46XY karyotype (which does not relate to the tumors treated in this work because it was a benign tumor). The tumor distribution is described in Table 1. The results obtained are expressed as percentage or mean with standard deviation. The comparison was carried out using the Fisher Exact test because of the small number of patients, and p < 0.05 was considered as significant. 3. Results Twenty patients were treated surgically for non-epithelial ovarian malignancies, amongst whom sixteen presented a MOGCT (80%), and four an OSCT (20%) (Table 1). According to the FIGO
classification of epithelial ovarian tumors, there were 11 stage I (55%), 5 stage II (25%), 2 stage III (10%) and 2 stage IV (10%) tumors. Fifty-five percent of the tumors were located on the left side, 35% on the right side and 10% were bilateral. The mean age of patients at the time of diagnosis was 29.1 19.1 years [min:6–max:70], including 4 pre-pubescent girls, 4 menopausal women, and 12 women of childbearing age. All the patients in the study underwent surgical treatment, 13 via laparotomy (two of them after laparoconversion) and 7 via exclusive laparoscopy (Table 2). In the laparoscopy group, 5 tumors were MOGCTs and 2 were OSCTs: finally, five of these tumors were stage I according to the FIGO classification. The average size of lesions was 6.7 3.2 cm, and the mean age of patients was 32.3 17.1 years. Six women had conservative treatment at the time of the initial surgery, including one who finally required radical surgery due to non-response to the chemotherapy. The only radical treatment concerned a 60 year old patient. All the patients underwent abdominal and pelvic exploration with peritoneal cytology, 3 had peritoneal biopsies, 2 had an omentectomy, and one a pelvic and aortic lymphadenectomy because of frozen sectioning of peritoneal biopsies positive for adenocarcinoma. The average hospital stay was 3.1 1.5 days and there were no per-operative complications. The mean duration of follow-up was 3.4 2.3 years. Five patients received platinum-based chemotherapy. Three patients had a second-look surgery, 1 stage II tumor for findings on imaging after chemotherapy (biopsies were positives), and 2 stage I tumors for young women who wished for pregnancy. Two of these surgeries proved to be negative, and the third was positive requiring radical treatment. Regarding complications, one patient developed a trocar site metastasis. Management was surgical and at the time of writing the patient is alive with no evidence of disease. Finally one patient died and the others are alive without recurrence at 2 years. The patient who died had a stage IV choriocarcinoma with lung and cerebral metastasis, and her death was due to the cerebral
Table 1 Tumor distribution.
Malignant non epithelial ovarian tumors N=22 Exclusions -1 gonadoblastoma -1 lost note
Malignant ovarian germ cell tumors (MOGCTs) n=16
Dysgerminoma n=3
Non Dysgerminoma Tumors n=13
Immature Teratoma n=5
Yolk sac tumor n=2
Ovarian sex cord stromal tumors (OSCTs) n=4
Granulosa Tumors n=2
Sertoli-Leydig tumors n=2
Secretive Tumors n=8
Choriocarcinoma n=2
Embryonal Carcinoma n=1
107
Mixed Germ Cell Tumors n=3 -Embryonic carcinoma and Yolk sac tumor -Choriocarcinoma and dysgerminoma -Choriocarcinoma and yolk sac tumor
108
A.-S. Gremeau et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 106–110
Table 2 Comparison laparoscopy vs. laparotomy in the management of rare ovarian tumors.
Stage FIGO I II III IV Tumor size (cm) Mean SD Median [min–max] Age (years) Mean SD Median [min–max] Tumor type MGOT MTSC Surgery Conservative Radical Procedures Salpingo-oophorectomy (SO) Cystectomy Bilateral salpingo-oophorectomy (BSO) Hysterectomy and BSO Omentectomy Lymphadenectomy Peritoneal biopsies Digestive resection Endometrial biospies Appendicectomy Hospital stay (days) Mean SD Median [min–max] Complications Follow up Lost to follow-up Recurrences Death Adjuvant treatment Chemotherapy Second look surgery Follow-up duration (years) Mean SD Median [min–max]
Laparoscopy (n = 7)
Laparotomy (n = 13)
p value
71.4% (5) 14.3% (1) 0% 14.3% (1)
46.2% (6) 30.8% (4) 15.4% (2) 7.7% (1)
NS NS NS NS
6.7 3.2 7 [3–11]
14 5.7 13 [6–23]
0.007
32.3 17.1 31 [6–60]
27.4 20.6 16 [8–70]
NS
71.4% (5) 28.6% (2)
84.6% (11) 15.4% (2)
NS NS
85.7% (6) 14.3% (1)
61.5% (8) 38.5% (5)
NS NS
6 0 1 1 2 1 2 0 3 0
7 1 1 4 6 4 4 1 0 2
NS NS NS NS NS NS NS NS 0.03 NS
3.1 1.5 3 [2–6] 14.3% (1)a
6.9 4.9 5 [2–16] 23.1% (3)b
0.03
0% 0% 14.3% (1)
30.8% (4) 15.4% (2) 0%
NS NS
71.4% (5) 42.9% (3)
69.2% (9) 46.2% (6)
NS NS
3.4 2.3 4 [0.7–7]
6.7 5.6 5 [2–20]
NS
NS
Note: Values are means SD. NS = non significant. a 2 transfusions, one umbilical hernia. b One trocar site metastasis.
complications. This patient was only managed by laparoscopy in order to have histology and orientate her to adequate adjuvant chemotherapy. Thirteen patients underwent a laparotomy, including eleven cases of MOGCT and two of OSCT. Two of these open surgeries followed a laparoscopy because according to the surgeon, the stage and the tumor size required a laparotomy. Six of these tumors were stage I according to the FIGO classification. The mean size of the lesions was 14.0 5.705 cm, and the mean age of patients was 27.4 20.6 years. Five patients had radical treatment and eight conservative treatments at the time of the initial surgery. One of the patients managed conservatively required hysterectomy and contralateral salpingo-oophorectomy treatment during the second-look surgery after chemotherapy for persistence of aortic lymph nodes. On histological analysis, lymph nodes and myometrium were positive (embryonic carcinoma). Average hospital stay was 6.9 days 4.9 and the complication rate was 23.1%. We observed 2 severe hemorrhages, (one intra-operative and one post-operative, both requiring a transfusion), and one umbilical hernia. The mean duration of follow-up was 6.7 5.6 years. Eight patients received platinumbased chemotherapy, the three remaining cases were all stage I immature teratoma not requiring any auxiliary treatment. Lastly, six patients had second-look surgery, 4 for findings on imaging, and two
for young age (12 and 16 at the time of the diagnosis) in order to check the treatment response before genital activity. Four of these surgeries proved to be positive: one patient underwent radical treatment; two patients received surgical removal of tumor residue and one patient a further course of chemotherapy. In the context of the study, 4 patients were lost to follow-up and amongst the 7 patients followed up; two had a recurrence respectively after one and four years. Finally, when comparing laparoscopy with laparotomy as described in Table 2, the hospital stay was shorter in the laparoscopy group (3.1 vs. 6.9, p = 0.03). There were no differences in terms of patients’ age, surgical procedures and complications. Moreover, more endometrial biopsies were done during laparoscopy in order to exclude endometrial or trophoblastic disease. The tumor size was larger in the laparotomy group (14.0 cm vs. 6.7 cm, p = 0.006). Seventy percent (n = 14) of the patients received conservative management at the time of initial surgery and thirty percent (n = 6) radical treatment. In the second group, one 34 year old patient had a stage IIIc dysgerminoma, one patient had a frozen section indicating ‘‘malignant ovarian tumor’’, and the four other patients were more than 50 years old. Among the 14 patients treated conservatively, 2 received radical treatment during a second-look surgery for recurrence of the disease. In our series, 5 women out of
A.-S. Gremeau et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 106–110
the 7 (62.5%) wanting a pregnancy obtained it and one patient developed premature ovarian failure (POF) after vincristine, bleomycine and platinum (VBP) chemotherapy. 4. Comments MOGCTs and OSCTs represent less than 10% of all ovarian tumors. Due to their low incidence no prospective randomized studies have been published, and the management of these tumors is based on the results of retrospective studies and on ovarian epithelial tumor management [5]. Although they are rare compared to epithelial ovarian tumors, they occur mainly among women of childbearing age and it is important, if possible, to preserve the patient’s fertility. While the traditional surgical treatment for epithelial tumors includes total hysterectomy, bilateral adnexectomy, omentectomy, cytology, peritoneal biopsies and lymphadenectomy, with respect to non-epithelial tumors there is a consensus to carry out conservative laparotomy with cytology, meticulous inspection of the abdominal cavity, peritoneal biopsy and unilateral adnexectomy. The majority of studies describe surgical management by open surgery for all ovarian tumors, but some authors have recently insisted on the advantages of laparoscopy in the treatment of early stage epithelial ovarian tumors (Table 3). Park et al. [10,11] compared 19 laparoscopies with 33 laparotomies for the staging of early epithelial ovarian cancer. They did not find any difference in terms of surgical procedure, omentectomy, size, number of nodes retrieved and survival rate. In addition, they showed advantages Table 3 Published studies on laparoscopic vs. laparotomy staging of early-stage epithelial ovarian cancer [10,12].
Hua et al. [12] Operative time (min) Blood loss (ml) Pelvic lymph nodes Postoperative illness rate Left their bed 48 h after surgery Chi et al. [13] Operative time (min) Blood loss (ml) Left pelvic lymph nodes Right pelvic lymph nodes Left para aortic nodes Right para aortic nodes Complications Hospital stay (days) Ghezzi et al. [14] Operative time (min) Blood loss (ml) Pelvic lymph nodes Para aortic lymph nodes Intraoperative complications Postoperative complications Hospital stay (days) Overall survival rate Park et al. [10] Operative time (min) Blood loss (ml) Pelvic lymph nodes Para aortic nodes Hospital stay (days) Return of bowel movements (days) Time to adjuvant chemotherapy (days) Survival rate (17 months)
Laparoscopy
Laparotomy
p
n = 10 298 60 min 280 156 ml 25 5 20.0% 7
n = 11 182 43 min 346 170 ml 27 7 72.7% 1
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Surgical management of non-epithelial ovarian malignancies: advantages and limitations of laparoscopy Anne-Sophie Gremeau a,b,*, Nicolas Bourdel a,b, Kris Jardon a,b, Benoit Rabischong a,b, Ge´rard Mage a,b, Jean-Luc Pouly a,b, Michel Canis a,b a CHU Clermont-Ferrand, CHU Estaing, Department of Obstetrics, Gynecology and Reproductive Medicine, 1 place Lucie Aubrac, 63003 Clermont-Ferrand cedex 1, France b CICE (International Center for Endoscopic Surgery), Faculty of Medicine, Bat 3C, 28 place Henri Dunand, 63000 Clermont-Ferrand, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 May 2013 Received in revised form 22 September 2013 Accepted 15 October 2013
Objective: To compare open and laparoscopic surgery in the management of non-epithelial ovarian malignancies. Study design: Retrospective study from University Hospital of Clermont-Ferrand, France, of 20 patients undergoing surgery for non-epithelial ovarian malignancies. We compared the outcome of 13 open surgeries and 7 laparoscopic surgeries. The main outcome measures were stage and size of the tumor, surgical procedure, hospital stay, adjuvant treatment, follow-up and fertility. Results: The mean age of the patients and the type of tumor at the time of diagnosis were similar in the two groups but the tumor size was significantly larger in the laparotomy group (14.0 cm vs. 6.7 cm; p < 0.05). Treatment was conservative in 85.6% vs. 61.5% in the laparoscopy and laparotomy groups respectively. Tumor stages were not statistically different in the two groups. The hospital stay was shorter in the laparoscopy group (3.1 days vs. 6.9 days p = 0.03) and there were no differences in terms of complications, surgical procedures, number of lymph nodes removed and adjuvant treatment. Conclusions: Laparoscopy respecting the usual oncologic principles appears to be a good alternative to laparotomy for the initial management of non-epithelial ovarian malignancies. The limiting factors of this technique remain the tumor size, the tumor stages and the surgeon’s experience. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Non-epithelial ovarian malignancies Laparoscopy
1. Introduction Non epithelial ovarian malignancies represent approximately 10% of ovarian cancers [1–3]. Two groups have been described in our study: ovarian sex cord-stromal tumors (OSCTs), including granulosa and Sertoli Leydig tumors, and malignant ovarian germ cell tumors (MOGCTs), including dysgerminoma, yolk sac tumors, choriocarcinoma, embryonal carcinoma, immature teratoma and mixed germ cell tumors [4]. Due to their low incidence, no prospective randomized studies have been published, and management of these tumors is based on the results of retrospective studies. Certain specific points need to be highlighted for management of these tumors: firstly, especially for germinal tumors, they are neoplasms with rapid
* Corresponding author at: Gyne´cologie Obste´trique Reproduction Humaine, CHU Estaing, 1 place Lucie Aubrac, 63003 Clermont-Ferrand cedex 1, France. Tel.: +33 4 73 755 042; fax: +33 4 73 750 152. E-mail addresses: [email protected], [email protected] (A.-S. Gremeau). 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.10.023
growth and they can reach voluminous dimensions rapidly. Secondly, the first operation is sometimes carried out in an emergency context (torsion or rupture) by a surgeon not always qualified in oncology. Lastly, they occur most often in young women and it is important to try to preserve these patients’ fertility. In young women, conservative surgery (unilateral adnexectomy, exploration of the pelvis and abdominal cavity, peritoneal cytology and biopsies) is usually performed in association with platinum-based chemotherapy [5,6]. Initial surgery is essential since it allows diagnosis, staging and the first treatment [7]. Usually the first oncologic surgery is performed by laparotomy, but for these rare tumors affecting young patients we wondered if laparoscopy could be an alternative to open surgery. In addition to its traditional advantages (painless, cosmetic result, fewer complications, faster return to normal activities, shorter hospital stay), laparoscopy could create fewer post-operative adhesions, which could be essential in this population [8,9]. The aim of the study is to assess the feasibility of the laparoscopic approach and to compare the outcomes of patients treated initially by laparoscopy or by laparotomy.
A.-S. Gremeau et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 106–110
2. Materials and methods This is a retrospective study including all non-epithelial ovarian malignancies, such as ovarian sex cord-stromal tumors (OSCTs) and malignant ovarian germ cell tumors (MOGCTs), indexed in the database of the pathology unit at Clermont-Ferrand University Hospital, France, between 1989 and 2009. Patients were treated in two different units: the Gynecology Unit, and the Children’s Surgery Unit. For each patient the following items were manually recorded from their notes: age, symptoms, investigations (imagery and markers), tumor location and size, surgical management (laparotomy or laparoscopy, peritoneal cytology or biopsy, surgical procedure, conservative or radical treatment, lymphadenectomy, omentectomy, FIGO stage), duration of hospital stay, adjuvant treatments (chemotherapy, second look surgery), survey and fertility (menstruation and pregnancy rate). Radical treatment was defined as hysterectomy and bilateral salpingo-oophorectomy and conservative treatment as unilateral salpingo-oophorectomy in order to preserve fertility. Twenty-two patients were listed, two of whom were excluded for the following reasons: one with lost notes, and a case of gonadoblastoma with 46XY karyotype (which does not relate to the tumors treated in this work because it was a benign tumor). The tumor distribution is described in Table 1. The results obtained are expressed as percentage or mean with standard deviation. The comparison was carried out using the Fisher Exact test because of the small number of patients, and p < 0.05 was considered as significant. 3. Results Twenty patients were treated surgically for non-epithelial ovarian malignancies, amongst whom sixteen presented a MOGCT (80%), and four an OSCT (20%) (Table 1). According to the FIGO
classification of epithelial ovarian tumors, there were 11 stage I (55%), 5 stage II (25%), 2 stage III (10%) and 2 stage IV (10%) tumors. Fifty-five percent of the tumors were located on the left side, 35% on the right side and 10% were bilateral. The mean age of patients at the time of diagnosis was 29.1 19.1 years [min:6–max:70], including 4 pre-pubescent girls, 4 menopausal women, and 12 women of childbearing age. All the patients in the study underwent surgical treatment, 13 via laparotomy (two of them after laparoconversion) and 7 via exclusive laparoscopy (Table 2). In the laparoscopy group, 5 tumors were MOGCTs and 2 were OSCTs: finally, five of these tumors were stage I according to the FIGO classification. The average size of lesions was 6.7 3.2 cm, and the mean age of patients was 32.3 17.1 years. Six women had conservative treatment at the time of the initial surgery, including one who finally required radical surgery due to non-response to the chemotherapy. The only radical treatment concerned a 60 year old patient. All the patients underwent abdominal and pelvic exploration with peritoneal cytology, 3 had peritoneal biopsies, 2 had an omentectomy, and one a pelvic and aortic lymphadenectomy because of frozen sectioning of peritoneal biopsies positive for adenocarcinoma. The average hospital stay was 3.1 1.5 days and there were no per-operative complications. The mean duration of follow-up was 3.4 2.3 years. Five patients received platinum-based chemotherapy. Three patients had a second-look surgery, 1 stage II tumor for findings on imaging after chemotherapy (biopsies were positives), and 2 stage I tumors for young women who wished for pregnancy. Two of these surgeries proved to be negative, and the third was positive requiring radical treatment. Regarding complications, one patient developed a trocar site metastasis. Management was surgical and at the time of writing the patient is alive with no evidence of disease. Finally one patient died and the others are alive without recurrence at 2 years. The patient who died had a stage IV choriocarcinoma with lung and cerebral metastasis, and her death was due to the cerebral
Table 1 Tumor distribution.
Malignant non epithelial ovarian tumors N=22 Exclusions -1 gonadoblastoma -1 lost note
Malignant ovarian germ cell tumors (MOGCTs) n=16
Dysgerminoma n=3
Non Dysgerminoma Tumors n=13
Immature Teratoma n=5
Yolk sac tumor n=2
Ovarian sex cord stromal tumors (OSCTs) n=4
Granulosa Tumors n=2
Sertoli-Leydig tumors n=2
Secretive Tumors n=8
Choriocarcinoma n=2
Embryonal Carcinoma n=1
107
Mixed Germ Cell Tumors n=3 -Embryonic carcinoma and Yolk sac tumor -Choriocarcinoma and dysgerminoma -Choriocarcinoma and yolk sac tumor
108
A.-S. Gremeau et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 106–110
Table 2 Comparison laparoscopy vs. laparotomy in the management of rare ovarian tumors.
Stage FIGO I II III IV Tumor size (cm) Mean SD Median [min–max] Age (years) Mean SD Median [min–max] Tumor type MGOT MTSC Surgery Conservative Radical Procedures Salpingo-oophorectomy (SO) Cystectomy Bilateral salpingo-oophorectomy (BSO) Hysterectomy and BSO Omentectomy Lymphadenectomy Peritoneal biopsies Digestive resection Endometrial biospies Appendicectomy Hospital stay (days) Mean SD Median [min–max] Complications Follow up Lost to follow-up Recurrences Death Adjuvant treatment Chemotherapy Second look surgery Follow-up duration (years) Mean SD Median [min–max]
Laparoscopy (n = 7)
Laparotomy (n = 13)
p value
71.4% (5) 14.3% (1) 0% 14.3% (1)
46.2% (6) 30.8% (4) 15.4% (2) 7.7% (1)
NS NS NS NS
6.7 3.2 7 [3–11]
14 5.7 13 [6–23]
0.007
32.3 17.1 31 [6–60]
27.4 20.6 16 [8–70]
NS
71.4% (5) 28.6% (2)
84.6% (11) 15.4% (2)
NS NS
85.7% (6) 14.3% (1)
61.5% (8) 38.5% (5)
NS NS
6 0 1 1 2 1 2 0 3 0
7 1 1 4 6 4 4 1 0 2
NS NS NS NS NS NS NS NS 0.03 NS
3.1 1.5 3 [2–6] 14.3% (1)a
6.9 4.9 5 [2–16] 23.1% (3)b
0.03
0% 0% 14.3% (1)
30.8% (4) 15.4% (2) 0%
NS NS
71.4% (5) 42.9% (3)
69.2% (9) 46.2% (6)
NS NS
3.4 2.3 4 [0.7–7]
6.7 5.6 5 [2–20]
NS
NS
Note: Values are means SD. NS = non significant. a 2 transfusions, one umbilical hernia. b One trocar site metastasis.
complications. This patient was only managed by laparoscopy in order to have histology and orientate her to adequate adjuvant chemotherapy. Thirteen patients underwent a laparotomy, including eleven cases of MOGCT and two of OSCT. Two of these open surgeries followed a laparoscopy because according to the surgeon, the stage and the tumor size required a laparotomy. Six of these tumors were stage I according to the FIGO classification. The mean size of the lesions was 14.0 5.705 cm, and the mean age of patients was 27.4 20.6 years. Five patients had radical treatment and eight conservative treatments at the time of the initial surgery. One of the patients managed conservatively required hysterectomy and contralateral salpingo-oophorectomy treatment during the second-look surgery after chemotherapy for persistence of aortic lymph nodes. On histological analysis, lymph nodes and myometrium were positive (embryonic carcinoma). Average hospital stay was 6.9 days 4.9 and the complication rate was 23.1%. We observed 2 severe hemorrhages, (one intra-operative and one post-operative, both requiring a transfusion), and one umbilical hernia. The mean duration of follow-up was 6.7 5.6 years. Eight patients received platinumbased chemotherapy, the three remaining cases were all stage I immature teratoma not requiring any auxiliary treatment. Lastly, six patients had second-look surgery, 4 for findings on imaging, and two
for young age (12 and 16 at the time of the diagnosis) in order to check the treatment response before genital activity. Four of these surgeries proved to be positive: one patient underwent radical treatment; two patients received surgical removal of tumor residue and one patient a further course of chemotherapy. In the context of the study, 4 patients were lost to follow-up and amongst the 7 patients followed up; two had a recurrence respectively after one and four years. Finally, when comparing laparoscopy with laparotomy as described in Table 2, the hospital stay was shorter in the laparoscopy group (3.1 vs. 6.9, p = 0.03). There were no differences in terms of patients’ age, surgical procedures and complications. Moreover, more endometrial biopsies were done during laparoscopy in order to exclude endometrial or trophoblastic disease. The tumor size was larger in the laparotomy group (14.0 cm vs. 6.7 cm, p = 0.006). Seventy percent (n = 14) of the patients received conservative management at the time of initial surgery and thirty percent (n = 6) radical treatment. In the second group, one 34 year old patient had a stage IIIc dysgerminoma, one patient had a frozen section indicating ‘‘malignant ovarian tumor’’, and the four other patients were more than 50 years old. Among the 14 patients treated conservatively, 2 received radical treatment during a second-look surgery for recurrence of the disease. In our series, 5 women out of
A.-S. Gremeau et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 106–110
the 7 (62.5%) wanting a pregnancy obtained it and one patient developed premature ovarian failure (POF) after vincristine, bleomycine and platinum (VBP) chemotherapy. 4. Comments MOGCTs and OSCTs represent less than 10% of all ovarian tumors. Due to their low incidence no prospective randomized studies have been published, and the management of these tumors is based on the results of retrospective studies and on ovarian epithelial tumor management [5]. Although they are rare compared to epithelial ovarian tumors, they occur mainly among women of childbearing age and it is important, if possible, to preserve the patient’s fertility. While the traditional surgical treatment for epithelial tumors includes total hysterectomy, bilateral adnexectomy, omentectomy, cytology, peritoneal biopsies and lymphadenectomy, with respect to non-epithelial tumors there is a consensus to carry out conservative laparotomy with cytology, meticulous inspection of the abdominal cavity, peritoneal biopsy and unilateral adnexectomy. The majority of studies describe surgical management by open surgery for all ovarian tumors, but some authors have recently insisted on the advantages of laparoscopy in the treatment of early stage epithelial ovarian tumors (Table 3). Park et al. [10,11] compared 19 laparoscopies with 33 laparotomies for the staging of early epithelial ovarian cancer. They did not find any difference in terms of surgical procedure, omentectomy, size, number of nodes retrieved and survival rate. In addition, they showed advantages Table 3 Published studies on laparoscopic vs. laparotomy staging of early-stage epithelial ovarian cancer [10,12].
Hua et al. [12] Operative time (min) Blood loss (ml) Pelvic lymph nodes Postoperative illness rate Left their bed 48 h after surgery Chi et al. [13] Operative time (min) Blood loss (ml) Left pelvic lymph nodes Right pelvic lymph nodes Left para aortic nodes Right para aortic nodes Complications Hospital stay (days) Ghezzi et al. [14] Operative time (min) Blood loss (ml) Pelvic lymph nodes Para aortic lymph nodes Intraoperative complications Postoperative complications Hospital stay (days) Overall survival rate Park et al. [10] Operative time (min) Blood loss (ml) Pelvic lymph nodes Para aortic nodes Hospital stay (days) Return of bowel movements (days) Time to adjuvant chemotherapy (days) Survival rate (17 months)
Laparoscopy
Laparotomy
p
n = 10 298 60 min 280 156 ml 25 5 20.0% 7
n = 11 182 43 min 346 170 ml 27 7 72.7% 1
