Gynekologisk Laparoskopisk
tumörkirurgi
Christer Borgfeldt
Överläkare
Kvinnokliniken
Universitetssjukhuset i Lund
• Ovarialtumörer och laparoskopi
• Cervixcancer
– Laparoskopisk robotassisterad radikal
hysterectomi
– Sentinel node konceptet vid cervixcancer
Laparoscopi vid
adnexförändringar och
ovarialcancer
4 out of 5
ovarian cyst spontainously
disappear in women 25-40 år
81% +/- 17%(95% CI)
Borgfeldt, C. Andolf, E. Transvaginal sonographic ovarian findings
in a random sample of women 25-40 years old.
1999 (13(5)) pp 345-350 Ultrasound in Obstetrics and Gynecology
Kolla med ultraljud att adnexförändringen
finns kvar!!!
Laura J. Havrilesky et al Obstet Gynecol 2003;102:243–51.
N=396
The Prevalence of adnexal lesions in
asymptomatic postmenopausal women
• 3–17%
• 17% more than half of the lesions were below 1
cm in size.
Levine D, et al Radiology 1992;184:653–9
Simple adnexal cysts: the natural history in postmenopausal women.
The Prevalence of adnexal lesions in
asymptomatic postmenopausal women
• Autopsy material from 104 postmenopausal
women.
– 56% (29/52) of the women had adnexal
lesions,
• cysts being detected in 54% (28/52)
• solid lesions in 12% (6/52).
– > 30 mm 8% (4/52)
– > 40 mm 4% (2/52)
Valentin L et al Frequency and type of adnexal lesions in autopsy material from postmenopausal women:
ultrasound study with histological correlation. Ultrasound Obstet Gynecol. 2003 Sep;22(3):284-9.
Morphologic Index
DePriest et al 1993
Risk analyze
How to manage an adnexal lesions?
• Laparoscopy
– No ascitic fluid
– <10 cm
• Cystectomy vs
Oophorectomy
– Age 40
• Laparotomy
– Complex cystic lesion
with ascitic fluid
– RMI>200
Laparoscopy
• One day procedure
• 2 10mm + 2 5mm troachars
• Avoid cyst rupture
• Cyst or adnex removed in plastic bag
• Wait for final histo-pathological report 7-12d
PORT placement
Ovarian adnexal lesion
HEAD
Umbilicus
10 mm
Optik
10 mm
Atraumatisk tång
Plastpåse
PUBIS
5 mm unipolär sax
5 mm bipolär tång
Laparoscopy
• One day procedure
• 2 10mm + 2 5mm troachars
• Avoid cyst rupture
• Cyst or adnex removed in plastic bag
• Wait for final histo-pathological report 7-12d
Management of adnexal cystic masses with unexpected
intracystic vegetations detected during laparoscopy.
Marana et al 2005 (12(6)) pp 502-507J Minim Invasive Gynecol
• Thirty-five (5.2%) of 667 patients had unexpected
intracystic vegetations.
• Frozen section
– benign in 32 patients and borderline in 3 patients
• Final pathology
– borderline ovarian tumor in 5 of the 35 patients (14.3%)
– benign in 30 patients (85.7%).
Port-site metastases after open laparoscopy: a study in 173
patients with advanced ovarian carcinoma.
Vergote, I. et al 2005 (15(5)) pp 776-779 Int J Gynecol Cancer
• Thirty (17%) patients developed port-site metastases.
• All port-site metastases disappeared during primary
therapy, and none of the patients developed a second
relapse in one of their port sites.
• Prognosis was not worse in this group of patients
Don't leak cystic fluid!
Vergote et al 2001
Meta-analysis of 1545 stage I ovca’s
DFS (%)
100
90
80
70
60
50
40
30
20
10
0
IA
IB
IC
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5 yrs
Complications
• Meta-analysis: 1809 laparoscopy vs. 1802 laparotomy
• The overall risk of complications was significantly lower for patients
operated by laparoscopic surgery [relative risk (RR)
0.59; 95% confidence interval (CI) 0.50-0.70].
– Major complications (RR 1.0; 95% CI 0.60-1.65).
– Minor complications was significantly lower for patients operated
by laparoscopic surgery (RR 0.55; 95% CI 0.45-0.66).
Chapron et al 2002 (17(5)) pp 1334-1342 Hum Reprod
Why perform complete staging
procedure in patients with early
ovarian cancer?
Should it be performed with
laparoscopy?
1 out of 4 will be upstaged in
patients with presumed
early ovarian cancer
• 24% upstaged to stage III
Young et al JAMA 1983
Subclinical metastases in presumed
early ovarian cancer
bowel
abdom.perit.
pevic perit.
pao lln
pelvic lln
omentum
diaphragm
cytology
%
0
5
10
15
20
25
14 references 1971-1994
Conclusions
Early Ovarian Cancer trials
• Icon1 study
– Adjuvant platinum-based chemotherapy improved
survival in women with early ovarian cancer
• Action study
– Adjuvant chemotherapy following optimal surgical staging
is of little or no benefit.
Film time
Laparoscopic robot-assisted
Para aortic lymphnode disection
• Indication:
50 year old women who had had surgery one
month earlier for granulosa cell tumor
presumable stage 1 a
Take home messages
• Laparoskopi om fertila kvinnor med adnexresistenser mindre än 10
cm
– Under 40 år cystectomi
– Över 40 år SOE unilateralt
• Laparoskopi har färre komplikationer än laparotomi
• Patienter med port-site metastases efter LS har inte sämre prognos
om de behandlas med chemoterapi
• Vid förmodat stadium 1 ovarialcancer bör patienten genomgå
fullständig staging procedure för bli rätt stadieindelade och undvika
onödig cytostatikabehandling
Laparoscopisk cervixcancer kirurgi
• Vad krävs?
– Volym av patienter
– Samtränat team
– Robot underlättar
Laparoskopiskt Robotassisterad
radikal hysterectomi
med pelvin lymfkörtelutrymning
erfarenheter ifrån Lund
• Ca 80 patienter opererade
• 3 operatörer plus 2 under träning
• Operationstider medel 270 minuter
• Blödning medel 150 ml
Radical HIT +
Pelvic lymphnode
disection
Magrina et al 2008
Robotic
LS
Laparotomy
Patients
(n)
27
31
35
Op time
(min)
190
220
167
Blood loss
(ml)
133
208
444
Lymph nodes removed
(n)
25,9
25,9
27,7
Hospital stay
(days)
1,7
2,4
3,6
Peroperativa Komplikationer i Lund
78 patienter opererade
Komplikationer
N
Åtgärd
Blödning >400 ml
5
Serosaskada på tarm
1
Sutur i tarmvägg
Kärlskada
1
Sutur i a.iliaca ext
Nervskada
1
Spontan restituering av N.Obturatorius
Ls robotkirugi vid cervixcancer
Fördelar
• Mindre blödning
• Kortare vårdtid
• Snabbare
•
återhämtning av pat
Om positiva SLN
körtlar snabbare start
av postoperativ
strålbehandling
Nackdelar
• Initialt förlängd op tid
• Mer träning krävs av
•
operatör och op team
Ökad kostnad för
robot och instrument
• Vad händer när
cervixcancer
patienten kräver
att bli erbjuden
Laparoskopisk
robotkirurgi i
framtiden?
Indikationer för
Sentinel node
vid cervix cancer:
1. att öka chansen att hitta den/de mest
väsentliga lymfkörtlarna
2. att vid användandet av ”skarp” SLN
minska morbiditeten
SLN distribution:
Sentinel nodes
Positive sentinel nodes
Rob et al. Gynecol Oncol 98:281-88, 2005
Sentinel node experiences in Lund
Mars 2005-juli 2008
Cervical cancer patients N=80
• Lymphoscintigram 120 MBq
• (Blue dye = Patent blue)
• Handhold gamma probe
SLN förfarande först sen fullständig lymfkörtelutrymning
Detection rate vid SLN
Author
Tumor size
N
No of Pat. with
No of Pat. with
detected SLN
Bilateral detected SLN
%
Lund 2005-2008
%
80
73
91
45
56
<20 mm
53
50
94
34
64
>20 mm
27
23
85
11
41
824
720
84
66
590
523
89
87
<20 mm
249
234
94
?
>20 mm
305
255
84
?
Total in literature
Hauspy et al 2007
Altgassen et al 2008
Sensitivitet vid SLN
No of Pat. with
Author
Tumor
size
positive SLN
detection
Hematoxylin
staining
LN
metastases
Hematoxylin
staining
%
73
14
13
93
<20 mm
50
3
3
100
>20 mm
23
11
10
91
824
161
148
92
504
106
82
77
<20 mm
232
22
20
91
>20 mm
239
77
56
73
Lund
2005-2008
Sensitivity
Total in
literature
N
Hauspy et al
2007
Altgassen et al
2008
Negative Predictive value
No of Patients
Author
Tumor size
Neg Pred Value
N
True neg
SLN neg
%
73
59
60
98
<20 mm
50
50
50
100
>20 mm
23
16
17
94
824
663
676
98
504
398
422
94
<20 mm
232
210
212
99,1
>20 mm
239
162
183
88,5
Lund 2005-2008
Total in literature
Hauspy et al 2007
Altgassen et al 2008
False neg SLN in literature
Hausny et al 2007
• När det inte går att detektera SLN på ena
sidan i bäckenet bör fullständig lymfkörtel
utrymning utföras på denna sidan.
Cervical cancer < 20 mm
• False negative SLN rate < 1%
• Expected incidence of positive pelvic
lymph nodes is approximately 10% (<3
cm stage IB1)
• Risk of missing a positive node with the
SLN procedure <1/1000 patients
• När börjar vi erbjuda alla patienter med
tidig cervixcancer (pre-operativt bedömd < 2 cm)
skarp Sentinel node analys?
