Introduction of Staging Laparoscopy in the Management of Advanced Epithelial Ovarian, Tubal and Peritoneal Cancer

Abstract

Most women with epithelial ovarian cancer (EOC) are diagnosed at advanced stages of disease (AEOC) when there is already widespread intraperitoneal disease. Survival rates are low for these women. The standard approach for AEOC patients is primary debulking surgery (PDS) followed by combination platinum-based chemotherapy. An option developed for these patients is use of neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). A critical prognostic factor for survival in patients with AEOC who receive PDS or NACT/IDS is the amount of visible tumor after surgery. Survival rates are higher in patients with no or minimal residual disease (RT). The European Organisation for Research and Treatment of Cancer–National Cancer Institute of Canada Clinical Trials Group trial showed that NACT followed by IDS decreased postoperative morbidity and provided similar survival outcomes to those of PDS. To guide management of primary AEOC patients toward either PDS or NACT, staging laparoscopy (S-LPS) is proposed to assess the intra-abdominal dissemination of disease and to predict the chances of optimal cytoreduction, but the effect of this strategy on survival outcomes has not been evaluated. This retrospective study was designed to determine the prognostic impact of routine use of S-LPS in patients with primary AEOC on the progression-free survival and overall survival in women with AEOC. The study subjects were patients at a single tertiary referral center treated between 2006 and 2010; all submitted to S-LPS before treatment with PDS or NACT. Residual disease was classified as follows: RT = 0 (absence of grossly visible tumor [complete cytoreduction]) and RT of 1 cm or less (optimal cytoreduction). Cases were stratified based on residual tumor at the time of treatment (PDS or IDS). Univariate and multivariate analyses were used to assess the surgical and survival outcome. Staging laparoscopy was performed in 300 consecutive patients; no complications occurred related to the surgical procedure. Laparoscopic staging revealed a high tumor load in almost half of the patients (46.3%). After S-LPS, 49.3% of the women received an attempt of PDS; the remaining 50.7% were submitted to NACT. There was no significant difference between PDS and NACT in the percentages of complete (RT = 0) and optimal cytoreduction (RT ≤1 cm); the percentages of complete cytoreduction were 62.1% in the PDS group and 57.5% in the IDS group, and the percentages of optimal cytoreduction were 27.7% in the PDS group and 22.5% in the IDS group. Postoperative complications were lower in the NACT/IDS group than in the PDS group (P = 0.01). Women with complete cytoreduction at PDS had a median progression-free survival of 25 months (95% confidence interval, 15.1–34.8); this shows a significant survival advantage compared with all other patients, irrespective of the type of treatment used (P = 0.0001). Multivariate analysis showed that only RT (P = 0.011) and the performance status (P = 0.016) maintained an independent association with the progression-free survival. These data show that use of S-LPS for the management of AEOC at a single tertiary referral center was safe and did not have a negative impact on survival. Use of this approach may help individualize treatment and avoid unnecessary laparotomies and surgical complications.