Gynekologisk Laparoskopisk tumörkirurgi

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1 Gynekologisk Laparoskopisk tumörkirurgi Christer Borgfeldt Överläkare Kvinnokliniken Universitetssjukhuset i Lund

2 Ovarialtumörer rer och laparoskopi Cervixcancer Laparoskopisk robotassisterad radikal hysterectomi Sentinel node konceptet vid cervixcancer

3 Laparoscopi vid adnexförändringar ndringar och ovarialcancer

4 4 out of 5 ovarian cyst spontainously disappear in women år 81% +/- 17%(95% CI) Borgfeldt, C. Andolf, E. Transvaginal sonographic ovarian findings in a random sample of women years old (13(5)) pp Ultrasound in Obstetrics and Gynecology

5 Kolla med ultraljud att adnexförändringen finns kvar!!! Laura J. Havrilesky et al Obstet Gynecol 2003;102: N=396

6 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.

7 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 Sep;22(3):284-9.

8 Morphologic Index DePriest et al 1993

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10 Risk analyze

11 How to manage an adnexal lesions? Laparoscopy No ascitic fluid <10 cm Laparotomy Complex cystic lesion with ascitic fluid RMI>200 Cystectomy vs Oophorectomy Age 40

12 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 7-12d7

13 PORT placement Ovarian adnexal lesion HEAD Umbilicus 10 mm Optik 10 mm Atraumatisk tång Plastpåse 5 mm unipolär sax 5 mm bipolär tång PUBIS

14 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 7-12d7

15 Management of adnexal cystic masses with unexpected intracystic vegetations detected during laparoscopy. Marana et al 2005 (12(6)) pp J 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%).

16 Port-site metastases after open laparoscopy: : a study in 173 patients with advanced ovarian carcinoma. Vergote,, I. et al 2005 (15(5)) pp 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

17 Don't leak cystic fluid! Vergote et al 2001 Meta-analysis analysis of 1545 stage I ovca s DFS (%) yrs IA IB IC

18 Complications Meta-analysis analysis: : 1809 laparoscopy vs laparotomy The overall risk of complications was significantly lower for patients operated by laparoscopic surgery [relative risk (RR) 0.59; 95% confidence interval (CI) ]. 0.70]. Major complications (RR 1.0; 95% CI ). Minor complications was significantly lower for patients operated by laparoscopic surgery (RR 0.55; 95% CI ). 0.66). Chapron et al 2002 (17(5)) pp Hum Reprod

19 Why perform complete staging procedure in patients with early ovarian cancer? Should it be performed with laparoscopy?

20 1 out of 4 will be upstaged in patients with presumed early ovarian cancer 24% upstaged to stage III Young et al JAMA 1983

21 Subclinical metastases in presumed early ovarian cancer bowel abdom.perit. pevic perit. pao lln pelvic lln omentum diaphragm cytology % references

22 Conclusions Early Ovarian Cancer trials Icon1 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.

23 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

24 Take home messages Laparoskopi om fertila kvinnor med adnexresistenser mindre än n 10 cm Under 40 år cystectomi Över 40 år r SOE unilateralt Laparoskopi har färre f 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

25 Laparoscopisk cervixcancer kirurgi Vad krävs? Volym av patienter Samtränat team Robot underlättar

26 Laparoskopiskt Robotassisterad radikal hysterectomi med pelvin lymfkörtelutrymning erfarenheter ifrån n Lund Ca 80 patienter opererade 3 operatörer rer plus 2 under träning Operationstider medel 270 minuter Blödning medel 150 ml

27 Radical HIT + Pelvic lymphnode disection Magrina et al 2008 Robotic LS Laparotomy Patients (n) Op time (min) Blood loss (ml) Lymph nodes removed (n) 25,9 25,9 27,7 Hospital stay (days) 1,7 2,4 3,6

28 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

29 Ls robotkirugi vid cervixcancer Fördelar Mindre blödning Kortare vårdtidv Snabbare återhämtning av pat Om positiva SLN körtlar snabbare start av postoperativ strålbehandling Nackdelar Initialt förlf rlängd op tid Mer träning krävs av operatör r och op team Ökad kostnad för f robot och instrument

30 Vad händer h när n cervixcancer patienten kräver att bli erbjuden Laparoskopisk robotkirurgi i framtiden?

31 Indikationer för f Sentinel node vid cervix cancer: 1. att öka chansen att hitta den/de mest väsentliga lymfkörtlarna 2. att vid användandet ndandet av skarp SLN minska morbiditeten

32 SLN distribution: Sentinel nodes Positive sentinel nodes Rob et al. Gynecol Oncol 98:281-88, 2005

33 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

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36 Detection rate vid SLN No of Pat. with No of Pat. with Author Tumor size N detected SLN Bilateral detected SLN % % Lund <20 mm >20 mm Total in literature Hauspy et al 2007 Altgassen et al <20 mm ? >20 mm ?

37 Sensitivitet vid SLN Author Tumor size N LN metastases No of Pat. with positive SLN detection Sensitivity Hematoxylin staining Hematoxylin staining % Lund <20 mm >20 mm Total in literature Hauspy et al 2007 Altgassen et al <20 mm >20 mm

38 Negative Predictive value No of Patients Neg Pred Value Author Tumor size N True neg SLN neg % Lund <20 mm >20 mm Total in literature Hauspy et al 2007 Altgassen et al <20 mm ,1 >20 mm ,5

39 False neg SLN in literature Hausny et al 2007

40 När r det inte går g r att detektera SLN påp ena sidan i bäckenet b bör b r fullständig lymfkörtel utrymning utföras påp denna sidan.

41 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

42 När r börjar b vi erbjuda alla patienter med tidig cervixcancer (pre-operativt bedömd < 2 cm) skarp Sentinel node analys?

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