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LAPAROSCOPY FOR OVARIAN MASSES

WITH DESERT WOMEN’S CARE

At Desert Women’s Care we have developed a treatment algorithm to assure appropriate referral of women with adnexal masses likely to represent ovarian cancer to Gynecologic Oncologists and treatment of adnexal masses felt to be benign using Minimally Invasive Surgical techniques while carefully observing standard principals of oncologic  surgery. 

The prevalence of adnexal masses is relatively high in the general population while ovarian cancer has a relatively low prevalence. Ovarian cancer has non-specific symptoms and is usually silent in its early stages. Presently we have no reliable screening test for ovarian cancer and we have a limited ability to detect it using current diagnostic strategies.

Various studies have addressed the likelihood of malignancy within an ovarian mass.

 

Table 1. Likelihood of Malignancy in Adnexal Masses

 

Mage et al, 1990

433

9

2.08%

Mecke et al,  1992

773

11

1.42%

Nezhat et al,  1992

1011

4

0.40%

Hulka et al,  1992

13793

411

2.98%

Canis et al,  1994

757

19

2.51%

Marzana et al,  1994

527

2

0.38%

Wenzl et al,  1996

16601

108

0.65%

Childers et al,  1996

138

19

13.77%

Canis et al,  1997

230

15

6.52%

Hidlebaugh et al,  1997

405

8

1.98%

Malik et al,  1998

292

11

3.77%

Mettler et al,  2001

493

8

1.62%

Valentin et al,  2006

1066

199

18.67%

Demir & Marchand  2011

257

15

5.84%

Total

36776

839

2.28%

 

In 2002 the American College of Obstetricians & Gynecologists evaluated the various predictors of ovarian malignancy and published ACOG Committee Opinion 280 setting forth criteria to refer both premenopausal and postmenopausal women for care by Gynecologic Oncologists.

 

Table  2. ACOG Committee Opinion 280 Referral Criteria [44]                                    

Premanopausal Women                          

 

CA 125 > 200 U/ml                                                    

Ascites

Evidence of abdominal or distant metastases

Family history 1st degree relative(s) with breast or ovarian cancer

 

Postmenopausal Women

Elevated CA 125

Ascites

Nodular or fixed pelvic mass

Evidence of abdominal or distant metastases

Family history 1st degree relative(s) with breast or ovarian cancer

 

 

What Is The Chance a Patient Has Cancer If The Pre-Operative Testing Suggests The Mass Is Benign?

Im, et al, in 2005, showed that strict adherence to ACOG Committee Opinion 280 in a referral population yields a negative predictive value (NPV) of 92.0 % % for all cases of ovarian cancer in premenopausal women and an NPV of 91.1% in post menopausal women.

Dearking, et al, in 2007, demonstrated that with strict adherence to ACOG Committee Opinion 280 in a non-referred population arising from their primary catchment area yields an NPV of 97.7% for all cases of ovarian cancer in premenopausal women and an NPV of 95.0% in post menopausal women.  In their referral population NPV was 91.0% in premenopausal and 90.5% in postmenopausal women, or essentially identical to the Im, et al, data. 

Our study has similar results with a NPV of 95.57% for premenopausal women and a NPV of 90.91% for postmenopausal women.

 

Table 3.  Negative Predictive Value of ACOG Committee Opinion 280

                                                                        Premenopausal                       Postmenopausal

Im et al,  2005

92.00

 

91.10

Dearking et al,  2007

--overall

93.10

 

91.70

--referral population

91.00

 

90.50

--general population

97.70

 

95.00

Demir & Marchand, 2011

95.57

 

90.91

 

 

 

What Happens If My Mass is Later Found To Be Malignant?

In this case a second surgery will be required.

Definitive staging of ovarian cancer includes: 1.) cytologic washings, total hysterectomy, bilateral salpingo-oophorectomy, peritoneal surface biopsies, total omentectomy and retroperitoneal lymphadenectomy from the pelvis and paraaortic regions to the left renal vessel.   Laparoscopy and laparotomy have equal efficacy in both early and advanced stage ovarian cancer.   If the mass is found to be malignant, the patient will be referred to a GYN Oncologist who will perform definitive surgery, usually using minimally invasive techniques.  Various studies show that when disease preoperatively was felt to be benign, upstaging on definitive surgery happens between 10 and 45% of the time.  It is essential to perform definitive surgery then to use chemotherapy and other adjuvant therapies based on the actual Stage of disease to assure the greatest long-term survival for the patient with ovarian malignancy.

 

Table 4. Frequency of Upstaging at Definitive Procedure

 

Pomel et al [79] 1995

10

1

10.00%

Childers et al [80] 1995

14

5

35.70%

Stier et al [81] 1996

45

7

15.56%

Tozzi et al [83] 2004

24

5

20.80%

Leblanc et al [84] 2004

44

8

18.20%

Spirtos et l [85] 2005

58

6

11.00%

Chi et al [86] 2005

20

2

10.00%

Ghezzi et al [87] 2007

15

4

26.70%

Colomer et al [72] 2008

20

4

20.00%

Nezhat et al [73] 2009

36

7

19.44%

Demir & Marchand 2011

9

4

44.44%

Total

295

53

17.96%

 

 

What This Means

Minimally Invasive Surgery is a safe, achievable treatment expectation for women with adnexal masses.  Laparoscopic adnexectomy, bagging and colpotomy is a desirable goal for patients with adnexal masses meeting selection criteria for suspected benign lesions outlined in ACOG Committee Opinion 280 affording a minimally invasive approach with attendant benefits including out-patient treatment, decreased incidence of capsular rupture, few complications and low necessity for re-operation after final pathology is evaluated.

We believe our treatment algorithm leads  to fewer laparotomies, fewer women unnecessarily upstaged as a consequence of inadvertent capsular rupture and heightened ability to offer out-patient treatment for women with presumed benign adnexal masses.

We know you have a choice in referral practices so we take thie request seriously. Give us a chance with your next complicated patient requiring surgery, then evaluate us based on the results provided to your patient. We are confident we will not disappoint.

 

Remember, the single most important factor in determining whether you will avoid abdominal surgery (laparotomy) is the choice of surgeon you make!

 

 

To view the full Paper Dr. Demir published in the Journal of the Society of Laparoendoscopic Surgeons (JSLS) in 2012, click on the icon below:

JSLS

To view the Abstract we submitted to AAGL for presentation at their 2011 Annual Meeting, click the AAGL Meeting 2011 icon below:

aagl

             

 

Desert Women's Care

80 North McClintock Drive, Suite 104, Chandler, Arizona 85226

9377 East Bell Road, Suite 131, Phoenix, Arizona 85260

 


 

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