Presentation on theme: "Minimally Invasive Surgery in Gynecologic Oncology"— Presentation transcript:
1Minimally Invasive Surgery in Gynecologic Oncology Financial Disclosure“As it pertains to CME, I have no relevant financial relationships with any commercial interest to disclose.”
2Minimally Invasive Surgery in Gynecologic Oncology William M. Merritt, MDApril 2010I would like to thank ____________ for this opportunity to speak at this months “For Women’s Only” series. Since moving back to Columbia from Houston, My wife and I truly feel like we are back home here in South Carolina. Today’s topic is an important one in medicine today, not only in cancer, but in our field of women’s care.
3Objectives Reviews types of gynecologic cancer and treatments Minimally Invasive Surgery (MIS)Role of MIS in Gynecologic Oncology (and Gynecology)Patient benefits and risks with MISThroughout the next 30 minutes I hope to provide you with information that will be helpful for you or your loved ones in understanding where our field is today in cancer care. First I will review the most common Gynecologic cancers we provide care for. Next, I will discuss the topic of MIS and more specifically the different types and there role in gynecologic cancer conditions, as well as some benign (non-cancerous) conditions. Lastly, I have prepared some slide with commonly asked questions that I hope will be informative. Following I know we will have time to discuss any additional questions that you have but please feel free to raise your hand or stop me at any point to ask a question. I would like to keep this as informal as possible.
5Ovarian Cancer 21,550 estimated new cases in 2009 Lifetime risk: 1.7% Average age: 59Risk Factors: family historySymptomsBloatingWeight gainAbdominal discomfortEarly satiety (feeling full)NauseaDetection:Pelvic examImaging (Ultrasound, CT Scan)Ca-125OVA1 (recently FDA approved)Ovarian cancer is second most common gynecologic cancer today and continues to be one of the most difficult to treat. The lifetime risk of developing ovarian cancer is 1.7%; however women with strong family history of ovary and/or breast cancer may have an increased risk due to genetics. Symptoms for ovarian cancer are generally nonspecific. When you interview women with ovarian cancer you will often hear that these type of symptoms have been occuring daily for several weeks and are/were different from their normal self. There are no good screening tests for this disease but using combination of exam, U/S, and ca-125 testing will help with diagnosis for certain patients.
6Endometrial/ Uterine Cancer Most common gynecologic cancer42,160 new cases in 2009Risk Factors: obesity, unopposed estrogen, no pregnanciesSymptoms:Abnormal uterine bleedingBleeding after menopauseDetection:Pelvic examEndometrial biopsyPelvic ultrasoundEndometrial or uterine cancer is the most common gynecologic cancer in the US and SC. Fortunately it is also very curable due to early detection. We know that women who have unopposed estrogen, that is not enough or no progesterone to the uterus are at high risk. HRT therapy has evolved to eliminate this possibility but unfortunately one of the main producers of estrogen is fat cells – hence obesity being a major risk factor. Women with AUB generally are evaluated with either a biopsy of U/S to confirm diagnosis.
7Endometrioid UPSC/Clear Cell Present in earlier stage Present with advanced stageStage I73%54%Stage II11%8%Stage III13%22%Stage IV3%16%5-yr survival85-90%60%70%50%40-50%20%15-20%5-10%Gehrig et al, Gyn Onc 2010
8Cervical Cancer 11,270 new cases in the 2009 Death rates decreasing due to early detectionRisk factors:HPV infectionCigarette smokingSexual activity at an early age (exposure)Symptoms:Abnormal vaginal bleedingVaginal dischargeDetection:Pelvic ExamPap smear / HPV testingCervical cancer is not nearly as common as it used to be thanks to PAP smears. Early detection of precancerous cells has led to a significant delice in new cases and in turn deaths due to ovarian cancer. With the introduction of HPV (or Human Papilloma Virus) testing – early detection and screening methods continue to improve. Not to head off on to far of a tangent – many of you may have heard of the HPV vaccine. I truly feel like the jury is still out on this. I can discuss this more later if you want.
9Vulvar Cancer Rare: 4% of all gynecologic cancers Risk factors HPVSmokingSkin disorders of the vulvaSymptomsItching (itch scratch cycle)Vulvar mass / ulcerBleedingDetectionPelvic examBiopsyVulvar cancer is even rarer than cervical cancer. Similar risk factors exist as for cervical cancer. Patients typically describe vulvar itching and bleeding. Diagnosis is made by biopsy.
10Treatment Ovarian cancer Endometrial cancer Cervical cancer Surgery + chemotherapyEndometrial cancerSurgery ± radiation (± chemotherapy)Cervical cancerSurgery OR radiation + chemotherapyVulvar cancerSurgery ± radiationVaginaUterusEndometriumMyometriumOvaryFallopian TubeCervixVaginaUterusEndometriumMyometriumOvaryFallopian TubeCervixTreatment for each of these cancers differs widely. This is mainly due to disease process itself. Ovarian cancer spreads like leaves off a tree. Goal at the time of surgery is take out all the visible cancer possible. Unfortunately, most patients that are diagnosed with ovarian cancer have disease already outside of the ovaries. For this reason, there is very little role for MIS. In a few cases, ovarian cancer is diagnosed in the early stage, i.e. confined to the ovary and these patients may be candidates for staging with MIS.Endometrial cancer spreads into the uterus, through the bloodstream and lymphatics. At the time of surgery, a hysterectomy with removal of tubes and ovaries are perfomed. In addition, staging procedures including removal of lymph nodes in the pelvis and abdomen maybe performed based on the tumor itself.Cervical cancer spreads by local extension, i.e. it invades tissue next to the cervix. It can also spread to lymph nodes. Upon diagnosis, patients are deemed surgical candidates based on size and stage of cancer. If surgery, then either a simple hysterectomy or radical hysterectomy is performed. Radical differs in that……Vulvar cancer is treated typically by surgical resection of the tumor and regional lymph nodes. Patients may need additional therapy following in the form of XRT.
11Surgical Options Traditional: Laparotomy Midline vertical Transverse So when patients go to the OR for cancer surgery, the traditional approach was to make a large incision. Usually either an up and down or low transverse incision was made. For most cancer cases, the vertical incision is preferred due to allowing access to the upper abdomen for exploration.Midline verticalTransverse
12Minimally Invasive Surgery (MIS) An approach to surgery whereby operations are performed with specialized instruments designed to be inserted through small incisions or natural body openingsTypesLaparoscopicRoboticOver the past 15 years MIS has become a large part of surgical therapy not only in our field but others as well. MIS in a nut shell is defined as …….Two types used in our specialty include.
13What can be done with MIS HysterectomySupracervicalTotalTubes and ovariesMyomectomyRemoval of fibroidsLymph node dissectionPelvicAorticDiagnostic (looking)
14MIS – What’s so good about it? Less post-operative painShorter hospital stayLess blood lossQuicker return to normal activitiesSmaller incisions
15Are there any drawbacks? Not all procedures are safe to do with MISTimeLearning curveSome cases take longer compared to traditional approachCost
16Role of MIS in endometrial cancer FeasibilityIs it possible?Reproducible?Comparison with standard approachBetter, worse, and equivalent?Risks/BenefitsAcuteLong term
18Laparoscopy vs Laparotomy – GOG LAP2 Study Population ( )L/S: 1,696 Open: 920Conversion rate: 434 (25.8%)Surgical StagingLymph node dissection99% (open) vs. 98% (L/S)Pelvic/aortic: 96% (open) vs. 92% (L/S)Aortic: 97% vs. 94%No difference in patients w/ advance surgical stageWalker et al, JCO 2009
19Hospital stay >2days 845 94 867 52 Laparotomy(n=920)%Laparoscopy(n=1,248)POR time (min)130204<0.001Hospital stay >2days8459486752Complications-Vascular294755-Post op fever338553-Ileus/SBO809-Wound infection53-Transfusion667143-Deaths110<1-Bladder/Bowel2358Walker et al, JCO 2009
20What do the patients think? L/S (n=535) vs. open (n=267)Quality of life (FACT-G)EmotionalPhysicalSocialFunctional well-well being6 weeksL/S: better physical functioning and body image, less pain, earlier resumption of normal activities and return to work6 monthsL/S: better body imageKornblith et al, Gyn Onc 2009.
21Are there acute benefits? MIS (L/S and robotic; n=66) vs open (n=115)OR time (min)284 vs 203 P<0.0001EBL300 vs 100 mL P<0.0001Hospital stay1 day vs 4 days P<0.0001Median narcotic use (24 hr post op)43 mg vs 10 mg (morphine equiv) P<0.0001Nausea – MIS patients required less rescue antiemetics 24hr pos opHavrilesky et al, Gyn Onc 2009
22Long term cancer benefit? L/S vs. Open(N)Follow up(months)Overall survivalDisease free survivalCancer-related survivalTozzi et al63 vs 594482% vs 86%87% vs 92%25% (2/8) vs 40% (2/5)Zullo et al40 vs 387982% vs 84%80% vs 82%50% (4/8) vs 44% (4/7)Malzoni et al81 vs 7838.5???No difference in survival recently reported for GOG LAP2 trial at 3-yr follow upTozzi et al, J Minim Invasive Gynecol 2005Zullo et al, Am J Obstet Gynecol 2009Malzoni et al, Gyn Onc 2009
23Cervical cancer No difference in recurrence or survival reported No. ptsOR time(min)EBL (mL)Hosp. stay (d)MarginsComplicationsSpirtos et al.All L/S78205225NRAll negative3 cystotomies1 ureterovaginal fistulaAbu-Rustum et al.L/S vs. open17 vs. 195371 vs. 295301 vs. 6934.5 vs. 9.7No ureteral injuries or fistulas reportedFrumovitz et al.35 vs. 54344 vs. 307319 vs. 5482 vs. 5- 18% vs. 53% infectious morbidities- No noninfectious reportedNR = not reportedNo difference in recurrence or survival reportedSpirtos et al, AJOG 2002Abu-Rustum et al, Gyn Onc 2003Frumovitz et al, Obstet Gynec 2007
26Robotic Surgeryda Vinci robot system is the only robotic surgical system is use todayBenefitsImproved visual fieldsLess dependence on surgical assistanceSurgeon comfortIncreased instrument mobilityDrawbacksCostLoss of tactile feedbackLearning curveAvailabilityBulky machineTrochar size
30Instruments are controlled by the surgeon’s hands Robotic InstrumentsInstruments are controlled by the surgeon’s handsHigh range of motion for robotic instruments allow for addressing complex surgical issues
31Comparison of 3 methods: open, L/S, robotic Open (n=138), L/S (n=81), & robotic (n=103)OR time: L/S (213 min) > robot (191) > open (147)RobotBetter lymph node countLower EBL 75 mLLower hospital stay (1 day)Complication rate: Robot (6%) vs. open (30%)Conversion rate: L/S (5%) & robot (3%)No long term follow up reportedBoggess et al, AJOG 2009
32Is robotic surgery better than laparoscopy? Robot assistedLaparoscopyOR time (min)26211692192320611413EBL (mL)509749100105Hospital stay (days)11.62No difference in survival at 40 months (n=141)41. Leitao et al, Gyn Onc 2009Lowe et al, Gyn Onc 2009Nevadunsky et al, Gyn Onc 2009Mendivil et al, Gyn Onc 2009
33Robotics and cervical cancer No. patientsEBL (mL)OR time (min)Hosp. stay (min)Kim et al102073557.9Fanning et al203003901Sert et alRobot vs. L/S7 vs. 771 vs. 160241 vs. 30004 vs. 8Nezhat et al.13 vs. 30157 vs. 200323 vs. 3182.7 vs. 3.8Boggess et alRobot vs. LAP51 vs. 4997 vs. 417211 vs. 2481 vs. 3.2Kim et al, Gyn Onc 2008Fanning et al, AJOG 2008Sert et al, Int J Med Robot 2007Nezhat et al, JSLS 2008Boggess et al, AJOG 2008
34Fertility preservation? Laparotomy / vaginal approachTraditional approachOR time: 163 to 253 minRecurrence rates: 2.7 to 7.3%Pregnancy (delivery >37 weeks) 60%Robotic approach4 studies (8 pts total)OR time – 172 to 373 minEBL (mL) – 62 to 200Hosp stay (d) – 1.5 to 3.5Complications: 2 (edema & neuropathy)F/U: no recurrence in 105 d (Ramirez et al , Gyn Onc 2010)No pregnancies reported to dateDursun et al, EJSO 2007Ramirez et al, Gyn Onc 2008Ramirez et al, Gyn Onc 2010
37Conclusions MIS surgery is a reasonable option in gynecologic cancer EndometrialCervicalOvary (early stage)Laparotomy, laparoscopy and robotic surgery offer advantages for patients short term but are equivalent in patient survivalRobotic surgery offers surgeon advantages over laparoscopy