some just wonderful pictures that I had from our trip to Almaty. So we had such a lovely time there and we thank you for your hospitality when we were there. So today we'll incorporate scientific data into the management of adnexal masses in ovarian cancer and integrate anatomic knowledge to improve surgical technique. So as we all know, traditionally, we've treated ovarian cancer with laparotomy in order to perform a total abdominal hysterectomy, bilateral salpingo-oophorectomy and staging or tumor-reductive surgery, followed by six cycles of a taxane and platinum-based chemotherapy. We then follow with surveillance and treat recurrence with adjuvant therapy. However, we have a changing landscape where we are transitioning to less open surgery and a more minimally invasive approach. And of course, this is so beneficial for our patients because it gets them back to their normal life with less blood loss and less pain very quickly. And so we've been able to incorporate minimally invasive surgery, whether a straight-sticks laparoscopy or robotics into multiple areas of management of ovarian cancer. And of course, this implies an increasing use of neoadjuvant chemotherapy, which allows this less morbid surgery. And so as I put my thoughts together around how we can use minimally invasive surgery in ovarian cancer, I identify five areas that we should discuss today. So the first is diagnosis. The second is primary surgery and staging in early stage disease. The third is evaluation of advanced stage disease at diagnosis, which allows us to make an accurate diagnosis and determine if we are able to achieve a complete resection. The fourth is interval cytoreduction following neoadjuvant chemotherapy in advanced stage disease. And lastly, consideration of resection of isolated recurrent disease. So let's first talk about diagnosis. When we consider adnexal masses, it's a whole range of considerations. Sometimes we have a small adnexal mass and sometimes that adnexal mass can be absolutely enormous, as you see here. We have very specific criteria for removal of the adnexal mass. And what we can see here is that things that cause us to suspect a malignancy include a solid component that might be nodular or papillary with thick septations, Doppler flow, or other findings of ascites, peritoneal masses, enlarged nodes or matted bowel. And of course, the patient may have pain associated with this or other symptoms. When we consider minimally invasive surgery and not a laparotomy, one thing that always comes up in the conversation is, does it lead to an increased risk of rupture? Because of course, we don't want to advance the stage of disease by performing a surgery that may lead to a worse outcome. So multiple authors have looked at this and it turns out that the overall rate of rupture of an adnexal mass is 25%. But there are specific risk factors that have been identified and those include endometriosis and adhesions, as well as clear cell carcinoma and non-mucinous histology. Tumor size and minimally invasive surgery actually are not risk factors. So if a patient asks you, will laparoscopy lead to an increased risk of rupture? The answer is no. It really relates to the underlying pathology instead. Now, of course, we will attempt to avoid that rupture, but there are some, I think, important details to recognize. And that is that patients who have more aggressive histologies, like clear cell carcinoma or other types of epithelial cancers actually have no difference in outcome as long as they get chemotherapy if rupture occurs. So of course, we don't want to rupture them, but if they do rupture, an adverse outcome will occur as long as they get chemotherapy. That's different in patients with borderline tumors and granulosa cell tumors, where an increased risk of relapse occurs with rupture because they tend to be less amenable to chemotherapy. Here in this country, we have multiple different options for contained extraction, but the idea with minimally invasive surgery and avoiding the rupture is that you have to use some sort of contained extraction approach. And so the key is to choose the right bag and exit for your mass. So in a small eight to 10 centimeter mass like this, we can use an impermeable bag, like an anchor bag, place the mass in the bag and bring the bag up through the umbilicus where it will not contaminate the port site because it will never touch the skin. And then we can enlarge that port site ever so slightly and remove the mass through the port site. Now, sometimes we see much larger masses and so we have to improvise with how we remove these. Sometimes we can use other types of bags and sometimes an approach like a vaginal approach in a patient who is having a hysterectomy can be useful. So this patient, it looks like has a normal sized uterus and right tube and ovary, but what you'll see is that her left ovary is enormous. Now I've measured this out very carefully and this may have been a case that Monica, you and I did together, but basically we have this 15 centimeter bag that we can put in vaginally with an occluder balloon so we don't lose our pneumoperitoneum. And we are sort of struggling to get the bag around the mass, but with good assistance and good visualization, you can wiggle the bag up around the mass. And then as long as you get it around the circumference, then you can pull down and basically get the bag around the mass. And sometimes you have to reorient the mass so that it will fit into that bag. But once you get it around the widest portion, then you can just bring it down, capture it, bring it out the vagina and then morsel it out the vagina. Now keep in mind that the key is keeping it in the bag so it never touches any other portion of the patient. The thing when I speak with benign gynecologists is that we really recommend not opening patients in the setting of a cancer and sending the patient to the gynecologic oncologist. So I'm sure you do the same, you make the same recommendations. We've really encouraged benign gynecologists to take a lot of pictures with laparoscopy so that we have a better idea of what is going on beforehand. So that's diagnosis. The second area where minimally invasive surgery can be helpful is primary surgery and staging an early stage disease. So if the disease appears to be confined to the pelvis, of course we stage with biopsies of suspicious lesions, the cul-de-sac, the bladder, the gutters, an infracolic omentectomy and a lymphadenectomy and then definitive surgery. We can do the same procedure laparoscopically that we can do open. And I would argue that you can actually sometimes get better sampling with some practice. So here's a patient who has, and you can see the visible tumor in the omentum. And we have typically three or four ports in place. My partner is opposite me and basically is lifting the omentum up so that I can come across with the harmonic scalpel and identify the appropriate plane to come across and perform an infracolic omentectomy. And you can see the large amount of tumor that's there. This is almost impossible to do robotically, but is easier to do laparoscopically. And you really get an excellent infracolic omentectomy. Once you come across, again, you detach the whole specimen, you place it into a specimen containment bag, and then you remove it in the same manner that we saw before. And I would argue that you do get a complete omentectomy and it's a little bit difficult with orientation when you're working in the upper abdomen at first, but with some practice, it becomes natural. You know, another very important component of staging is a laparoscopic pelvic lymphadenectomy. And so here we're opening the sidewalls at the level of the round ligament. We're making sure that we elevate that round ligament so that we can open the space and we mobilize the infantibulopelvic ligament in order to open the cephalad border of the dissection. We see the psoas muscle and the psoas tendon and genofemoral nerve behind us. We open this filmy adventitia and we make sure that we have enough visualization by working parallel to the vascular structures. We can dissect, therefore, the fat and the lymphatic tissue away using traction and counter traction in order to mobilize this tissue away from the sidewall and away from the iliacs. And then once you see your external iliac artery, as you see it pulsating below, you can use that to strip that tissue away and you can see that your nodal bundle of tissue becomes more evident. It's important to work in parallel to these vascular structures to remove all of the nodal tissue over the artery. And the importance of traction and counter traction cannot be stressed enough. The suction device is also used as an excellent way to dissect here as well. Here, I'm using the harmonic scalpel, but it doesn't have to be the harmonic. It can be any sealing device of your preference. It's important to retract the nodes medially and doing so exposes that external iliac vein. There are always these small bleeders there. And you can see that we can really completely strip these vessels and make sure that we remove all of the nodal tissue. We then identify their obturator nerve at the deep border of dissection, making sure that we spare all the nodal tissue and seal the lymphatic tissue. In doing so, we can make sure that we really do not leave any nodal tissue behind. And you can see, we can separate this all away from the vascular structures. We seal it so there's no bleeding and you can get just as good of a dissection laparoscopically or robotically as you can in an open approach. So in the interest of time, we'll move forward. Now, what happens if you see disseminated disease as we do see sometimes? Well, again, if this is a benign gynecologist, I would say take biopsies and stop. If you're an oncologist, the question is, determine if you can get an R0 or optimal resection at the time of that initial surgery. And if you can, go ahead. If not, you can stop without a laparotomy and give neoadjuvant chemotherapy. Because what we don't want to do is end up with a suboptimal tumor-reductive surgery. And of course, gynecologic oncologists, people who are trained to do this, really should be the ones to operate on these patients. So we've talked about diagnosis. We've talked about evaluation upfront of management of early-stage disease. And now let's talk about evaluation of advanced-stage disease at the time of initial diagnosis. Using straightforward laparoscopy to determine if a patient is resectable or unresectable is really standard practice for us now. So when we look inside, we take the Fugati score, which looks at carcinomatosis, diaphragmatic involvement, mesenteric involvement, omental caking, involvement of the stomach, and liver metastases. And we score each of these items with either a zero or a two. We add those up. And if the total score is at least eight, that means that it is incredibly unlikely that the patient can be adequately debulked. So instead we give neoadjuvant chemotherapy and come back after three cycles. And here we can see, as we look, you can get an excellent view with minimally invasive surgery. You can score that patient. You can see the diaphragm. You can see the liver. You can see the stomach and the omentum and the deep pelvis, so you can score. So that leads us to the utility of minimally invasive surgery in interval cytoreduction after neoadjuvant chemotherapy. And the studies that we have really look at open surgery after neoadjuvant chemotherapy. But this is important to understand how we can utilize this because for so long, we have trained that the bigger the surgery, the better. The more aggressive, the better. And that actually is in question at this point. And I would say we've answered that question because we now have four randomized trials that show us that we are able to obtain a higher rate of optimal status after neoadjuvant chemotherapy. So again, these are patients who have bulky disease initially. They're treated with chemotherapy first. And then after three to four cycles of chemotherapy, they have an interval laparotomy. So in the EORTC, the CORUS trial, the Japanese Oncology Group trial, and the SCORPION trial, we see that the rate of optimal status is the same or better after neoadjuvant chemotherapy. And the SCORPION trial also showed us that these patients have a lower complication rate and a lower risk of permanent colostomy. In addition, their progression-free and overall survival is equivalent. Now, when we pivot to talk about laparoscopy for interval debulking instead of laparotomy, we don't have as much information. Fegatti and Chereau both showed that this is feasible and safe and reduces the rate of unnecessary laparotomy. And the SCORPION trial showed no randomized trials. Three other authors have looked at oncologic outcome and showed better perioperative outcomes. But these are really very small groups of patients. Sometimes when we come back to remove carcinomatosis, the chemotherapy has worked so well that literally this is all you see. You just pluck off these little bitty implants. And you get bigger surgery. And so here's a good example of, after three cycles, this patient who had still very extensive disease involving her colon. She's had three cycles initially. We couldn't even see. That's tattooing from a colonoscopy that she had that demonstrated involvement of the colon. So here we can see that she has disease We're debulking the patient, getting the disease out of the pelvis. We move up to the omentum. We're able to get all of that disease out. We mobilize her colon. You can see we've cleared her pelvis to give us room to work. We are taking out every implant, and this is tedious and takes some time, but it certainly can be done. All of these are placed in bags for removal. We do our complete omentectomy, just as you saw before. And we're even able to do bowel surgery with the utility of a hand port by resecting the colon. And then we come back, not come back, then we immediately perform a resection so that the patient does not need, or a reanastomosis, so the patient does not need to have colostomy. She can have a reanastomosis at the same time. And you can see that with a laparoscopic approach, she's had an R0 resection. Now, we studied our outcomes with this, and what we were able to see is that in patients who had minimally invasive surgery compared to open surgery for interval debulking after neoadjuvant chemotherapy, we had pretty amazing results. Our R0 rate and optimal rate, so total, put together in the minimally invasive surgery group was 96%, and that was not found to be any significantly different from patients who had open surgery. In fact, our R0 rate in the minimally invasive surgery group was 60%. And I mean, I think that's really pretty remarkable. There were only 4% of patients who were left suboptimal after neoadjuvant chemotherapy. Now, one of the criticisms that we had when we published this was, well, you've determined which patients are going to respond, and of course they do better because you're doing minimally invasive surgery on them. But that's actually exactly the point because that's how we practice medicine. We give the appropriate treatment to the appropriate patient, and that's exactly what we did here. We gave neoadjuvant chemotherapy to patients with bulky disease. Patients who had a good response were triaged to minimally invasive surgery. And with trained surgeons, we have a 96% optimal surgery rate, so it does appear to be feasible. 10% of patients had no visible or pathologic disease remaining, and our conversion rate was only 17%. We did use a hand port or a mini lab in about half of patients. And what we found was no difference between progression-free and overall survival in these groups of patients. We've updated our data and combined with the University of North Carolina for a total of 254 patients. 84%, so same numbers, were able to be accomplished without conversion with the same rate in both laparoscopic and robotic arms. And the surgical outcomes are exactly the same as what you would expect, with less blood loss, shorter hospital stay, and lower 30-day complication and readmission rates, with, again, no difference in outcomes for progression-free and overall survival. So I think the best evidence is leaving no macroscopic disease. And what we see is that using neoadjuvant chemotherapy and minimally invasive surgery for initial assessment and in selected cases for interval debulking is really where we're headed in the future. One word about recurrent disease. You know, GOG213 did not show any benefit. The desktop trial did. I think laparoscopy may really change the way that we view our options for patients with recurrent disease, because we don't have the morbidity of laparotomy. And so I think that's sort of the next thing that we'll end up needing to study. So in summary, I think these are the five areas where we can consider minimally invasive surgery in ovarian cancer. And it's a process. You know, certainly when we start using minimally invasive surgery, we're not gonna do the aggressive interval cytoreductions, but with continued practice and study, these are the options for our patients and they're better for it. So thank you very much. I'm happy to chat further.

minimally invasive surgery

adnexal masses

ovarian cancer

recovery time

blood loss

neoadjuvant chemotherapy