General Surgical Guidelines

The absolute diagnosis of an ovarian malignancy can only be made by microscopic pathologic evaluation of a surgically obtained specimen. Detailed surgical approach recommendations are included in the Appendix. The importance of appropriate initial staging cannot be overemphasized, as a small percentage of patients have apparent early-stage disease but have positive lymph nodes on final review. This can then affect the stage, recommended treatment, and overall prognosis.

Although the occasional patient may undergo lapa-roscopic evaluation for a small solid adnexal mass or complex ovarian cyst, the patient with a large, solid adnexal mass or evidence of hemodynamic instability should undergo laparotomy through a vertical skin incision to ensure appropriate full surgical staging. Upon entering the peritoneal cavity, pelvic washings should be obtained, and hemoperitoneum, if present, evacuated. The site of hemorrhage is most commonly the mass itself, and such that surgical removal of the tumor may be all that is necessary to control the bleeding. A unilateral mass in a patient of any age should be removed by unilateral salpingo-oophorectomy and sent for immediate histologic evaluation. Every attempt should be made to avoid rupture, as this upstages an otherwise stage 1A or 1B carcinoma and may adversely affect survival [34, 35]. For this reason, the tumor should never be morcel-lated to effect laparoscopic removal.

Occasionally, an ovarian cystectomy is performed in an attempt to preserve ovarian tissue for an apparently benign dermoid cyst. The tumor must be sent for immediate histologic evaluation to confirm its benign nature; in the event of a malignancy the entire ovary should be removed.

If the diagnosis is an epithelial tumor or a malignant GCT of any histologic subtype, excluding the benign mature cystic teratoma, complete surgical staging is indicated. In young patients where fertility is a vital concern, preservation of reproductive potential should be attempted at the time of surgery. The contralateral ovary is inspected and, if normal in appearance, left undisturbed. Due to the low yield from random ovarian biopsy, and the potential for disruption of reproductive potential due to adhesions or trauma, the routine biopsy of a normal-appearing contralateral ovary is not advised [36]. If the contralateral ovary appears to contain a cyst, an ovarian cystectomy should be performed and sent for immediate histologic evaluation. If malignant disease is revealed, bilateral oopho-

Table 13.5 Modified (1987) International Federation of Gynecology and Obstetrics (FIGO) staging system [39, 40]

Stage I:

Growth limited to the ovaries

Stage IA:

Growth limited to one ovary; no malignant cells in ascites or positive peritoneal washings; no tumor on the external surfaces; capsule intact

Stage IB:

Growth limited to both ovaries; no malignant cells in ascites or positive peritoneal washings; no tumor on the external surfaces; capsules intact

Stage IC:

Tumor stage IA or IB but with tumor on the surface of one or both ovaries or with the capsule ruptured or with ascites present containing malignant cells or with positive peritoneal washings

Stage II:

Growth involving one or both ovaries with pelvic extension

Stage IIA:

Extension or metastases to the uterus or tubes

Stage IIB:

Extension to other pelvic tissues

Stage IIC:

Tumor is stage IIA or IIB, but with tumor on the surface of one or both ovaries or with the capsule or capsules ruptured or with ascites containing malignant cells or with positive peritoneal washings

Stage III:

Tumor involving one or both ovaries with peritoneal implants outside the pelvis or positive retroperitoneal or inguinal nodes. Superficial liver metastasis equals stage III. Tumor is limited to the true pelvis but with histologically proved malignant extension to the small bowel or omentum

Stage IIIA:

Tumor grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces

Stage IIIB:

Tumor of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, with none exceeding 2 cm in diameter. Nodes are negative

Stage IIIC:

Abdominal implants greater than 2 cm in diameter or positive retroperitoneal or inguinal nodes

Stage IV:

Growth involving one or both ovaries with distant metastases. If pleural effusion is present, there must be positive cytology to allot a case to stage IV. Parenchymal liver metastasis equals stage IV

Table 13.6 Pediatric Intergroup Trial (POG/CCG) - ovarian GCTstaging [11, 12]

I

Limited to ovary, peritoneal washings negative for malignant cells; no clinical, radiologic, or histiologic evidence of disease beyond the ovaries (gliomatosis peritonei did not result in upstaging); tumor markers negative after appropriate half-life decline

II

Microscopic residual or positive lymph nodes (<2 cm); peritoneal washings negative for malignant cells (gliomatosis peritonei did not result in upstaging); tumor markers positive or negative

III

Gross residual or biopsy only, tumor positive lymph node(s) >2 cm diameter; contiguous visceral involvement (omentum, intestine, bladder): peritoneal washings positive for malignant cells

IV

Distant metastases that may include liver

rectomy is performed. In 5-10% of malignant GCTs there is an associated contralateral benign mature cystic teratoma, and in these situations the remainder of that ovary can be preserved.

Unless grossly involved with a tumor, the uterus is left in place in the young patient with the desire for continued reproductive potential. The conventional approach of total abdominal hysterectomy with bilateral salpingo-oophorectomy for older patients with epithelial ovarian cancer is not indicated for younger women in view of current assisted reproductive techniques using donor oocytes with hormonal support. Such techniques make conception and childbearing a viable future alternative for such patients with a uterus but no ovaries [36-38].

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