Staging Procedures
PROCEDURE OVERVIEW
Box 29-1 Master Surgeon’s Corner
Complete surgical staging including lymph node dissection, omentectomy, appendectomy, and staging biopsies should be performed for all patients with apparent early-stage epithelial ovarian carcinomas because nearly a third of patients will have metastatic disease that was not appreciated visually or by palpation.
The extent of surgical staging for endometrial carcinoma remains controversial as to when pelvic and/or para-aortic lymph nodes should be removed. Surgeons managing patients with endometrial carcinoma should be prepared for the possibility of performing these procedures in all cases.
Accurate and complete surgical staging is a crucial part of managing patients with gynecologic malignancies and allows for appropriate informed discussions regarding further interventions and accurate risk stratification of patients on clinical trials.
Indications
Currently, ovarian and endometrial carcinomas are recommended to be surgically staged cancers by the International Federation of Obstetrics and Gynecology (FIGO). This requires removal of the primary site and any area of spread or potential spread when possible. Surgical staging is a crucial portion of the treatment for these gynecologic malignancies. Accuracy and completeness of staging ensures objective data, which helps guide appropriate administration of adjuvant therapies and development of clinical trials.
Historical Perspective
For patients with ovarian cancer, Young et al1 established the importance of surgical staging. These investigators performed systematic restaging on 100 patients and showed a 31% rate of upstaging after patients were fully surgically staged, which included multiple peritoneal biopsies and removal of pelvic and para-aortic lymph nodes. In addition, 77% of these 31 patients actually had stage III disease. Prior to this study, the staging of ovarian cancer was either not performed or relied on bipedal lymphangiography, intravenous pyelography, barium enemas, and peritoneoscopy (laparoscopy). Today, in early-stage ovarian cancer, comprehensive staging as defined by the National Cancer Institute–sponsored Gynecologic Oncology Group (GOG) includes a systematic evaluation and biopsies to determine a need for adjuvant therapy. In advanced-stage ovarian cancer, an attempt at optimal cytoreduction is the standard of care and is addressed in detail elsewhere in this text.
Prior to 1988, endometrial cancer was clinically staged through uterine sounding and imaging to determine possible spread. It was treated with a combination of preoperative radiation followed by surgery. The GOG helped transition from clinical staging to surgical staging through a prospective cohort that underwent a staging surgery; the GOG found surgical staging to be more beneficial to patients.2 In 1988, FIGO changed the staging to a surgical-pathologic system which has not been changed until recently.3 In 2009, FIGO updated the staging of endometrial cancer. Most recently, a GOG prospective randomized controlled trial (LAP2) showed that a laparoscopic approach to endometrial cancer shows no difference in detecting advanced-stage disease compared with an open approach.4
Vulvar and vaginal cancer staging is discussed elsewhere in this text.
Expected Clinical Outcomes
The primary purpose of a staging procedure is to provide an accurate account of the extent of disease to determine the need for further therapy. In addition, a universal staging system allows comparison of the outcomes of patients between institutions and countries. Interpretable results from clinical trials evaluating adjuvant therapies rely on accuracy and completeness of the surgical staging of the enrolled patients. Thus, some patients can often be excluded from participation from clinical trials due to improperly performed cancer surgery.
PREOPERATIVE PREPARATION
Patient Evaluation and Work-Up
All patients who are undergoing a surgical evaluation need a preoperative work-up for their comorbidities as determined by the surgery team and anesthesia.
According to the National Comprehensive Cancer Network (NCCN), if a patient is suspected of having ovarian cancer, it is necessary to obtain a family history and, depending on results, consider family history evaluation with genetics. A complete physical examination including an abdominal/pelvic examination is performed, and evaluation of any gastrointestinal symptoms is pursued if clinically indicated. Imaging with an ultrasound and/or abdominal/pelvic computed tomography with chest imaging is usually indicated. Laboratory tests that are typically obtained include a CA-125 or other tumor markers as clinically indicated, complete blood count (CBC), and chemistry profile with liver function tests.5
For endometrial cancer, initial evaluation includes a pathology review of the endometrial sample. Patients who are less than 50 years old may need genetic counseling if they have a significant family history and/or selected pathologic risk features. This can occur after surgery as well. The NCCN also recommends a CBC, chest x-ray, and current cervical cytology.6
Consent Considerations
Consent is permission, granted by the patient to the surgeon, to make a diagnostic or therapeutic intervention on the patient’s behalf.7 To be valid, the patient must be informed. For all staging procedures, it is important that the patient is aware of risks, benefits, and alternatives to the procedure being done. The risk of most staging procedures is low, for example taking random peritoneal biopsies and washings, but higher risk may be associated with performing lymph node dissection (discussed in Chapter 28) for early-stage endometrial cancer. The risk of lymphedema and other adverse effects of lymph node removal should be discussed with the patient.
Patient Preparation
In the past, bowel preparation has been used to decrease intraluminal fecal mass, presumably to decrease the bacteria load in the bowel. It has been used widely in general surgery and in gynecology oncology. Despite the widespread use of bowel preparation, there are limited data on its effectiveness. Multiple randomized controlled trials have shown no benefit of a mechanical bowel preparation. A Cochrane review analyzing 13 randomized controlled trials with 4777 participants found no difference in patient outcomes between patients who had a mechanical bowel preparation and patients who did not.8 We do not routinely use bowel preparations in our patients; there is no proven benefit with level I evidence, and bowel preparations are expensive, uncomfortable, and unpleasant for patients. There is still debate about the uses of bowel preparation in patients with planned left colon resections. Special considerations should also be made for patients with partial obstructions or chronic constipation.
Antimicrobial prophylaxis to reduce surgical site infection has been clearly established. For our endome-trial cancer cases that are unlikely to involve any bowel, we use cefazolin for prophylaxis as per the American College of Obstetrics and Gynecology (ACOG) recommendations for hysterectomies. For patients undergoing ovarian cancer staging, we often use cefoxitin, which is recommend for bowel surgeries and which may be more appropriate given ovarian cancer involvement of the bowel and need for bowel resections for cytoreduction.
According to American College of Chest Physicians guidelines, for gynecologic patients undergoing major surgical procedures for either benign disease or malignancy, venous thromboembolism (VTE) prophylaxis with chemical or mechanical prophylaxis is necessary.9 The duration of VTE prophylaxis for patients undergoing major gynecologic procedures is at least until hospital discharge, and one should consider extending prophylaxis for higher risk patients. Almost all patients undergoing surgical staging for a gynecologic malignancy are considered higher risk patients, especially if over age 60 years. The ENOXACAN II trial showed that 40 mg of enoxaparin preoperatively and continued for 4 weeks postoperatively significantly decreased VTEs.10 At our institution, we give postoperative, prolonged, prophylactic low molecular weight heparin to these patients after discharge for home administration.
Required Instrumentation
Instrumentation for staging procedures includes standard instruments. In addition, we have found electrosurgical vessel-sealing devices to be very useful for omentectomies and other surgical staging procedures. These electrosurgical devices have been shown to be safe and effective both in laparotomy and laparoscopic procedures.11–15
OPERATIVE PROCEDURE
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