How to assess metastasis in ovarian cancer during diagnostic laparoscopy?

Assessment of Metastasis in Ovarian Cancer During Diagnostic Laparoscopy

Thorough systematic exploration of the peritoneal cavity with peritoneal cytology and targeted biopsies is essential for accurate assessment of metastasis in ovarian cancer during diagnostic laparoscopy.

Systematic Approach to Metastasis Assessment

Initial Peritoneal Evaluation

• Collect ascitic fluid or perform peritoneal lavage for cytological examination immediately upon entering the peritoneal cavity 1
• If no free fluid is present, perform peritoneal washings with 50-100 ml of normal saline 2
• Cytologic evaluation of peritoneal fluid is critical as it can detect malignant cells even when no gross disease is visible 2

Visual Inspection and Documentation

• Systematically examine all peritoneal surfaces in a methodical manner 1
• Document findings in detail, including:
  • Presence/absence of visible implants
  • Size and location of any lesions
  • Characteristics of peritoneal surfaces
  • Presence of adhesions
  • Extent of disease spread

Targeted Sampling Techniques

Peritoneal Cytology

• Perform cytologic smears of peritoneal surfaces, which can identify disease in areas that appear normal on visual inspection 3
• Cytologic smears have been shown to identify disease in areas where biopsies may miss microscopic spread 3

Peritoneal Biopsies

• Take biopsies from any suspicious areas or adhesions 1
• If no suspicious areas are visible, perform random peritoneal biopsies from:
  • Diaphragmatic peritoneum (or diaphragm scraping for cytology) 1
  • Paracolic gutters 1
  • Pelvic peritoneum 1
  • Bladder peritoneum 1

Lymph Node Assessment

• Evaluate pelvic and para-aortic lymph nodes 1
• Para-aortic lymph node dissection should extend to at least the level of the inferior mesenteric artery, preferably to the renal vessels 1
• Pelvic lymph node assessment should include nodes overlying and medial to external iliac and hypogastric vessels, from the obturator fossa, and overlying the common iliac vessels 1

Omentum Evaluation

• Perform infracolic omentectomy for proper staging 1
• Examine the omentum carefully for metastatic deposits, as this is a common site for peritoneal spread 1

Special Considerations

Port Site Placement

• Be aware of the risk of port-site metastases, which can occur in up to 31% of cases when examined pathologically 4
• Consider excision of port sites during definitive surgery if ovarian cancer is confirmed 5, 4

Risk Factors for Peritoneal Spread

• Presence of ascites (especially >500 ml) significantly increases risk of peritoneal and port-site metastases 5
• Higher tumor stage and presence of peritoneal carcinomatosis correlate with increased risk of metastatic spread 5
• Serous carcinomas have higher rates of positive peritoneal cytology (76.9%) compared to endometrioid (44%) and mucinous (25%) carcinomas 2

Documentation Requirements

• Quantify and document the extent of initial and residual disease 1
• Record all findings in detailed operative notes 1
• Ensure proper handling of specimens:
  • Transport specimens intact and unopened to the laboratory promptly 1
  • Include detailed clinical information with specimens 1

Pitfalls to Avoid

• Inadequate sampling: Failure to sample all relevant areas can lead to understaging
• Rupture of tumor capsule: Avoid rupture during manipulation as it can lead to upstaging 1
• Incomplete visual assessment: Ensure thorough examination of all peritoneal surfaces, as visual inspection alone may miss microscopic disease
• Neglecting cytology: Peritoneal cytology can detect disease in 31% of cases that appear normal on visual inspection 2
• Delayed processing: Ensure specimens are promptly transported to pathology for optimal preservation and analysis 1

By following this systematic approach, diagnostic laparoscopy can provide accurate assessment of metastatic spread in ovarian cancer, guiding appropriate treatment decisions and improving patient outcomes.