Is staging laparotomy performed in all stages of mucinous adenocarcinoma, particularly in ovarian cancer, or only in early stages, specifically Federation Internationale de Gynecologie et d'Obstetrique (FIGO) Stage I and II?

Staging Laparotomy in Mucinous Ovarian Adenocarcinoma

Comprehensive staging laparotomy via midline incision is required for all apparent early-stage (FIGO I-II) mucinous ovarian adenocarcinoma, regardless of stage, with the critical exception that lymphadenectomy can be omitted in expansile-type mucinous carcinomas with radiologically and clinically negative nodes. 1, 2

Surgical Staging Requirements for All Early Stages

For all patients with apparent FIGO stage I-II mucinous adenocarcinoma, the following comprehensive staging procedures are mandatory 1, 2:

• Midline laparotomy (not laparoscopy, due to increased capsule rupture risk) 1
• Peritoneal washings for cytological examination 1, 2
• Thorough inspection and palpation of the entire abdominal cavity 1, 2
• Biopsies from all visible lesions and systematic biopsies from diaphragmatic peritoneum, paracolic gutters, and pelvic peritoneum 1, 2
• Infracolic omentectomy 1, 2
• Appendectomy (absolutely mandatory in mucinous carcinoma, as 8% have appendiceal involvement and primary appendiceal cancer frequently mimics ovarian mucinous cancer) 1, 3
• Bilateral salpingo-oophorectomy and hysterectomy (unless fertility-sparing criteria met) 1

The Lymphadenectomy Question: Histologic Subtype Matters

The most recent ESMO guideline (2023) provides critical nuance for mucinous carcinoma 1:

• Lymphadenectomy can be omitted in patients with expansile-type mucinous carcinoma who have radiologically and clinically negative nodes, as the rate of lymph node metastases is <1% 1
• Systematic pelvic and para-aortic lymphadenectomy is recommended for high-grade histologies and infiltrative-type mucinous carcinoma 1, 4

This distinction is supported by research showing that in expansile mucinous carcinomas, no nodal involvement was found in 8 patients who underwent lymphadenectomy, whereas 17% of infiltrative-type cases had positive nodes 4. Another study of 31 mucinous ovarian cancer patients found zero metastatic disease in 190 dissected pelvic nodes 5.

Why Complete Staging Cannot Be Skipped

The rationale for comprehensive staging in all apparent early-stage disease is compelling 1, 6:

• 31-60% of patients with apparent early ovarian cancer are upstaged after complete surgical staging 1, 6
• 77% of upstaged patients actually have stage III disease 1, 6
• Only 25% of patients receive adequate initial surgical incisions for proper staging 1, 6
• Upstaging directly impacts survival outcomes and determines whether adjuvant chemotherapy is needed 1

Critical Pitfalls to Avoid

Inadequate initial surgery is the most common error 3, 6:

• If initial surgery was inadequate, restaging laparotomy must be performed as soon as possible 1, 3, 7
• Laparoscopic management of potentially malignant masses is not recommended due to increased capsule rupture risk and inadequate staging 1
• Trochar tracks must be resected if diagnosis is made after laparoscopy 1

Forgetting appendectomy in mucinous histology is a critical error, as primary appendiceal cancer must be excluded 1, 3

Advanced Stage Disease (FIGO IIb-IV)

For advanced disease, the surgical approach shifts from staging to maximal cytoreductive surgery 1, 3:

• Goal is complete resection of all visible disease (R0 resection) 3
• Includes total abdominal hysterectomy, bilateral salpingo-oophorectomy, complete omentectomy, appendectomy, and resection of all visible disease 1, 3
• Lymphadenectomy is performed if abdominal tumor resection is complete/optimal and there is nodal enlargement 1