European Journal

and Reproductive

of Obstetrics & Gynecology

Biology 61 (1995) 147-150

Laparoscopic management of malignant ovarian cysts: a 7%case

national survey. Part 2: Follow-up and final treatment
Bernard

Blanc*, Claude

DErcole,

Eric Nicoloso,

LCon Boubli

Service de GynPcologie ObstPtrique B, H6pital de la Conception. I3385 Marseille Cedex 5, France

Accepted

10 May 1994

Abstract

This paper reports a retrospective multi-institutional French survey carried out in 1992 to determine the incidence of laparoscopic
management of malignant ovarian cysts. Of 5307 ovarian lesions treated endoscopically, 78 were malignant (1.47%) including 60
borderline tumours (77%) and 18 ovarian cancers (23%). Laparoscopic treatment was puncture in 23% of cases, partial exeresis
in 51% and total removal in 26%. Laparotomy was immediately performed in 25% of the cases and as a second stage procedure
in 58% (mean delay: 78 days). Laparotomy was not performed in 16% of the cases. Our findings suggest that laparoscopic management of ovarian lesions that subsequently prove to be malignant is not uncommon. To prevent the risk of metastasis, thorough
pre-operative and per-operative evaluation is mandatory. In 22.4% of the patients presenting lesions in this study, laparoscopic
tampering resulted in an upgrading of FIG0 stage.
Keywords:

Laparoscopy; Ovarian cancer; Borderline lesion; Surgical management; FIG0

1. Introduction
This paper reports a retrospective multi-institutional
French survey, carried out from April to October 1992,
to determine the incidence of laparoscopic management
of malignant
ovarian cysts. A total of 7122 ovarian
lesions were examined
laparoscopically
and 5307 of

Table 1
Laparoscopic

treatment

of 78 ovarian

Procedure
Puncture

cysts subsequently
Borderline

only

Intraperitoneal
Transparietal
Intraperitoneal
Intraperitoneal
Transparietal
Total

cystectomy
cystectomy
annexectomy
ovariectomy
ovarectomy

* Corresponding

author,

0301-2115/95/$09.50
0
SSDI 0301-2115(95)0211

found

these were treated, including

78 malignant
tumors
(1.47%) (60 borderline tumors and 18 ovarian cancers).
Table 1 summarizes the laparoscopic procedures performed. In 41 cases (52.3%), the cystic lesions were
punctured.
In 18 patients (23.08%), puncture was the
only laparoscopic procedure. In 40 cases (56.3%), partial
exeresis limited to the cystic lesion was performed. In 20

to be malignant

Neoplastic

12

19
16
5
3
5
60

1
4
1
2
4
18

Tel.: +33 91 383786; Fax: +33 91 480940.

1995 Elsevier Science Ireland

l-5

staging

Ltd. All rights reserved

Total

18
20
20
6
5
9
78

23.08
25.64
25.64
7.69
6.41
11.54

B. Blanc et al. /European Journal of Obstetrics & Gynecology and Reproductive Biology 61 (1995) 147-150

148

Table 2
Overall management
Ovarian

of 78 adnexal

masses subsequently

disease

Borderline

Laparoscopy
only
Immediate laparotomy
Immediate laparotomy
+ second stage laparotomy
Delayed laparotomy
Lost to follow-up
Total

found to be malignant

lesion

Cancer

Laparoscopic
US findings

between

ultrasonographic

aspect

Liquid
Septation
Solid
Both solid/liquid
Vegetations
No echo
Total
US, Ultrasonographic.

12
11
2

0
5
2

12
16
4

15.4
20.5
5.1

34
I
60

II
0
18

45
1
78

57.7
1.28

cases (25.6%), the ovary or the whole adnexal was completely removed.
Frozen sections were studied preoperatively in 23
cases (29.5%). Findings were concordant with the final
diagnosis in 16 cases (69.6%) and discordant in three
cases (13%), i.e. three borderline lesions. In four cases
(17.4%), frozen sections were doubtful, i.e. three
borderline lesions and one cancer. In 11 cases (47.8%),
frozen section findings led to immediate laparotomy
during the same surgical procedure. However, in 10
cases (43.5%) surgery was postponed for a mean duration of 75 days (range: 2-380 days) despite a positive
frozen section. In two cases, frozen sections were negative and only laparoscopic treatment was performed.
Follow-up in these two patients is currently 6 and 72
months. The recovery period after laparoscopy was
uneventful in 77 cases (98.8%), the only complication
mentioned being parietal infection.
Tables 2 and 3 present a summary of surgical management in the 78 patients. Twelve patients (15.4%) with
borderline lesions were treated by laparoscopy alone.
Twenty patients (25.6%) underwent immediate laparotomy. Of these patients, 19 presented suspicious laparoscopic findings and four required repeat laparotomy.
Forty-five patients (57.7%) underwent delayed laparotomy. Of these patients, 11 had ovarian cancer. One
foreign patient was lost to follow-up after the laparos-

Table 3
Correlation

Total

findings,

laparoscopic

appearance

No suspicion
n

Immediate

15
11
2
8
9
I
46

1
0
0
0
0
0
1 (2.17%)

copy. This patient, who presented a borderline lesion,

underwent transparietal cystectomy.
An upgrade in FIG0 stage was observed in 11 cases
(22.4%), including eight within the first month after laparoscopy. Upgrading was noted in live out of 60 patients
presenting borderline lesions (8.3%) and six out of 18
patients with ovarian cancer (30%). Of the 11 patients,
whose histories are exhaustively presented in Table 4, 10
did not undergo immediate laparotomy. In three of
these cases, frozen section was positive and correlated
with the final diagnosis. In the patient (no. 3) that
underwent immediate laparotomy, frozen section was
not performed but the decision to open the abdomen
was taken because pyosalpinx was suspected. The final
diagnosis in this patient was a cystadenocarcinoma and
repeat laparotomy was performed. Case no. 9 involved
a 34-year-old woman in whom intraperitoneal cystectomy yielded suspicious findings. Two months after laparoscopy, the cyst recurred and a transparietal
cystectomy was performed demonstrating a stage IA
borderline tumor. Three and half years later this patient
presented a second recurrence and laparotomy was performed demonstrating stage IIIC cystadenocarcinoma.
Tumor implantation was noted along the pathway of
transparietal cystectomy needle. This patient is currently
undergoing chemotherapy.
Follow-up data is presented in Table 5. The mean

and decision

to perform

laparotomy

during

Suspicion
laparotomy

Immediate
8
5

I
8
9
1
32

4
3
1
5
5

I
19 (58.06%)

laparotomy

the laparoscopy

B. Blanc et al. /European

Table 4
Exhaustive

CaSe

presentation

Journal of Obstetrics

of 11 cases in which an upgrade

Laparoscopic
treatment

Second-stage
laparotomy

Histology

& Gynecology and Reproductive

in FIG0

stage was noted between

FIG0
upgrading

Macroscopic
implants

15
16
21
21
21
25
380
440

K
K
K
BL
BL
BL
BL
K
BL
K

IA-HA
ICI11
IA-IC
IA-IC
IC-III
IA-III
IA-WC
IA-II
IA-WC
IA-III

X
X
X

X
X

120

BL

IA-IV

Biology 61 (1995) 147-150

laparoscopy

Microscopic
implants

and laparotomy

Histology

Duration
follow-up
(months)

type

delay a
1
2

OTPb
KIP

3
4
5
6

PctO+LI
KIP
PctBb

I
8
9
IO

ATP
KIP
KIPlb,
OTP

11

KIP

8
15

KIP2

Pet, puncture; LI, imediate laparotomy;

Delay between laparoscopic
treatment
bFrozen section examination.

Serous
Clear cell
Serous
Serous
Serous
Serous
Serous
?
Serous
Androblastoma
Mutinous

?
?

PctB, puncture and biopsy;

and second stage laparotomy.

duration of follow-up in all 78 patients is 14.6 months.

Three (3.8%) are dead including two from lesion-related
causes. Fifty-nine patients (75.6%) are alive with no evidence of complication. Fourteen patients (17.9%) have
been lost to follow-up. Laparoscopy was considered as
the sole treatment in all these patients, one of whom had
ovarian cancer. It is noteworthy that regular surveillance was possible in only 66 patients and that in 37 of
these 66 patients (56.1%), the duration of follow-up is
less than 1 year.

NED, no evidence

findings

aspect

Current
status

21
9
6
20
6
50
9
12
I
23

K breast
Died tumor
NED
NED
NED
NED
NED
NED
NED
NED

38

Died tumor

in the American

American

<8C

Cystic
Unilocular
Unilateral
No suspicious

of

of disease.

Table 6
Comparison
of macroscopic
French studies
Tumor

149

findings

study

and present

French

W)

W)

61
62
48
81
31

66.10
96
39.10
96
33

study

2. Discussion
Our perusal of the literature turned up one study, very
similar to this one, performed by Maiman in the United
States [ 11. It included 42 cases involving laparoscopic
excision of ovarian neoplasms subsequently found to be
malignant. Like our study, the American experience
indicates that laparoscopic management of malignant

Table I
Comparison
of laparoscopic
present French studies

procedures

American

Procedure

Puncture
Partial exeresis
Total exeresis

used in the American

study

French

W)

(%)

38
33
29

23.10
51.28
25.60

and

study

Table 5
Follow-up of 18 patients who underwent laparoscopic
management
adnexal cystic masses subsequently
found to be malignant
n

NED
Died

59
3

15.65
3.84

Tumor-related
No precision
Complications
Cancer of the contralateral
Breast cancer
No precision

(2)
(1)
(:,

Current

status

NED, no evidence

of disease.

Table 8
Comparison
of overall
present French studies

surgical

management

Procedure

American

2.56

Immediate laparotomy
Delayed laparotomy

11.95

No laparotomy
Lost to follow-up
Mean delay to repeat

41%
11%
12%
0%
36 days

ovary
(1)
14

of

in the American

study

French
20.5%
62.82%
15.38%
15.38%
18 days

and

study

150

Table 9
Comparison

B. Blanc et al. /European Journal of Obstetrics & Gynecology and Reproductive Biology 61 (1995) 147-150

of histology

Procedure

Borderline
Cancer
Germ. cell tumors
Stromal tumors
Stages II-IV

in the American
American

and present French

study

French

(/I

(Q

29
57
9.5
4.1
50

14.36
20.51
1.28
3.85
11.54

studies
study

adnexal masses is not uncommon. In fact it seems likely

that both studies underestimate the incidence of laparoscopic tampering since we addressed our questionnaire
only to surgical teams whose practices include routine
laparoscopy and Maiman included only members of
Oncologic Gynecology Society.
Tables 6, 7, 8, and 9, summarize the results of these
two studies. The laparoscopic and macroscopic aspects
of the lesions, as well as therapeutic procedures used,
were quite similar in the two studies. In contrast,
histologic findings were different. Maiman reported
more invasive lesions (57% vs. 20.51%). Furthermore,
initial staging revealed > 50% of lesions to be stage II or
more in the American survey as compared to only 11.5%
in our study.
Recurrence or transformation into real cancer has
been documented after laparoscopic management of
borderline tumors [2-51. In the present study, upgrading of FIG0 staging was observed in five
laparoscopically treated borderline tumors (Table 4). In
four of these cases, frank cancer was noted with parietal
implants (two cases) and/or peritoneal implants (four
cases). In the fifth case, intraperitoneal cystectomy led
to an upgrade from stage IA to IC. It is noteworthy that
in three cases, the upgrade was documented by repeat
laparoscopy within 1 month after tampering. In the
other two cases, repeat laparoscopy was performed
much later (380 and 780 days). In this study the average
age in patients with borderline tumors was 5 years lower
than in those with ovarian cancer. In a previous report,
a lo-year difference was reported [6]. The fact that many
of these women still want children underscores the need
for careful selection to avoid upgrading of a borderline
tumor.
This study also documented spreading of cancer after
laparoscopic treatment of ovarian cancer (see Table 4).
In six cases, further invasion was noted between the
laparoscopy and laparotomy. Prognosis is not changed
by either intraperitoneal rupture or perlaparoscopic
puncture of the cyst change the prognosis or by
peroperative handling or traumatism [7,8].

When malignancy is ascertained, surgical treatment

should be undertaken immediately, if possible on the
day of the laparoscopy. In our survey no spreading was
noted when the surgery was performed immediately
after the laparoscopy. Our data showing a mean delay
of >8 weeks between diagnostic laparoscopic and surgery indicates that treatment is often postponed.
Our findings confirm the following previous recommendations for laparoscopy management of adnexal
cystic masses: (a) Patients must be careful selected
(ultrasonography). Blind application of laparoscopic
treatment is hazardous. (b) During laparoscopy strict
guidelines should be followed to rule out malignancy
(complete investigation of the abdominal cavity and
routine analysis of peritoneal liquid) and malignant
seeding (single-use of puncture needles, complete emptying of the cyst, per-operative cystoscopy, and abdominal
cavity irrigation and wrapping of the resection specimen
before extraction). (c) If suspicious lesions are noted
outside the ovary or inside the cyst, laparotomy should
be performed to remove the ovary for frozen section
study. Further study is needed to assess the risk of
malignant transformation of borderline lesions.
Acknowledgments

We would like to thank all the responding surgeons

without whose cooperation this survey would not have
been possible.
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