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Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 51-52

The role of laparoscopy and the value of peritoneal carcinomatosis index in patients with intra-abdominal malignancies who are scheduled to laparotomy

Department of Obstetrics and Gynecology, Taipei Veterans General Hospital; Department of Obstetrics and Gynecology; Institute of Clinical Medicine, National Yang-Ming University, Taipei; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan

Date of Submission30-Sep-2018
Date of Acceptance01-Oct-2018
Date of Web Publication29-Apr-2019

Correspondence Address:
Dr. Peng-Hui Wang
Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei 112

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/GMIT.GMIT_93_18

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How to cite this article:
Wang PH. The role of laparoscopy and the value of peritoneal carcinomatosis index in patients with intra-abdominal malignancies who are scheduled to laparotomy. Gynecol Minim Invasive Ther 2019;8:51-2

How to cite this URL:
Wang PH. The role of laparoscopy and the value of peritoneal carcinomatosis index in patients with intra-abdominal malignancies who are scheduled to laparotomy. Gynecol Minim Invasive Ther [serial online] 2019 [cited 2020 Sep 29];8:51-2. Available from: http://www.e-gmit.com/text.asp?2019/8/2/51/257340

To improve disease-free survival and/or overall survival (DFS and/or OS) of patients with advanced epithelial ovarian cancer/primary  Fallopian tube More Details cancer/primary peritoneal serous carcinoma (EOC/PFTC/PPSC), combination of optimal debulking surgery and adjuvant chemotherapy is the only option for enhancing long-term OS of these patients with EOC, PFTC, and PPSC.[1],[2],[3] Although there are many strategies available and some of them, such as hyperthermic intraperitoneal chemotherapy (HIPEC), dose-intense therapy, metronomic therapy, anti-angiogenesis agents, targeted therapy, immunomodulation agents, and many uncertain investigated agents, reported their benefits on survival,[4],[5],[6],[7],[8] there is no doubt that many of them only increase long-term DFS without increasing OS. To achieve the better chance of survival, sometimes, complete optimal cytoreductive surgery should include resection of segments of the digestive tract, spleno-pancreatectomy, diaphragmatic resection, peritonectomy, and removal of bulk-sized lymph nodes near vital organs and/or vessels.

The treatment was, for a long time, a first surgery as complete as possible followed by adjuvant chemotherapy; however, primary optimal debulking surgery, as shown above, is often associated with substantial morbidity, including complications that might delay chemotherapy. Therefore, neoadjuvant chemotherapy (NACT) followed by interval debulking surgery and adjuvant chemotherapy has become an increasingly suggestive alternative to the primary cytoreductive surgery for the management of women with far-advanced EOC/PFTC/PPSC.[9],[10] The American Society of Clinical Oncology and the European Society for Medical Oncology recommended NACT for women who have a high per-operative risk profile (patients with poor performance status and low albumin levels) and/or a low likelihood of primary optimal debulking surgery (patients with very extensive tumor dissemination) based on the NACT-related benefits, such as less perioperative and postoperative morbidity and mortality and shorter hospitalization.[10] Therefore, the identification of patients with extensive disease who are likely to have unsuccessful primary cytoreductive surgery is important.[11]

Several different scoring systems have been introduced to quantify the tumor extent in the abdomen and the involvement of the peritoneum,[11],[12] the Sugarbaker's Peritoneal Cancer (Carcinoma) Index (PCI), ranging from 0 to 39, has been accepted as one of the most appropriate intraoperative staging system and regarded it as a standard, based on the effectiveness in predictive the prognosis.[13] However, the PCI score system was originally created to be used intraoperatively but is now also applied in the preoperative status of the patients with far-advanced stage EOC/PFTC/PPSC, since survival is strongly correlated with the size of residual tumor after primary cytoreductive surgery.[11] To achieve this goal, many examinations were tested. Among these, preoperative radiological imaging, especially computed tomography (CT) is the most common acceptance for the patients with EOC/PFTC/PPSC to exclude the distant metastasis and to estimate the extent of peritoneal tumor spreading regarding PCI scores.[13] However, some reported showed that these noninvasive diagnostic methods, including physical examination, ultrasound, CT, and serum markers, and even though combination of various imaging techniques and clinical features as the prediction models did not predict completeness of primary cytoreductive surgery accurately, suggesting that other tools should be considered to be useful to prevent futile laparotomy in daily practice.[11] In the April-June issue of the Gynecology and Minimally Invasive Therapy, Dr. EI-Agwany published an interesting article, entitled “Laparoscopy and CT imaging in advanced ovarian tumors: A roadmap for prediction of optimal cytoreductive surgery.”[14] The author analyzed 15 patients with far-advanced stage EOC who had an abdominal CT PCI score <15 and these 15 patients underwent three-port laparoscopy evaluation. Finally, the author found that laparoscopy failed to evaluate six patients clearly (40%), due to severe dense adhesion (previous surgery, such as cholecystectomy and splenectomy, and total obliteration of tumor embedding into the cul-de-sac, and invisible areas, such as the posterior surface of the diaphragm).[14] However, CT failed to detect seven patients (46.7%) accurately, including four cases diagnosed with an in-operatable condition by laparoscopy and three cases with missed detection of terminal ileum involvement >50% by CT.[14] Therefore, the author concluded that laparoscopy is a useful adjunct with CT and combination of CT and laparoscopy might be a better assessment for patients with far-advanced stage EOC before a plan of primary cytoreductive surgery. I congratulate the success of the publication. This article is interesting. At least two parts should be emphasized.

First, the role of laparoscopy in the ovarian cancer is relatively clear, and it is a promising test because of the high specificity of laparoscopy in diagnosing resectability and good sensitivity. The use of criteria for the unresectable disease will result in no patients inappropriately unexplored or reduce the number of futile laparotomies significantly.[11],[15] If one would like to proceed with primary “optimal” cytoreductive surgery for these far-advanced stage EOC patients, the performance of diagnostic laparoscopy first is reasonable.[11] No one can always be against the value of the laparoscopy in the evaluation of the patients with far-advanced stage EOC.

Second, evidence has shown the value of PCI, even before and during operation in the prediction of outcomes of the patients with various kinds of intra-abdominal malignancies. Physicians, especially surgical oncologists, including gynecologic oncologists should be familiar with this system. The use of this application should not be only limited to the patients who undergo HIPEC treatment.


This article was supported by grants from the Ministry of Science and Technology, Executive Yuan (MOST 106-2314-B-075-061-MY3), and Taipei Veterans General Hospital (V106C-129; V106D23-001-MY2-1; and V107C-136).

Conflicts of interest

There are no conflicts of interest.

  References Top

Wang PH, Yuan CC, Shyong WY, Chiang SC, Chao JY, Yen MS, et al. Optimal debulking surgery is an independent prognostic factor in patients with FIGO IIIC primary epithelial ovarian carcinoma. Zhonghua Yi Xue Za Zhi (Taipei) 2000;63:220-5.  Back to cited text no. 1
Wang PH, Yuan CC, Chao HT, Yen MS, Ng HT. Outcome of advanced primary fallopian tube adenocarcinoma. Zhonghua Yi Xue Za Zhi (Taipei) 1999;62:782-6.  Back to cited text no. 2
Sung PL, Wen KC, Horng HC, Chang CM, Chen YJ, Lee WL, et al. The role of α2,3-linked sialylation on clear cell type epithelial ovarian cancer. Taiwan J Obstet Gynecol 2018;57:255-63.  Back to cited text no. 3
Yarema R, Fetsych T, Volodko N, Оhorchak M, Petronchak O, Huley R, et al. Evaluation of the peritoneal surface disease severity score (PSDSS) in ovarian cancer patients undergoing cytoreductive surgery and HIPEC: Two pathogenetic types based study. J Surg Oncol 2018;117:1806-12.  Back to cited text no. 4
Kireeva GS, Gafton GI, Guseynov KD, Senchik KY, Belyaeva OA, Bespalov VG, et al. HIPEC in patients with primary advanced ovarian cancer: Is there a role? A systematic review of short- and long-term outcomes. Surg Oncol 2018;27:251-8.  Back to cited text no. 5
Liu CH, Chang Y, Wang PH. Poly (ADP-ribose) polymerase (PARP) inhibitors and ovarian cancer. Taiwan J Obstet Gynecol 2017;56:713-4.  Back to cited text no. 6
Wong CN, Wong CN, Liu FS. Continuous oral cyclophosphamide as salvage or maintenance therapy in ovarian, primary peritoneal, and fallopian tube cancers: A retrospective, single institute study. Taiwan J Obstet Gynecol 2017;56:302-5.  Back to cited text no. 7
Su WH, Ho TY, Li YT, Lu CH, Lee WL, Wang PH, et al. Metronomic therapy for gynecologic cancers. Taiwan J Obstet Gynecol 2012;51:167-78.  Back to cited text no. 8
Cole AL, Austin AE, Hickson RP, Dixon MS, Barber EL. Review of methodological challenges in comparing the effectiveness of neoadjuvant chemotherapy versus primary debulking surgery for advanced ovarian cancer in the United States. Cancer Epidemiol 2018;55:8-16.  Back to cited text no. 9
Elies A, Rivière S, Pouget N, Becette V, Dubot C, Donnadieu A, et al. The role of neoadjuvant chemotherapy in ovarian cancer. Expert Rev Anticancer Ther 2018;18:555-66.  Back to cited text no. 10
Rutten MJ, van Meurs HS, van de Vrie R, Gaarenstroom KN, Naaktgeboren CA, van Gorp T, et al. Laparoscopy to predict the result of primary cytoreductive surgery in patients with advanced ovarian cancer: A randomized controlled trial. J Clin Oncol 2017;35:613-21.  Back to cited text no. 11
Suidan RS, Ramirez PT, Sarasohn DM, Teitcher JB, Iyer RB, Zhou Q, et al. Amulticenter assessment of the ability of preoperative computed tomography scan and CA-125 to predict gross residual disease at primary debulking for advanced epithelial ovarian cancer. Gynecol Oncol 2017;145:27-31.  Back to cited text no. 12
Suzuki C, Wallgren H, Abraham-Nordling M, Palmer G. Preoperative CT-based predictive factors for resectability and medium-term overall survival in patients with peritoneal carcinomatosis from colorectal cancer. Clin Radiol 2018;73:756.e11-16.  Back to cited text no. 13
El-Agwany AS. Laparoscopy and computed tomography imaging in advanced ovarian tumors: A Roadmap for prediction of optimal cytoreductive surgery. Gynecol Minim Invasive Ther 2018;7:66-9.  Back to cited text no. 14
[PUBMED]  [Full text]  
Allen VB, Gurusamy KS, Takwoingi Y, Kalia A, Davidson BR. Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev 2016;7:CD009323.  Back to cited text no. 15

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