Robotic Laparoscopy Improves Outcomes for Patients With Ovarian Cancer, Reaffirms Role of Surgery

Mario M. Leitao, Jr, MD, FACOG, FACS

Refined surgical techniques continue to be explored and validated in the field of ovarian cancer to improve survival for these patients and, in some cases, preserve fertility, explains Mario M. Leitao, Jr, MD, FACOG, FACS.

In a retrospective single-center study, investigators reviewed experience with robotic interval cytoreduction (IRC) following neoadjuvant chemotherapy for patients with advanced ovarian cancer who were treated between 2011 and 2016 at the University of Rochester Medical Center. After a mean of 3.9 cycles of neoadjuvant chemotherapy, 29 patients underwent IRC. One case (3.3%) was converted to an open versus robotic procedure because of extensive tumor not amenable to robotic cytoreduction.

Results showed that the median overall survival was 39.7 months and median progression-free survival was 21.2 months. The investigators concluded that IRC following neoadjuvant chemotherapy is feasible and may be preferable to open interval cytoreductive surgery in select patients to decrease morbidity and length of hospital stay.

OncLive^®: You spoke on surgery tonight. How has this area of the landscape evolved?

Leitao, attending surgeon, fellowship director in gynecologic oncology at Memorial Sloan Kettering Cancer Center, discusses how surgery retains its imperative role in ovarian cancer and sheds light on the challenges that still remain. He gave insight on this topic in an interview during the 2017 OncLive^® State of the Science Summit™ on Treatment Options in Ovarian Cancer.Leitao: Surgery is still a big part of ovarian cancer treatment, so the goal of surgeons is meant to reduce the amount of complications and make people recover quicker from surgery, with less complications and less time in hospital so they can get on to other treatment. In the past, standard surgery was very challenging, especially for ovarian cancer patients, because of the complexity of the surgeries.

Now, with the introduction of a robotic platform, we can do lots of surgeries and offer minimally invasive surgery, so that is what the robotic surgery has become. It is just a tool to do more laparoscopies for more patients and, therefore, decrease complications, improve their recovery, and get them onto the other therapies that they need. Then, we can use it for staging ovarian cancers where the cancer seems to be confined to the ovary and you just want to stage and see if it has spread to the lymph nodes. Without the robotics, it’s very difficult to do that.

Now, we’ve started to do more laparoscopic surgery, using the robotic approach for debulking of ovarian cancers. It’s a little limited in the upfront setting because of the amount of disease that you have to deal with. With relatively lower-volume disease, you can absolutely use the robotic approach and get folks home the same day of the surgery.

For the recurrent setting, it’s been helpful—especially with isolated recurrences—and being able to remove that. We can also do multi-organ resection with the robotic method now. We routinely consider these patients eligible to go home the same day of surgery—back to their family and their home. They receive their therapies quicker and deal with a lot less complications compared with traditional open surgery.

You also highlighted the role surgery has regarding fertility preservation. What is important to note in that area?

That’s an interesting point. Not all patients know that they could have this option.

How would you like to see surgery advance even further in the field of gynecologic malignancies?

Surgery still plays a big role in the treatment of ovarian cancer. Previously, patients were a little less willing to consider it because it was done traditionally with large incisions. Now, because we can do smaller incisions with less complications, surgery is an important part and should be considered in many situations. In terms of fertility preservation, for women with ovarian cancer that is confined to the ovary in an early stage, they can still potentially preserve the other ovary and uterus, get chemotherapy, and be able to have a family in the future. But you really need to see someone who is an expert and understands what is best and safe for them, so that they can not only survive their cancer, but have a family. It is, but it’s for select patients. It’s not for all patients, unfortunately, because we can’t detect ovarian cancer earlier enough to offer that. However, if you are fortunate enough to have been discovered to have the cancer early enough, you can still potentially have children. Once it is advanced, it’s not possible yet. But we’re always trying to make it better for the future. A lot of the focus now in gynecologic cancers, and even for most cancers, in general, for surgery, is identifying better ways to identify cancer during surgery to get better margins. At the same time, [we want to avoid] having to remove normal organs in the area because we try to estimate the negative margin during surgery. Sometimes, that means taking out the normal structures and nerves, which can lead to problems in the future.

What is the message on surgery in ovarian cancer for community physicians?

There is a lot of work trying to better image the cancers during surgery while we’re operating, which is quite difficult. [Surgeons] could get the entire tumor out and make people live as long, but we do find that there are long-term complications. There is a lot of work on intraoperative imaging and to find cancers better when we’re operating. There is continued work on how to do less invasive surgeries, and there’s also some work on trying to see how we can deliver certain therapies while we’re operating right into the surgical sites. Therefore, it’s an exciting time during surgery to see how we can make it better—from the surgical aspect of cancer treatment. The main thing is that they need to find someone who can offer good surgery to their patients, because surgery is different from giving a drug. There is some skill involved with that surgery, and there are lots of skilled surgeons out there. You need to find…a good skilled surgeon to offer the best surgery possible because that does offer benefit to patients who have ovarian cancer.

Also, now there are fertility options for younger women. Even in the recurrent setting, surgery can offer a benefit if done correctly and with the right surgeon.