Proposed section structure
For this topic, a clinically appropriate structure is: Highlights; Clinical background and unmet need; Study design and methods; Patient population and surgical approaches; Key results; Clinical interpretation; Strengths and limitations; Practical implications for surgeons and multidisciplinary teams; Conclusion; Funding and trial registration; References.
Highlights
First, in this multicenter cohort of 337 patients with stage I adult granulosa cell tumors and Sertoli-Leydig cell tumors, laparoscopic surgery was associated with lower unadjusted 10-year disease-free survival than laparotomy, but minimally invasive surgery itself did not remain an independent predictor after multivariable adjustment.
Second, FIGO stage IC was independently associated with recurrence, with an odds ratio of 3.058 (95% confidence interval 1.482-6.312; p=0.002).
Third, ovarian tumor morcellation independently predicted worse disease-free survival, with an odds ratio of 2.848 (95% confidence interval 1.432-5.663; p=0.003), and morcellation was more common in the minimally invasive surgery group.
Fourth, the recurrence pattern was notable for peritoneal seeding, a biologically and surgically plausible consequence of tumor disruption, reinforcing the importance of intact specimen removal when minimally invasive surgery is contemplated.
Clinical background and unmet need
Adult granulosa cell tumors (aGCTs) and Sertoli-Leydig cell tumors (SLCTs) are rare ovarian sex cord-stromal tumors. Most present at an early stage and are generally associated with favorable survival, but they are also characterized by a meaningful risk of recurrence, sometimes after prolonged intervals. Because these tumors are uncommon, the surgical evidence base is thinner than it is for epithelial ovarian cancer, and many operative decisions are extrapolated from limited retrospective series.
The rise of minimally invasive surgery (MIS) in gynecologic oncology has brought clear perioperative advantages in selected settings, including reduced blood loss, shorter hospitalization, and faster recovery. However, for ovarian neoplasms, concerns persist regarding intraoperative rupture, incomplete staging, specimen extraction difficulties, and especially tumor morcellation or fragmentation. Those concerns are particularly important in tumors that may recur within the peritoneal cavity after spillage or disruption.
For stage I sex cord-stromal tumors, the practical question is not simply whether laparoscopy is feasible, but whether it preserves oncologic integrity. This study addresses that question directly by comparing oncologic outcomes after laparoscopic versus open surgery in stage I aGCTs and SLCTs and by identifying recurrence-associated factors in a relatively large multicenter dataset.
Study design and methods
Kong and colleagues conducted a multicenter retrospective study through the Gynecologic Oncology Research Investigators coLLaborAtion, designated GORILLA-3005. The analysis included 337 patients treated between February 2001 and April 2022 for stage I adult granulosa cell tumors (n=288) or Sertoli-Leydig cell tumors (n=49).
The primary clinical objective was to compare oncologic outcomes between minimally invasive and laparotomic surgery. The principal endpoint was disease-free survival (DFS), estimated by the Kaplan-Meier method. Clinicopathologic variables were evaluated for association with recurrence, and prognostic factors for DFS were examined using Cox proportional hazards regression with backward elimination.
The study therefore combined two clinically important tasks: first, a direct comparison of operative approaches; and second, a search for the factors most responsible for recurrence risk. This distinction matters, because the safety of MIS may depend less on the route of access itself than on whether oncologic principles are maintained during tumor handling and specimen retrieval.
Patient population and surgical approaches
Among the 337 patients, 157 underwent laparotomy and 180 underwent laparoscopic surgery. The median follow-up was 53.0 months, with a range of 6 to 230 months. That duration is reasonably informative, although it remains important to remember that adult granulosa cell tumors in particular may recur late, sometimes beyond 10 years.
The study focused on stage I disease, which is clinically appropriate because operative route is often most debatable in patients with apparently confined tumors. At the same time, stage I disease is not biologically uniform. FIGO stage IC includes intraoperative spill, capsule rupture, tumor on the ovarian surface, or malignant cells in ascites/peritoneal washings, and those features can substantially alter recurrence risk. The present study confirms that point.
Although the abstract does not detail all staging procedures, the main interpretive issue is whether laparoscopy can be safely performed without compromising tumor containment. The study’s most consequential finding suggests that what happens to the tumor during surgery may matter more than whether the surgeon uses small incisions or a laparotomy.
Key results
Recurrence rates and recurrence pattern
Of 157 patients treated by laparotomy, 12 patients (7.6%) developed recurrence. Seven of these recurrences were peritoneal seedings. Of 180 patients treated laparoscopically, 21 patients (11.7%) recurred, including 15 cases of peritoneal seeding.
This recurrence pattern is clinically revealing. The higher absolute number and proportion of peritoneal seeding events in the laparoscopic group does not by itself prove causation, but it is strongly consistent with the concern that tumor disruption, spill, or morcellation can contribute to intraperitoneal dissemination.
Disease-free survival
The unadjusted 10-year DFS rates differed significantly between the operative groups: 74.3% for laparotomy versus 53.9% for laparoscopic surgery (p=0.040). On face value, this result could be interpreted as evidence against MIS in these rare tumors. However, the multivariable analysis adds a more nuanced and clinically useful perspective.
Independent prognostic factors
In multivariate analysis, two factors were independently associated with worse DFS. The first was FIGO stage IC, with an odds ratio of 3.058 (95% confidence interval 1.482-6.312; p=0.002). The second was ovarian tumor morcellation, with an odds ratio of 2.848 (95% confidence interval 1.432-5.663; p=0.003).
Importantly, MIS itself was not independently associated with disease-free survival after adjustment. This means that the poorer unadjusted DFS observed in the laparoscopic group appears to have been driven, at least in substantial part, by adverse intraoperative factors linked to surgical execution, especially morcellation, rather than by the minimally invasive route alone.
What this means statistically and clinically
This distinction between unadjusted and adjusted findings is central. A crude comparison suggested inferior long-term DFS with laparoscopy. But after accounting for relevant prognostic variables, the independent risk was tied to stage IC disease and tumor morcellation. Clinically, that shifts the question from “Is MIS oncologically unsafe?” to “Can MIS be performed without rupture, spill, or morcellation, and in which patients?”
For surgeons, this is a highly actionable message. If MIS is chosen, the operative plan must prioritize intact en bloc resection and protected specimen extraction. If that cannot be confidently achieved, conversion to laparotomy is not a technical failure but an oncologic safeguard.
Clinical interpretation
The most important contribution of this study is that it isolates tumor morcellation as a modifiable surgical hazard. In rare ovarian tumors where randomized data are unlikely, identifying a practice-linked factor that independently predicts recurrence is valuable. Morcellation can fragment tumor tissue, increase the risk of microscopic dissemination, and obscure pathologic assessment of capsular integrity and other staging details. All of those mechanisms plausibly contribute to recurrence, especially peritoneal relapse.
The finding that stage IC independently worsens DFS is unsurprising but still clinically important. Stage IC is a composite category, and some of its defining features are themselves related to intraoperative events such as surgical spill. That makes operative discipline especially relevant. In other words, some adverse prognostic features may be biological, but others may be at least partly iatrogenic.
For adult granulosa cell tumors, these results fit with longstanding concerns about late relapse and peritoneal recurrence. For Sertoli-Leydig cell tumors, which are less common and biologically heterogeneous, the same principles likely apply, although the smaller sample size makes histology-specific inferences more tentative. The combined analysis is reasonable given the rarity of both diseases, but clinicians should still avoid assuming that both subtypes behave identically.
Strengths of the study
The study has several notable strengths. First, it assembles a relatively large cohort for rare ovarian tumors, increasing the practical relevance of the findings. Second, the multicenter design improves external validity compared with a single-institution experience. Third, the authors did not stop at comparing operative routes; they evaluated recurrence-associated variables and identified a modifiable surgical factor. That makes the study more useful for clinical decision-making.
Another strength is the emphasis on long-term DFS. Because sex cord-stromal tumors may recur years after initial treatment, long follow-up is particularly valuable. The reported 10-year DFS comparison therefore adds meaningful perspective beyond short-term perioperative outcomes.
Limitations and cautions
As with all retrospective surgical oncology studies, selection bias is a major limitation. Patients selected for laparoscopy may have differed from those selected for laparotomy in ways not fully captured by the available variables. Tumor size, surgeon experience, referral patterns, temporal changes in practice, fertility-sparing intent, and institutional protocols may all have influenced both surgical approach and outcomes.
The study period spans more than two decades, from 2001 to 2022. During that time, laparoscopic technology, specimen retrieval techniques, imaging, pathologic classification, and postoperative surveillance have evolved. Earlier-era MIS cases may therefore not reflect current best practice. Conversely, the long interval also means that the data incorporate real-world variability that many clinicians encounter.
The abstract does not provide granular data on extent of staging, use of endobags, rates of intraoperative rupture distinct from morcellation, adjuvant therapy, fertility-sparing surgery, or histology-specific subgroup outcomes. Those details would help refine counseling. It is also worth noting that the abstract reports odds ratios from a Cox model, where hazard ratios are more commonly presented; this is likely a reporting simplification in the abstract, but the exact metric should be verified in the full paper.
Finally, while median follow-up exceeded four years, that may still underestimate very late recurrences, especially in aGCT. Continued surveillance remains essential regardless of operative route.
Practical implications for surgeons and multidisciplinary teams
When MIS may still be reasonable
This study does not argue that laparoscopy should be abandoned for all stage I aGCTs and SLCTs. Rather, it suggests that MIS can be considered only when strict oncologic principles can be upheld. These include careful preoperative assessment, gentle handling of the adnexal mass, avoidance of capsular rupture, no morcellation, and intact retrieval in a protective specimen bag when feasible.
When laparotomy should be favored
Laparotomy should be strongly considered when the mass is large, friable, difficult to extract intact, suspicious for surface involvement, or technically likely to require fragmentation for removal. The threshold to convert from MIS to open surgery should remain low if there is any concern about preserving tumor integrity.
Counseling patients
For patients, the message is nuanced. Minimally invasive surgery may offer faster recovery, but those benefits should not come at the cost of tumor disruption. Shared decision-making should explicitly address oncologic handling of the mass, the possibility of conversion to laparotomy, and the long-term implications of stage IC events and morcellation.
Implications for pathology and follow-up
Intact specimen removal also matters for pathology. Fragmented tumors can complicate assessment of capsule status, surface involvement, and margin interpretation. Given the risk of delayed recurrence, especially in granulosa cell tumors, long-term follow-up remains necessary even after apparently successful stage I treatment.
How this study fits into the broader literature
Because randomized trials in these rare tumors are unlikely, practice has relied on retrospective series and extrapolation from broader ovarian oncology principles. Current gynecologic oncology practice generally emphasizes intact resection and avoidance of tumor spill for adnexal malignancies and tumors of uncertain malignant potential. The present study strengthens that principle specifically for stage I aGCTs and SLCTs by linking morcellation to inferior DFS in a multicenter cohort.
These findings also align with broader concerns from gynecologic surgery that tissue fragmentation can compromise oncologic outcomes when occult or known malignancy is present. In that sense, the study’s message is not anti-laparoscopy; it is anti-compromise of tumor containment.
Conclusion
This multicenter study offers a clinically important refinement to the MIS debate in rare ovarian sex cord-stromal tumors. In stage I adult granulosa cell tumors and Sertoli-Leydig cell tumors, the worse unadjusted disease-free survival observed after laparoscopic surgery appears to be driven largely by factors linked to operative conduct, especially tumor morcellation, rather than by minimally invasive access itself. FIGO stage IC and ovarian tumor morcellation independently predicted recurrence.
For clinical practice, the takeaway is straightforward: if MIS is selected, it must be performed with uncompromising adherence to oncologic principles, particularly intact tumor resection and strict avoidance of morcellation. When those conditions cannot be assured, laparotomy remains the more prudent approach. Future studies should better define which patients can safely undergo MIS, incorporate histology-specific analyses, and standardize reporting of rupture, extraction technique, and staging completeness.
Funding and trial registration
No funding source or ClinicalTrials.gov registration number is reported in the provided abstract. The study was conducted as the Gynecologic Oncology Research Investigators coLLaborAtion study GORILLA-3005.
References
1. Kong TW, Lee J, Kim J, Son JH, Jang EB, Shim SH, Kim NK, Kim MK, Suh DH, Hwang DW, Kim HS, Lee YY, Lee JE, Nam EJ, Chang SJ. A multicenter study of laparoscopic versus laparotomic surgery in the treatment of stage I adult granulosa cell and Sertoli-Leydig cell tumors: (LARGES): Gynecologic Oncology Research Investigators coLLaborAtion study (GORILLA-3005). Gynecologic Oncology. 2026;210:148-152. PMID: 42242177.
2. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Ovarian Cancer, including Fallopian Tube Cancer and Primary Peritoneal Cancer. Current guideline versions include recommendations relevant to malignant sex cord-stromal tumors and emphasize oncologic surgical principles.