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Diaphragmatic surgery during cytoreduction for primary or recurrent epithelial ovarian cancer: a review of the literature

  • Gynecologic Oncology
  • Published:
Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Purpose

Surgical cytoreduction remains a cornerstone in the management of patients with advanced and recurrent epithelial ovarian cancer (EOC). Diaphragm involvement is a common site of metastases and represents a major limit in the achievement of an optimal cytoreduction. The purpose of this manuscript is to discuss the rationale of diaphragmatic surgery and the morbidity related to this procedure in advanced and recurrent EOC.

Methods

A search of the National Library of Medicine’s MEDLINE/PubMed database until August 2012 was performed using the keywords: ‘diaphragmatic surgery’ and ‘ovarian cancer’.

Results

Surgical treatment of diaphragmatic disease in advanced stage and recurrent EOC patients leads to high rates of optimal cytoreduction. It also correlates with an improved survival in advanced-stage EOC. The most common post-operative complication is a pleural effusion with rates ranging from 10 to 60 %. Pleural effusions are more common after diaphragmatic resections as compared to diaphragmatic stripping or coagulation. The need for post-operative thoracentesis or chest tube placement is low. The routine use of intraoperative trans-diaphragmatic decompression of pneumothorax reduces these rates. Diaphragmatic lesions at the time of interval debulking are less frequent and smaller in size. The morbidity of diaphragmatic surgery in this setting is lower as compared to a primary debulking; this is probably related to the fewer multivisceral radical procedures performed.

Conclusions

Diaphragmatic surgery at the time of cytoreduction increases rates of optimal cytoreduction and improves survival in advanced-stage and recurrent EOC patients. Gynecologic oncologists should be confident with its indication, technique and morbidity.

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References

  1. Siegel R, Naishadham D, Jemal A (2012) Cancer statistics, 2012. CA Cancer J Clin 62:10–29

    Article  PubMed  Google Scholar 

  2. Cannistra SA (2004) Cancer of the ovary. N Engl J Med 351:2519–2529

    Article  PubMed  CAS  Google Scholar 

  3. Bristow RE, Tomacruz RS, Armstrong DK, Trimble EL, Montz FJ (2002) Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. J Clin Oncol 20:1248–1259

    Article  PubMed  Google Scholar 

  4. Du Bois A, Reuss A, Pujade-Lauraine E, Harter P, Ray-Coquard I, Pfisterer J (2009) Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: a combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials: by the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and the Groupe d’Investigateurs Nationaux Pour les Etudes des Cancers de l’Ovaire (GINECO). Cancer 115:1234–1244

    Article  PubMed  Google Scholar 

  5. Vergote I, Tropè CG, Amant FA et al (2010) Neoadjuvant chemotherapy or primary surgery in stage IIIc–IV ovarian cancer. N Engl J Med 363:943–953

    Article  PubMed  CAS  Google Scholar 

  6. Armstrong DK, Bundy B, Wenzel L et al (2006) Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med 354:34–43

    Article  PubMed  CAS  Google Scholar 

  7. Chi DS, McCaughty K, Diaz JP et al (2006) Guidelines and selection criteria for secondary cytoreductive surgery in patients with recurrent, platinum-sensitive epithelial ovarian carcinoma. Cancer 106:1933–1939

    Article  PubMed  Google Scholar 

  8. Harter P, du Bois A, Hahmann M et al (2006) Surgery in recurrent ovarian cancer: the Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) DESKTOP OVAR trial. Ann Surg Oncol 13:1702–1710

    Article  PubMed  Google Scholar 

  9. Zang RY, Harter P, Chi DS et al (2011) Predictors of survival in patients with recurrent ovarian cancer undergoing secondary cytoreductive surgery based on the pooled analysis of an international collaborative cohort. Br J Cancer 105:890–896

    Article  PubMed  CAS  Google Scholar 

  10. Meredith MA, Cliby WA, Keeney GL, Lesnick TG, Nagorney DM, Podratz KC (2003) Hepatic resection for metachronous metastases from ovarian carcinoma. Gynecol Oncol 89:16–21

    Article  Google Scholar 

  11. Eisenkop SM, Spirtos NM, Lin WC (2006) Splenectomy in the context of primary cytoreductive operations for advanced epithelial cancer. Gynecol Oncol 100:344–348

    Article  PubMed  Google Scholar 

  12. Magtibay PM, Adams PB, Silverman MB, Cha SS, Podratz KC (2006) Splenectomy as part of cytoreductive surgery in ovarian cancer. Gynecol Oncol 102:369–374

    Article  PubMed  Google Scholar 

  13. Aletti GD, Podratz KC, Jones MB, Cliby WA (2006) Role of rectosigmoidectomy and stripping of pelvic peritoneum in outcomes of patients with advanced ovarian cancer—a preliminary report. J Am Coll Surg 203:521–526

    Article  PubMed  Google Scholar 

  14. Chi DS, Eisenhauer EL, Zivanovic O, Sonoda Y, Abu-Rustum NR, Levine DA, Guile MW, Bristow RE, Aghajanian C, Barakat RR (2009) Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm. Gynecol Oncol 114:26–31

    Article  PubMed  Google Scholar 

  15. Tan DS, Argarwal R, Kaye SB (2006) Mechanisms of transcoelomic metastasis in ovarian cancer. Lancet Oncol 7:925–934

    Article  PubMed  Google Scholar 

  16. Sehouli J, Senyuva F, Fotopoulou C, Neumann U, Denkert C, Werner L, Gülten OO (2009) Intra-abdominal tumor dissemination pattern and surgical outcome in 214 patients with primary ovarian cancer. J Surg Oncol 99:424–427

    Article  PubMed  Google Scholar 

  17. Einekel J, Ott R, Handzel R, Braumann UD, Horn LC (2009) Characteristics and management of diaphragm involvement in patients with primary advanced-stage ovarian, fallopian tube or peritoneal cancer. Int J Gynecol Cancer 19:1288–1297

    Article  Google Scholar 

  18. Deppe G, Malviya VK, Boike G, Hampton A (1986) Surgical approach to diaphragmatic metastases from ovarian cancer. Gynecol Oncol 24:258–260

    Article  PubMed  CAS  Google Scholar 

  19. Montz FJ, Schlaerth JB, Berek JS (1989) Resection of diaphragmatic peritoneum and muscle: role in cytoreductive surgery for ovarian cancer. Gynecol Oncol 35:338–341

    Article  PubMed  CAS  Google Scholar 

  20. Fiorica JV, Hoffman MS, La Polla JP, Roberts WS, Cavanagh D (1989) The management of diaphragmatic lesions in ovarian carcinoma. Obstet Gynecol 74:927–929

    PubMed  CAS  Google Scholar 

  21. Kapnik JS, Griffiths TC, Finkler NJ (1990) Occult pleural involvement in stage III ovarian carcinoma: role of diaphragmatic resection. Gynecol Oncol 39:135–138

    Article  Google Scholar 

  22. Eisenkop SM, Spirtos NM (2001) What are the current surgical objectives, strategies, and technical capabilities of gynecologic oncologists treating advanced epithelial ovarian cancer? Gynecol Oncol 82:489–497

    Article  PubMed  CAS  Google Scholar 

  23. Cliby W, Dowdy S, Feitoza SS, Gostout BS, Podratz KC (2004) Diaphragm resection for ovarian cancer: technique and short-term complications. Gynecol Oncol 94:655–660

    Article  PubMed  Google Scholar 

  24. Zivanovic O, Eisenhauer EL, Zhu K, Iasonos A, Sabbatini P, Sonoda Y, Abu-Rustum NR, Barakat RR, Chi DS (2008) The impact of bulky upper abdominal disease cephalad of the greater omentum and surgical outcome for stage IIIC epithelial ovarian, fallopian tube and primary peritoneal cancer. Gynecol Oncol 108:287–292

    Article  PubMed  Google Scholar 

  25. Eisenhauer EL, Chi DS (2007) Liver mobilization and diaphragm peritonectomy/resection. Gynecol Oncol 104:25–28

    Article  PubMed  Google Scholar 

  26. Tsolakidis D, Amant F, Van Gorp T, Leunen K, Neven P, Vergote I (2010) The role of diaphragmatic surgery during interval debulking after neoadjuvant chemotherapy an analysis of 74 patients with advanced epithelial ovarian cancer. Int J Gynecol Cancer 20:542–551

    Article  PubMed  Google Scholar 

  27. Aletti GD, Dowdy SC, Podratz KC, Cliby WA (2006) Surgical treatment of diaphragmatic disease correlates with improved survival in optimally debulked advanced stage ovarian cancer. Gynecol Oncol 100:283–287

    Article  PubMed  Google Scholar 

  28. Dowdy SC, Loewen RT, Aletti G, Feitoza SS, Cliby W (2008) Assessment of outcomes and morbidity following diaphragmatic peritonectomy for women with ovarian cancer. Gynecol Oncol 109:303–307

    Article  PubMed  Google Scholar 

  29. Eisenhauer EL, D’Angelica MI, Abu-Rustum NR, Sonoda Y, Jarnagin WR, Barakat RR, Chi DS (2006) Incidence and management of pleural effusions after diaphragm peritonectomy or resection for advanced mullerian cancer. Gynecol Oncol 103:871–877

    Article  PubMed  Google Scholar 

  30. Zapardiel I, Peiretti M, Zagagnolo V, Biffi R, Bocciolone L, Landoni F, Aletti G, Colombo N, Maggioni A (2011) Diaphragmatic surgery during primary cytoreduction for advanced ovarian cancer peritoneal stripping versus diaphragmatic resection. Int J Gynaecol Cancer 21:1698–1703

    Article  Google Scholar 

  31. Chereau E, Ballester M, Selle F, Cortez A, Pomel C, Darai E, Rouzier R (2009) Pulmonary morbidity of diaphragmatic surgery for stage III/IV ovarian cancer. BJOG 116:1062–1068

    Article  PubMed  CAS  Google Scholar 

  32. Chéreau E, Rouzier R, Gouy S et al (2011) Morbidity of diaphragmatic surgery for advanced ovarian cancer: retrospective study of 148 cases. Eur J Surg Oncol 37:175–180

    Article  PubMed  Google Scholar 

  33. Fanfani F, Fagotti A, Gallotta V et al (2010) Upper abdominal surgery in advanced and recurrent ovarian cancer: role of diaphragmatic surgery. Gynecol Oncol 116:497–501

    Article  PubMed  Google Scholar 

  34. Tsolakidis D, Amant F, Van Gorp T, Leunen K, Neven P, Vergote I (2010) Diaphragmatic surgery during primary debulking in 89 patients with stage IIIB–IV epithelial ovarian cancer. Gynecol Oncol 116:489–496

    Article  PubMed  CAS  Google Scholar 

  35. Devolder K, Amant P, Neven T, van Gorp T, Leunen K, Vergote I (2008) Role of diaphragmatic surgery in 69 patients with ovarian carcinoma. Int J Gynaecol Cancer 18:363–368

    Article  CAS  Google Scholar 

  36. Bashir S, Gerardi MA, Giuntoli RL, Montes TP, Bristow RE (2010) Surgical technique of diaphragm full-thickness resection and trans-diaphragmatic decompression of pneumothorax during cytoreductive surgery for ovarian cancer. Gynecol Oncol 119:255–258

    Article  PubMed  Google Scholar 

  37. Tsolakidis D, Amant F, Leunen K, Cadron I, Neven P, Vergote I (2011) Comparison of diaphragmatic surgery at primary or interval debulking in advanced ovarian carcinoma: an analysis of 163 patients. Eur J Cancer 47:191–198

    Article  PubMed  Google Scholar 

  38. Gouy S, Chereau E, Custodio AS, Uzan C, Pautier P, Haie-Meder C, Duvillard P, Morice P (2010) Surgical procedures and morbidities of diaphragmatic surgery in patients undergoing initial or interval debulking surgery for advanced stage ovarian cancer. J Am Coll Surg 210:509–514

    Article  PubMed  Google Scholar 

  39. Terauchi F, Okamoto A, Wada Y, Hasegawa E, Sasaki T, Akutagawa O, Sagawa Y, Nishi H, Isaka K (2010) Incidental events of diaphragmatic surgery in 82 patients with advanced ovarian, primary peritoneal and fallopian tubal cancer. Oncol Lett 1:861–864

    Article  PubMed  Google Scholar 

  40. Fuks D, Dumont F, Bera P et al (2009) Case report—complex management of a postoperative bronchogastric fistula after laparoscopic sleeve gastrectomy. Obes Surg 19:261–264

    Article  PubMed  Google Scholar 

  41. Hiles M, Record Ritchie RD, Altizer AM (2009) Are biologic grafts effective for hernia repair?: a systematic review of the literature. Surg Innov 16:26–37

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, University of Genova Medical School, IRCCS, AOU San Martino IST, Largo R. Benzi 1, 16132, Genoa, Italy

    Andrea Papadia & Matteo Morotti

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  1. Andrea Papadia
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  2. Matteo Morotti
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Correspondence to Matteo Morotti.

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Papadia, A., Morotti, M. Diaphragmatic surgery during cytoreduction for primary or recurrent epithelial ovarian cancer: a review of the literature. Arch Gynecol Obstet 287, 733–741 (2013). https://doi.org/10.1007/s00404-013-2715-1

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  • DOI: https://doi.org/10.1007/s00404-013-2715-1

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