Abstract
To achieve optimal debulking, cytoreductive surgery often involves diaphragm stripping. We describe our complications and survival outcomes after diaphragm surgery in epithelial ovarian cancer. A retrospective analysis on patients with advanced stage epithelial ovarian cancer between January 2012 and September 2019. The details of the diaphragmatic resections and stripping and their complications were looked into. During the study period, 616 patients with epithelial ovarian cancers were operated of which, 81 (13.2%) had diaphragm surgery. The majority underwent diaphragm stripping (60%) while 33% had resection and 7% cases had diaphragmatic nodule excision. Optimal debulking was achieved in 89% of cases. The complexity of surgery was intermediate in 64% of patients and complex in 33% as per Aletti’s scoring. Mean operating time was 300 min (SD113). Moderate to severe pleural effusion was seen in 26 (32. %) patients necessitating pleural tapping in 16% and single lumen pleurex catheter insertion in 11%. Median recurrence-free and overall survival were 22 (95% CI 16.9–27) and 32 months (95% CI 25.5–38) respectively. Diaphragm stripping and resection is an important step in achieving optimal debulking of advanced and recurrent ovarian cancer. Diaphragmatic disease clearance is a necessary skill to be acquired by the gynaecologic oncology surgeons. Choosing the patients correctly and anticipation of complications can reduce morbidity and mortality
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References
Globocan 2018 data. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424.
Heintz AP, Odicino F, Maisonneuve P, Beller U, Benedet JL, Creasman WT et al (2003) Carcinoma of the ovary. Int J Gynecol Obstet 83(Suppl 1):135–166
Pecorelli S, Favalli G, Zigliani L, Odicino F (2003) Cancer in women. Int J Gynecol Obstet 82:369–379
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
Chi DS, Eisenhauer EL, Lang J et al (2006) What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)? Gynecol Oncol 103:559–564
Shih KK, Chi DS (2010) Maximalcytoreductive effort in epithelial ovarian cancer surgery. J Gynecol Oncol 21:75–80
Guidozzi F, Ball JH (1994) Extensive primary cytoreductive surgery for advanced epithelial ovarian cancer. Gynecol Oncol 53:326–330
Kehoe SM, Eisenhauer EL, Chi DS (2008) Upper abdominal surgical procedures: liver mobilization and diaphragm peritonectomy/resection, splenectomy, and distal pancreatectomy. Gynecol Oncol 111:51–55
Aletti GD, Dowdy SC, Podratz KC et al (2006) Surgical treatment of diaphragm disease correlates with improved survival in optimally debulked advanced stage ovarian cancer. Gynecol Oncol 100:283–287
Chéreau E, Rouzier R, Gouy S et al (2011) Morbidity of diaphragmatic surgery for advanced ovarian cancer: a retrospective study of 148 cases. Eur J Surg Oncol. 37:175–180
Griffiths CT (1975) Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma. Natl Cancer Inst Monogr 42:101–104
Hoskins W (1994) Epithelial ovarian carcinoma: principles of primary surgery. Gynecol Oncol 55:91–96
Eisenhauer E, Chi D (2007) Liver mobilization and diaphragm peritonectomy/resection. Gynecol Oncol 104:25–8
Rosenoff S, Young R, Chabreu B (1975) Use of peritoneoscopy for initial staging and posttherapy evaluation of patients with ovarian cancer. Natl Canc Inst Monogr 42:81–86
Arora V, Somashekhar S (2018) Essential surgical skills for a gynecologic oncologist. Int J Gynecol Obstet 143:118–130
Eisenkop S, Spirtos N (2001) What are the current surgical objectives, strategies, and technical capabilities of gynecologic oncologists treating advanced epithelial ovarian cancer. Gynecol Oncol 82:489–497
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
Tozzi R, Ferrari F, Nieuwstad J, Campanile RG, SoleymaniMajd H (2020) Tozzi classification of diaphragmatic surgery in patients with stage IIIC–IV ovarian cancer based on surgical findings and complexity. J Gynecol Oncol. 31(2):e14
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213
Pestieau SR, Esquivel J, Sugarbaker PH (2000) Pleural extension of mucinous tumor in patients with pseudomyxomaperitonei syndrome. Ann Surg Oncol 7:199–203
Meigs J, Armstrond S, Hamilton H (1943) A further contribution to the syndrome of fibroma of the ovary with fluid in the abdomen and chest. Meigs’ syndrome Am J Obstet Gynecol 46:19–37
Lieberman F, Peters R (1970) Cirrhotic hydrothorax Further evidence that an acquired diaphragmatic defect is at fault. Arch Intern Med 125:114–7
Hartz R, Bomalaski J, LoCicero J 3rd, Murphy R (1984) Pleural ascites without abdominal fluid: surgical considerations. J Thorac Cardiovasc Surg 87:141–143
Eisenhauer E, D’Angelica M, Nadeem R, Sonoda Y, Jarnagin W, Barakat R et al (2006) Incidence and management of pleural effusions after diaphragm peritonectomy or resection for advanced mullerian cancer. Gynecol Oncol 103:871–877
Zapardiel I, Peiretti M, Zanagnolo V, Biffi R (2011) BoccioloneL, Landoni F, Aletti G, Colombo N and Maggioni A: Diaphragmaticsurgery during primary cytoreduction for advanced ovarian cancer: peritoneal stripping versus diaphragmatic resection. Int J Gynecol Cancer 21:1698–1703
Ye S, He T, Liang S, Chen X, Wu X, Yang H, Xiang L (2017) Diaphragmatic surgery and related complications in primary cytoreduction for advanced ovarian, tubal, and peritoneal carcinoma. BMC Cancer 17(1):317. https://doi.org/10.1186/s12885-017-3311-8
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
Gouy S, Chereau E, Custodio AS, Uzan C, Pautier 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
Pathiraja P, Garruto-Campanile R, Tozzi R (2013) Diaphragmatic peritonectomy versus full thickness diaphragmatic resection and pleurectomy during cytoreduction in patients with ovarian cancer. Int J Surg Oncol 2013:876150. https://doi.org/10.1155/2013/876150
Fanfani F, Fagotti A, Gallotta V, Ercoli A, Pacelli F, Costantini B, Vizzielli G, Margariti PA, Garganese G, Scambia G (2010) Upper abdominal surgery in advanced and recurrent ovarian cancer: role of diaphragmatic surgery. Gynecol Oncol 116:497–501
Chi DS, Zivanovic O, Levinson KL et al (2010) The incidence of major complications after the performance of extensive upper abdominal surgical procedures during primary cytoreduction of advanced ovarian, tubal and peritoneal carcinomas. Gynecol Oncol 119:38–42
Ionescu O, Bacalbasa N, Ionescu P, Balescu I (2016) Diaphragmatic surgery in patients with advanced-stage ovarian cancer A literature review. SM J Pulm Med. 2(1):1012
Chang SJ, Bristow RE, Chi DS, Cliby WA (2015) Role of aggressive surgical cytoreduction in advanced ovarian cancer. J Gynecol Oncol 26(4):336–342
Dowdy SC, Loewen RT, Aletti G, Feitoza SS, Cliby W (2008) Assessment of outcomes and morbidity following diaphragmatic peritonectomy for women with ovarian carcinoma. Gynecol Oncol 109(2):303–307
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(4):542–551
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Datta, A., Sebastian, A., Chandy, R.G. et al. Complications and Outcomes of Diaphragm Surgeries in Epithelial Ovarian Malignancies. Indian J Surg Oncol 12, 822–829 (2021). https://doi.org/10.1007/s13193-021-01438-x
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DOI: https://doi.org/10.1007/s13193-021-01438-x