The Feasibility of Cardiophrenic Lymphnode Assessment and Removal in Patients Requiring Diaphragmatic Resection During Interval Debulking Surgery for Ovarian Cancer

Feasibility of laparoscopic Visceral-Peritoneal Debulking (L-VPD) in patients with stage III-IV ovarian cancer: the ULTRA-LAP trial pilot study

OBJECTIVE

A non-randomized prospective clinical trial (ULTRA-LAP) was registered to test safety, side effects and efficacy of laparoscopic Visceral-Peritoneal Debulking (L-VPD) in patients with stage III-IV ovarian cancer (OC). A pilot study was designed to identify which OC patients are suitable to undergo L-VPD.

METHODS

Between March 2016 and October 2021, all consecutive patients with OC underwent exploratory laparoscopy (EXL). All patients whose disease was deemed amenable for a complete resection (CR) at imaging review and EXL, underwent VPD. In all patients a consistent attempt was made at completing L-VPD.

RESULTS

Two hundred and eight OC had EXL in the study period: 121 underwent interval VPD and 87 up-front VPD. Overall, 158 patients had VPD by laparotomy (75.9%) and 50 (24.1%) had L-VPD, of which 34 patients as interval (iL-VPD) and 16 as up-front (uL-VPD). Intra- and post-operative morbidity was very low in the L-VPD group. CR rate was 98% in L-VPD group and 94% in VPD. Most common reason for conversion was diaphragmatic disease extending dorsally.

CONCLUSION

In the pilot study of ULTRA-LAP, L-VPD was completed in 24,1% of OC. Initial analysis supports the feasibility of L-VPD in 2 groups of OC: those with no gross disease at interval surgery and those with gross visible disease at upfront or interval surgery, but limited to: pelvis (including recto-sigmoid), gastro colic omentum, peritoneum and diaphragm, the latter not requiring dorsal liver mobilization. Both groups had 100% feasibility and have been thus forth recruited to ULTRA-LAP.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05862740.

What are the implications of radiologically abnormal cardiophrenic lymph nodes in advanced ovarian cancer? An analysis of tumour burden, surgical complexity, same-site recurrence and overall survival

INTRODUCTION

Our paper evaluates the relationship between radiologically abnormal cardiophrenic lymph nodes (CPLN) in advanced ovarian cancer and pattern of disease distribution, tumour burden, surgical complexity, rates of cytoreduction and same-site recurrence. Impact of suspicious CPLN and CPLN dissection on overall survival also determined.

MATERIALS AND METHODS

Retrospective review of index CT imaging for 151 consecutive patients treated for stage III/IV ovarian malignancy in a large UK cancer centre to identify radiologically abnormal CPLN. Corresponding surgical, histo-pathological and survival data analysed.

RESULTS

42.6% of patients had radiologically 'positive' CPLN on index CT. Radiological identification of CPLN involvement demonstrated a sensitivity of 82% within our centre. Patients with cardiophrenic lymphadenopathy on pre-operative CT had significantly more co-existing ascites (p = 0.003), omental (p = 0.01) and diaphragmatic disease (p < 0.0001). At primary debulking (PDS), suspicious CPLN were associated with significantly higher surgical complexity scores, without feasibility of complete cytoreduction being impacted. Cardiophrenic involvement at initial diagnosis was associated with same-site relapse at recurrence (p = 0.001). No significant difference in overall survival was demonstrated according to CPLN status following either PDS or delayed debulking (DDS). CPLN dissection did not improve patient outcomes.

CONCLUSION

Radiological identification of abnormal CPLN is reliable. Suspicious CPLN appear to represent a surrogate marker of tumour volume - in particular, heralding upper abdominal disease - and should prompt anticipation of high complexity surgery and referral to an appropriate centre. Patients with prior CPLN involvement are more likely to develop same-site recurrence at relapse. Our survival data suggests cardiophrenic LN disease does not worsen patient prognosis and that the therapeutic benefit of CPLN dissection remains unclear.

Survival in Advanced-Stage Epithelial Ovarian Cancer Patients with Cardiophrenic Lymphadenopathy Who Underwent Cytoreductive Surgery: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the clinical outcomes of enlarged cardiophrenic lymph node (CPLN) in advanced-stage epithelial ovarian cancer (AEOC) patients who underwent cytoreductive surgery.

METHODS

The Embase, Medline, Web of Science, Cochrane Library, and Google Scholar databases were searched for articles from the database inception to June 2021. Meta-analysis was conducted to determine the prognostic impact of surgical outcome, postoperative complication, and survival using random-effects models.

RESULTS

A total of 15 studies involving 727 patients with CPLN adenopathy and 981 patients without CPLN adenopathy were included. The mean size of preoperative CPLN was 9.1± 3.75 mm. Overall, 82 percent of the resected CPLN were histologically confirmed pathologic nodes. Surgical outcomes and perioperative complications did not differ between both groups. The median OS time was 42.7 months (95% CI 10.8-74.6) vs. 47.3 months (95% CI 23.2-71.2), in patients with and without CPLN adenopathy, respectively. At 5 years, patients with CPLN adenopathy had a significantly increased risk of disease recurrence (HR 2.14, 95% CI 1.82-2.52, p < 0.001) and dying from the disease (HR 1.74, 95% CI 1.06-2.86, p = 0.029), compared with those without CPLN adenopathy. CPLN adenopathy was significantly associated with ascites (OR 3.30, 95% CI 1.90-5.72, p < 0.001), pleural metastasis (OR 2.58, 95% CI 1.37-4.82, p = 0.003), abdominal adenopathy (OR 2.30, 95% CI 1.53-3.46, p < 0.001) and extra-abdominal metastasis (OR 2.30, 95% CI 1.61-6.67, p = 0.001).

CONCLUSIONS

Enlarged CPLN in preoperative imaging is highly associated with metastatic involvement. Patients with CPLN adenopathy had a lower survival rate, compared with patients without CPLN adenopathy. Further randomized controlled trials should be conducted to definitively demonstrate whether CPLN resection at the time of cytoreductive surgery is beneficial.

Transdiaphragmatic resection of enlarged cardiophrenic lymph node during interval debulking surgery for advanced ovarian cancer

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Gaining trans-diaphragmatic access to thoracic cavity to facilitate cardio-phrenic lymph node assessment.

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Safe dissection of bulky cardio-phrenic lymph nodes at laparotomy.

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Feasibility of cardio-phrenic lymph node dissection as a component of optimal debulking surgery for ovarian cancer.

Surgery in advanced ovarian malignancy is indicated when complete debulking can be achieved. In patients with disease above the diaphragm, achieving R0 can present a surgical challenge and bring into question the feasibility of surgery (Soleymani majd et al., 2016, Pinelli et al., 2019).

We present a surgical video demonstrating the technique of cardiophrenic lymph node dissection in advanced ovarian malignancy.

Following type 3 liver mobilisation, the diaphragm is stripped and muscle opened to gain access to the thoracic cavity. Transdiaphragmatic assessment of the cardiophrenic lymph node bundle is performed. A bulky node – correlating with pre-operative radiology – is removed using an advanced energy device, maintaining the surrounding lung parenchyma and underlying pericardium safely in view throughout. The diaphragmatic is closed using a loop non-absorbable suture and placing continuous, locking sutures (Addley et al., 2021).

We demonstrate that the presence of cardiophrenic lymphadenopathy is not an obstacle to complete debulking. By employing a trans-diaphragmatic technique to gain thoracic access, involved cardio-phrenic nodes – and hence all visible disease – can be surgically excised, successfully achieving R0 status and offering patients optimal prognosis.

Primary diaphragmatic closure following diaphragmatic resection and cardiophrenic lymph node dissection during interval debulking surgery for advanced ovarian malignancy

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Gaining trans-diaphragmatic access to thoracic cavity during de-bulking laparotomy.

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Assessment and dissection of bulky cardiophrenic lymph nodes to achieve optimal cytoreduction.

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Technique for primary closure of diaphragm following radical resection.

Interval Debulking Surgery for Advanced Ovarian Cancer in Elderly Patients (≥70 y): Does the Age Matter?

BACKGROUND

Elderly ovarian cancer (OC) patients are more likely to be managed suboptimally, with worse clinical outcomes as a result. Strategies to decrease morbidity are lacking.Methodology: Consecutive patients with advanced stage OC (IIIC-IV) who were managed in our center between January 2016 and July 2018 were retrospectively analyzed. All patients underwent neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) according to our institution protocol. We divided patients into two groups: Group 1 (age ≥ 70 years) and Group 2 (age < 70 years). The primary outcome of the study was assessment of peri-operative morbidity amongst two groups.

RESULTS

A total of 153 patients were referred during the study period. 114 patients underwent IDS after NACT (74.5%), 46 in Group 1 and 68 in Group 2. Elderly patients were more likely to receive more than three cycles of NACT prior to IDS compared to younger patients (39% vs. 19%, p = 0.03). Elderly patients were more frequently subjected to Cardiopulmonary Exercise Testing (CPET) as pre-operative assessment (63% vs. 27%, p = 0.002). Optimal/complete resection was achieved in all patients in Group 1 (100%) and in 97% of patients in Group 2. With the exception of higher postoperative cardiac arrhythmias in Group 1 (11% vs. 1%, p = 0.04), no significant differences in 30-day morbidity were observed. No 90-day death in both groups was registered.

CONCLUSION

Older age should not preclude clinicians from offering ultra-radical resection to patients with advanced OC after NACT. In our series, elderly patients received the same treatment with similar outcomes to the younger group. Clinicians should be encouraged to use CPET for patients' selection following NACT.