1
|
Khatib G, Misirlioglu M, Varli M, Kucukgoz Gulec U, Güzel AB, Vardar MA. Right diaphragmatic peritonectomy in extensive involvement of the coronary area: no touch principle. Int J Gynecol Cancer 2023; 33:1821-1822. [PMID: 37463746 DOI: 10.1136/ijgc-2023-004446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Affiliation(s)
- Ghanim Khatib
- Department of Gynecologic Oncology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Mesut Misirlioglu
- Department of Gynecologic Oncology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Murat Varli
- Department of Obstetrics and Gynecology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Umran Kucukgoz Gulec
- Department of Gynecologic Oncology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ahmet Baris Güzel
- Department of Gynecologic Oncology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Mehmet Ali Vardar
- Department of Gynecologic Oncology, Cukurova University Faculty of Medicine, Adana, Turkey
| |
Collapse
|
2
|
Turrel E, Chopin N, Meeus P, Blache A, Ray-Coquard I, Tredan O, Treilleux I, Ebring C, Heinemann M, Rossi L. Do surgeons overestimate diaphragmatic peritoneal disease in interval debulking surgery of ovarian cancer? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106963. [PMID: 37394316 DOI: 10.1016/j.ejso.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Cytoreductive surgery is a key point in ovarian cancer treatment. Substantial morbidity may be consecutive to this major radical surgery. However, the objective of no residual tumor (CC-0) had demonstrated its clear improvement of prognosis. Could macroscopically-driven interval debulking surgery (IDS) overestimate active cancer cells and be unnecessarily morbid? MATERIALS AND METHODS This retrospective cohort study was conducted in Center Leon Berard Cancer Center between 2000 and 2018. We included women with advanced epithelial ovarian cancer who received neoadjuvant chemotherapy and underwent an IDS including resection of peritoneal metastases on the diaphragmatic domes. The primary endpoint was the pathological outcome of peritoneal resections of diaphragmatic domes. RESULTS Peritoneal resections of diaphragmatic domes consisted of 117 patients. 75 patients required resection of nodules from the right cupola only, 2 patients from the left cupola only, and 40 patients bilaterally. Pathological analysis of the diaphragmatic domes found that 84.6% of samples demonstrated the presence of malignant cells, and only 12.8% found no tumor involvement. Pathology analysis could not be performed for 3 patients (2.6%) (vaporization). CONCLUSION Surgical evaluation after neoadjuvant chemotherapy in ovarian cancer does not often overestimate peritoneal involvement by active carcinomatosis. Potential surgical morbidity due to peritoneal resection in IDS is admissible.
Collapse
Affiliation(s)
- Estelle Turrel
- Centre Jean Perrin, Clermont-Ferrand, France; Université Clermont Auvergne, Clermont-Ferrand, France; Centre Léon Bérard, Lyon, France
| | | | | | | | - Isabelle Ray-Coquard
- Centre Léon Bérard, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France
| | | | | | | | | | | |
Collapse
|
3
|
Deo SVS, Ray MD, Kumar L, Khuranna S, Pramanik R, Mishra A, Bansal B, N P, Bhatnagar S, Garg R, Kumar V. Pattern of Care in Real-World Scenario on Advanced Epithelial Ovarian Cancer in a Tertiary Referral Oncology Centre in India - ISPSM Collaborative Study. Indian J Surg Oncol 2023; 14:233-239. [PMID: 37359919 PMCID: PMC10284739 DOI: 10.1007/s13193-023-01746-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 04/06/2023] [Indexed: 06/28/2023] Open
Abstract
The treatment of advanced epithelial ovarian cancer (EOC) has evolved over time. With advent of platinum-based chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC), there is a paradigm shift in the patterns of care with improved survival. In this study, we analysed our advanced EOC patients aiming to gain insights into the pattern of care. An ambispective study of 250 patients of advanced EOC was done from our prospectively maintained computerised database in the Department of Surgical Oncology, tertiary care referral centre from 2013 to 2020. We analysed the demographic profile, treatment patterns, and perioperative outcomes. In this study, there were 83.6% stage III and 16.4% stage IVA. There were 62 (24.8%) upfront and 112 (44.8%) in interval settings. There was a higher number of patients receiving neo-adjuvant chemotherapy. One hundred twenty-six (50.4%) underwent cytoreductive surgery (CRS) only and 124 (49.6%) underwent CRS and HIPEC. CC-0 was achieved in 84.4% and CC-1 in 15.6% patients. HIPEC programme was started in 2013. With advent of RCTs in HIPEC, there was a substantial increase in the number of patients receiving HIPEC from 2015 (n = 10), 2017 (n = 20) to 2019 (n = 41). We offer secondary CRS in a limited subset of patients, n = 76 (30.4%). There was 24.8% early and 8.4% late postop complications. We have median follow-up of 50 months with attrition rate of 4%. With practice changing updates, the treatment of advanced EOC has been evolving over time. Though the primary CRS followed by systemic therapy is the standard to date, there is change in pattern of care with neo-adjuvant chemotherapy followed by interval CRS and HIPEC because of various RCTs. The addition of HIPEC has acceptable morbidity and mortality. There is a definite learning curve and the team has to evolve as a whole. In a tertiary care referral centre from LMIC, good patient selection, logistics, and implementing recent advances will definitely add to improved survival.
Collapse
Affiliation(s)
- S. V. S. Deo
- Department of Surgical Oncology, AIIMS, Dr. Brairch, New Delhi, India
| | - M. D. Ray
- Department of Surgical Oncology, AIIMS, Dr. Brairch, New Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology, AIIMS, Dr. BRAIRCH, New Delhi, India
| | - Sachin Khuranna
- Department of Medical Oncology, AIIMS, Dr. BRAIRCH, New Delhi, India
| | - Raja Pramanik
- Department of Medical Oncology, AIIMS, Dr. BRAIRCH, New Delhi, India
| | - Ashutosh Mishra
- Department of Surgical Oncology, AIIMS, Dr. Brairch, New Delhi, India
| | - Babul Bansal
- Department of Surgical Oncology, AIIMS, Dr. Brairch, New Delhi, India
| | - Premanand N
- Department of Surgical Oncology, AIIMS, Dr. Brairch, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anesthesia and Palliative Medicine, AIIMS, Dr. BRAIRCH, New Delhi, India
| | - Rakesh Garg
- Department of Onco-Anesthesia and Palliative Medicine, AIIMS, Dr. BRAIRCH, New Delhi, India
| | - Vinod Kumar
- Department of Onco-Anesthesia and Palliative Medicine, AIIMS, Dr. BRAIRCH, New Delhi, India
| |
Collapse
|
4
|
Tozzi R, Soleymani Majd H, Campanile RG, Ferrari F. Feasibility of laparoscopic diaphragmatic peritonectomy during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer. J Gynecol Oncol 2021; 31:e71. [PMID: 32808498 PMCID: PMC7440979 DOI: 10.3802/jgo.2020.31.e71] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/24/2020] [Accepted: 05/08/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To describe the surgical technique and evaluate the safety, feasibility and efficacy of laparoscopic diaphragmatic peritonectomy during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer (OC). METHODS This report is part of a Service Evaluation Protocol (Trust number 3267) on laparoscopy in patients with OC following neo-adjuvant chemotherapy. Between April 2015 and November 2017, all patients underwent to exploratory laparoscopy and a selected court was offered laparoscopic VPD. Laparoscopic diaphragmatic surgery was considered if there was no full thickness involvement. Primary endpoints of this part of the study were the safety, feasibility and efficacy of laparoscopic diaphragmatic peritonectomy. We report the surgical technique and outcomes. RESULTS Ninety-six patients underwent diaphragmatic surgery during the study period. Fifty patients (52.1%) had intra-operative exclusion criteria and/or full thickness diaphragmatic resection, 46 (47.9%) had peritonectomy and were included in the study. Laparoscopic diaphragmatic peritonectomy was performed in 21 patients (45.4%, group 1), while in 25 patients (54.6%, group 2) laparotomy was necessary. Extent of disease and complexity of surgery were similar. Reasons for conversions were disease coalescing the liver to the diaphragm preventing safe mobilization (22 patients) and accidental pleural opening (3 patients). Overall, intra- and post-operative morbidity was lower in group 1 and pulmonary specific morbidity was very low. CONCLUSION Diaphragmatic peritonectomy can be safely accomplished by laparoscopy in almost half of the patients with OC whose disease is limited to the diaphragmatic peritoneum.
Collapse
Affiliation(s)
- Roberto Tozzi
- Department of Women's and Reproductive Health, University of Oxford, Old Road, Headington, Oxford, UK.
| | - Hooman Soleymani Majd
- Department of Women's and Reproductive Health, University of Oxford, Old Road, Headington, Oxford, UK
| | | | - Federico Ferrari
- Department of Women's and Reproductive Health, University of Oxford, Old Road, Headington, Oxford, UK
| |
Collapse
|
5
|
Tozzi R, Ferrari F, Nieuwstad J, Campanile RG, Soleymani Majd H. Tozzi classification of diaphragmatic surgery in patients with stage IIIC-IV ovarian cancer based on surgical findings and complexity. J Gynecol Oncol 2019; 31:e14. [PMID: 31912672 PMCID: PMC7044006 DOI: 10.3802/jgo.2020.31.e14] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/12/2019] [Accepted: 08/18/2019] [Indexed: 12/15/2022] Open
Abstract
Objective To introduce a systematic classification of diaphragmatic surgery in patients with ovarian cancer based on disease spread and surgical complexity. Methods For all consecutive patients who underwent diaphragmatic surgery during Visceral-Peritoneal debulking (VPD) in the period 2009–2017, we extracted: initial surgical finding, extent of liver mobilization and type of procedure. Combining these features, we aimed to classify the surgical procedures necessary to tackle different presentation of diaphragmatic disease. We also report histology, intra- and post-operative specific complication rate based on the classification. Results A total of 170 patients were included in this study, 110 (64.7%) had a peritonectomy, while 60 (35.3%) had a full thickness resection with pleurectomy. We identified 3 types of surgical procedures. Type I treated 28 out of 170 patients (16.5%) who only had anterior diaphragm disease, needed no liver mobilization, included peritonectomy and had no morbidity recorded. Type II pertained to 105 out of 170 patients (61.7%) who had anterior and posterior disease, needed partial and sometimes full liver mobilization, had a mix of peritonectomy and full thickness resection, and experienced 10% specific morbidity. Type III included 37 out of 170 patients (21.7%) who needed full mobilization of the liver, always had full thickness resection, and suffered 30% specific morbidity. Conclusion Diaphragmatic surgery can be classified in 3 types. The adoption of this classification can facilitate standardization of the surgery, comparison of data and define the expertise required. Finally, this classification can be a benchmark to establish the training required to treat diaphragmatic disease.
Collapse
Affiliation(s)
- Roberto Tozzi
- Department of Gynaecologic Oncology, Oxford Cancer Centre, Churchill Oxford University Hospital, Oxford, United Kingdom.
| | - Federico Ferrari
- Department of Gynaecologic Oncology, Oxford Cancer Centre, Churchill Oxford University Hospital, Oxford, United Kingdom
| | - Joost Nieuwstad
- Department of Gynaecologic Oncology, Oxford Cancer Centre, Churchill Oxford University Hospital, Oxford, United Kingdom
| | - Riccardo Garruto Campanile
- Department of Gynaecologic Oncology, Oxford Cancer Centre, Churchill Oxford University Hospital, Oxford, United Kingdom
| | - Hooman Soleymani Majd
- Department of Gynaecologic Oncology, Oxford Cancer Centre, Churchill Oxford University Hospital, Oxford, United Kingdom
| |
Collapse
|
6
|
Identifying the incidence of respiratory complications following diaphragmatic cytoreduction and hyperthermic intraoperative intraperitoneal chemotherapy. Clin Transl Oncol 2019; 22:852-859. [DOI: 10.1007/s12094-019-02195-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022]
|
7
|
Ferron G, Narducci F, Pouget N, Touboul C. [Surgery for advanced stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. ACTA ACUST UNITED AC 2019; 47:197-213. [PMID: 30792175 DOI: 10.1016/j.gofs.2019.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Indexed: 01/10/2023]
Abstract
Debulking surgery is the key step of advanced stage ovarian cancer treatment with chemotherapy. The quality of surgical resection is the main prognosis factor, thus a complete resection must be achieved (grade A) in an expert center (grade B). Surgery for stage IV is possible and has a benefit in case of complete peritoneal resection (LoE3). Pelvic and aortic lymphadenectomies are recommended in case of clinical or radiological suspicious lymph nodes (grade B). In absence of clinical or radiological suspicious lymph nodes and in case of complete peritoneal resection during initial debulking surgery, lymphadenectomy can be omitted because it won't change nor medical treatment nor overall survival (grade B). Neoadjuvant chemotherapy can be proposed in case of: impossibility to perform initial complete surgical resection (grade B) ; alteration of general state or co-morbidities or elderly patient (in order to decrease morbidity and increase quality of life) (grade B); stage IV with multiple intra-hepatic or pulmonary metastasis or important ascites with miliary (grade B). In case of stage III or IV ovarian cancer diagnosed on a biopsy during prior laparotomy, a neoadjuvant chemotherapy and interval debulking surgery should be preferred (gradeC). In case of palliative surgery or peroperative impossibility to perform a complete resection, no data regarding the type of surgery to perform influencing survival or quality of life is available. Peritoneal carcinosis description before resection and residual disease at the end of the surgery should be reported (size, location and reason of non-extirpability) (grade B). A score of peritoneal carcinosis such as Peritoneal Carcinosis Index (PCI) should be used in order to objectively evaluate the tumoral burden (gradeC). A standardized operative report is recommended (gradeC).
Collapse
Affiliation(s)
- G Ferron
- Inserm CRCT 19, département de chirurgie oncologique, institut Claudius Regaud, institut universitaire du cancer, 31000 Toulouse, France
| | - F Narducci
- Inserm U1192, département de chirurgie oncologique, centre Oscar Lambret, 59000 Lille, France
| | - N Pouget
- Département de chirurgie oncologique, chirurgie gynécologique et mammaire, institut Curie, site Saint-Cloud, 75005 Paris, France
| | - C Touboul
- IMRB, U955 Inserm, service de gynécologie obstétrique et médecine de la reproduction, centre hospitalier intercommunal de Créteil, institut Mondor de recherche biomédicale, 94000 Créteil, France.
| |
Collapse
|
8
|
Failure-to-Rescue Following Cytoreductive Surgery with or Without HIPEC is Determined by the Type of Complication-a Retrospective Study by INDEPSO. Indian J Surg Oncol 2019; 10:71-79. [PMID: 30886497 DOI: 10.1007/s13193-019-00877-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023] Open
Abstract
To determine factors influencing failure-to-rescue in patients with complications following cytoreductive surgery and HIPEC. A retrospective analysis of patients enrolled in the Indian HIPEC registry was performed. Complications were graded according to the CTCAE classification version 4.3. The 30- and 90-day morbidity were both recorded. Three hundred seventy-eight patients undergoing CRS with/without HIPEC for peritoneal metastases from various primary sites, between January 2013 and December 2017 were included. The median PCI was 11 [range 0-39] and a CC-0/1 resection was achieved in 353 (93.5%). Grade 3-4 morbidity was seen 95 (25.1%) at 30 days and 122 (32.5%) at 90 days. The most common complications were pulmonary complications (6.8%), neutropenia (3.7%), systemic sepsis (3.4%), anastomotic leaks (1.5%), and spontaneous bowel perforations (1.3%). Twenty-five (6.6%) patients died within 90 days of surgery due to complications. The failure-to-rescue rate was 20.4%. Pulmonary complications (p = 0.03), systemic sepsis (p < 0.001), spontaneous bowel perforations (p < 0.001) and PCI > 20 (p = 0.002) increased the risk of failure-to-rescue. The independent predictors were spontaneous bowel perforation (p = 0.05) and systemic sepsis (p = 0.001) and PCI > 20 (p = 0.02). The primary tumor site did not have an impact on the FTR rate (p = 0.09) or on the grade 3-4 morbidity (p = 0.08). Nearly one-fifth of the patients who developed complications succumbed to them. Systemic sepsis, spontaneous bowel perforations, and pulmonary complications increased the risk of FTR and multidisciplinary teams should develop protocols to prevent, identify, and effectively treat such complications. All surgeons pursuing this specialty should perform a regular audit of their results, irrespective of their experience.
Collapse
|
9
|
Diaphragmatic peritonectomy vs. full thickness resection with pleurectomy during Visceral-Peritoneal Debulking (VPD) in 100 consecutive patients with stage IIIC–IV ovarian cancer: A surgical-histological analysis. Gynecol Oncol 2016; 140:430-5. [DOI: 10.1016/j.ygyno.2015.12.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 12/09/2015] [Accepted: 12/11/2015] [Indexed: 01/10/2023]
|
10
|
Mehta SS, Gelli M, Agarwal D, Goéré D. Complications of Cytoreductive Surgery and HIPEC in the Treatment of Peritoneal Metastases. Indian J Surg Oncol 2016; 7:225-9. [PMID: 27065713 DOI: 10.1007/s13193-016-0504-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 01/28/2016] [Indexed: 12/29/2022] Open
Abstract
The combined treatment concept of cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC) has shown to be an efficient therapeutic option for selected patients with primary and secondary peritoneal carcinomatosis (PC). This strategy represents the standard of care for diseases like pseudomyxoma peritonei and peritoneal mesothelioma, and offers the best long-term results for PC from colorectal cancer. Despite these results, skepticism exists regarding this therapeutic approach partly because of its perceived high toxicity. In this article, we review the current evidence on complications that can occur after CRS and HIPEC and the risk factors associated with increased incidence of morbidity and mortality.
Collapse
Affiliation(s)
- Sanket S Mehta
- Division of Peritoneal Surface Oncology, Saifee Hospital, MK marg, Charni road, Mumbai, Girgaum 400004 India
| | - Maxilliano Gelli
- Department of Surgical Oncology, Gustave Roussy, Cancer Campus, 114, Av Edouard Vaillant, 94805 Villejuif, Cedex France
| | - Deepesh Agarwal
- Division of Peritoneal Surface Oncology, Saifee Hospital, MK marg, Charni road, Mumbai, Girgaum 400004 India
| | - Diane Goéré
- Department of Surgical Oncology, Gustave Roussy, Cancer Campus, 114, Av Edouard Vaillant, 94805 Villejuif, Cedex France
| |
Collapse
|
11
|
Surgical Techniques for Diaphragmatic Resection During Cytoreduction in Advanced or Recurrent Ovarian Carcinoma. Int J Gynecol Cancer 2016; 26:371-80. [DOI: 10.1097/igc.0000000000000597] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
12
|
Prognostic value of histological type in stage IV ovarian carcinoma: a retrospective analysis of 223 patients. Br J Cancer 2015; 112:1376-83. [PMID: 25867257 PMCID: PMC4402461 DOI: 10.1038/bjc.2015.97] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/23/2015] [Accepted: 02/16/2015] [Indexed: 12/02/2022] Open
Abstract
Background: Patients with FIGO stage IV epithelial ovarian carcinoma have a poor but non-uniform prognosis. This study aimed to compare the survival of patients with serous or endometrioid tumours (S/E) and clear cell or mucinous tumours (non-S/E). Methods: Data for 223 patients who underwent surgery between 1987 and 2010 and were diagnosed by centralized pathology review and were retrospectively analysed. The patients included 169 with S/E tumours and 54 with non-S/E tumours. Results: The median overall survivals (OSs) of the S/E and non-S/E groups were 3.1 and 0.9 years, respectively (P<0.001). Six patients (2.7%), all with non-S/E tumours, died within 6 weeks after the initial surgery. Multivariate OS analysis revealed that performance status, residual tumor, metastatic sites, no debulking surgery, and non-S/E tumours were independent poor prognostic factors. For patients with non-S/E tumours, prognosis was more favourable for single-organ metastasis, except for liver or distant lymph nodes, no residual tumor, and resection of metastasis (median OS: 4.1, 4.6, and 2.6 years, respectively). Conclusions: In stage IV ovarian carcinoma, non-S/E tumours are associated with a significantly poorer prognosis and higher rates of early mortality compared to S/E tumours. Therefore, careful management and development of new strategies are required.
Collapse
|
13
|
|
14
|
Diaphragmatic peritonectomy versus full thickness diaphragmatic resection and pleurectomy during cytoreduction in patients with ovarian cancer. Int J Surg Oncol 2013; 2013:876150. [PMID: 24455228 PMCID: PMC3880699 DOI: 10.1155/2013/876150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 11/04/2013] [Indexed: 01/20/2023] Open
Abstract
Objectives. Compare the surgical morbidity of diaphragmatic peritonectomy versus full thickness diaphragmatic resection with pleurectomy at radical debulking. Design. Prospective cohort study at the Oxford University Hospital. Methods. All debulking with diaphragmatic peritonectomy and/or full thickness resection with pleurectomy in the period from April 2009 to March 2012 were part of the study. Analysis is focused on the intra- and postoperative morbidity. Results. 42 patients were eligible for the study, 21 underwent diaphragmatic peritonectomy (DP, group 1) and 21 diaphragmatic full thickness resection (DR, group 2). Forty patients out of 42 (93%) had complete tumour resection with no residual disease. Histology confirmed the presence of cancer in diaphragmatic peritoneum of 19 patients out of 21 in group 1 and all 21 patients of group 2. Overall complications rate was 19% in group 1 versus 33% in group 2. Pleural effusion rate was 9.5% versus 14.5% and pneumothorax rate was 14.5% only in group 2. Two patients in each group required postoperative chest drains (9.5%). Conclusions. Diaphragmatic surgery is an effective methods to treat carcinomatosis of the diaphragm. Patients in the pleurectomy group experienced pneumothorax and a higher rate of pleural effusion, but none had long-term morbidity or additional surgical interventions.
Collapse
|
15
|
Ansaloni L, Coccolini F, Catena F, Frigerio L, Bristow RE. Cytoreductive surgery in primary advanced epithelial ovarian cancer. World J Obstet Gynecol 2013; 2:116-123. [DOI: 10.5317/wjog.v2.i4.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 02/02/2013] [Accepted: 03/07/2013] [Indexed: 02/05/2023] Open
Abstract
Epithelial ovarian cancer is one of the most common malignancy and one of the principal causes of death among gynaecological neoplasm. The majority of patients (about 70%) present with an advanced International Federation of Gynaecology and Obstetrics stage disease. The current standard treatment for these patients consists of complete cytoreduction and combined systemic chemotherapy (CT). An increasing proportion of patients undergoing complete cytoreduction to no gross residual disease (RD) is associated with progressively longer overall survival. As a counterpart, some authors hypothesized the improving in survival could be due more to a less diffused initial disease than to an increase in surgical cytoreduction rate. Moreover the biology of the tumor plays an important role in survival benefit of surgery. It’s still undefined how the intrinsic features of the tumor make intra-abdominal implants easier to remove. Adjuvant and hyperthermic intraperitoneal CT could play a decisive role in the coming years as the completeness of macroscopic disease removal increases with advances in surgical techniques and technology. The introduction of neo-adjuvant CT moreover will play a decisive role in the next years Anyway cytoreduction with no macroscopic residual of disease should always be attempted. However the definition of RD is not universal. A unique and definitive definition is needed.
Collapse
|
16
|
Kato K, Tate S, Nishikimi K, Shozu M. Assessment of intraoperative tube thoracostomy after diaphragmatic resection as part of debulking surgery for primary advanced-stage Müllerian cancer. Gynecol Oncol 2013; 131:32-5. [PMID: 23891788 DOI: 10.1016/j.ygyno.2013.07.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/09/2013] [Accepted: 07/15/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The present study assessed the use of an intraoperative tube thoracostomy for patients with primary advanced-stage ovarian, fallopian tube, or peritoneal cancer who underwent a diaphragmatic resection as part of debulking surgery and to define which patients are more likely to benefit from an intraoperative tube thoracostomy. METHODS All consecutive patients with stage IIIC-IV Müllerian cancer who underwent diaphragmatic resection at our institution between April 2008 and March 2013 were retrospectively reviewed. When a full-thickness resection of the diaphragm was performed and the thoracic cavity was opened, a chest tube was routinely placed during surgery. Patient-, disease-, and surgery-related data were collected from the patients' medical records. The data were evaluated with particular attention directed at pleural effusion after diaphragmatic resection. RESULTS A total of 37 patients were included in this study. No complications associated with the intraoperative tube thoracostomy procedures occurred. An infection of the thoracic cavity occurred in one patient, following the presence of intra-abdominal abscess. The total volume of pleural drainage ranged from 88 to 2826 mL (median, 965 mL). The estimated blood loss, intraoperative blood transfusion, and area of the diaphragmatic opening were significantly associated with the total volume of pleural drainage in univariate analyses. In a multivariate analysis, the estimated blood loss was the only factor to be significantly associated with the total volume of pleural drainage. CONCLUSIONS A prophylactic tube thoracostomy might be considered if the volume of the estimated blood loss is higher than usual.
Collapse
Affiliation(s)
- Kazuyoshi Kato
- Department of Gynecology, Chiba University School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | | | | | | |
Collapse
|
17
|
Maximal cytoreduction in patients with FIGO stage IIIC to stage IV ovarian, fallopian, and peritoneal cancer in day-to-day practice: a Retrospective French Multicentric Study. Int J Gynecol Cancer 2013; 22:1337-43. [PMID: 22964527 DOI: 10.1097/igc.0b013e31826a3559] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To evaluate the outcome of maximal cytoreductive surgery in patients with stage IIIC to stage IV ovarian, tubal, and peritoneal cancer regarding overall survival (OS) and disease-free survival (DFS). MATERIALS AND METHODS Five hundred twenty-seven patients with stage IIIC (peritoneal) and stage IV (pleural) ovarian, fallopian tube, and peritoneal carcinoma underwent surgery between January 2003 and December 2007 in 7 gynecologic oncology centers in France. Patients undergoing primary and interval debulking surgery were included, whichever the number of chemotherapy cycles. The extent of disease, type of surgical procedure, and amount of residual disease were recorded. A multivariate analysis of the outcome was performed, taking into account the stage, grade, and timing of surgery. RESULTS Median DFS was 17.9 months, but median OS was not reached at the time of analysis. Complete cytoreductive surgery, without evident residual tumor at the end of the procedure, was obtained in 71% of all patients (primary surgery, 33%). After neoadjuvant therapy, the rate of complete debulking surgery was higher (74%) compared to primary cytoreductive surgery (65%). Twenty-three percent of patients needed "ultra radical surgery" to achieve this goal. The most significant predictive factor for DFS and OS was complete cytoreductive surgery compared to any amount, even minimal (1-10 mm), of residual disease. In the group of patients with complete cytoreductive surgery, the patients undergoing surgery before chemotherapy showed better DFS than those having first chemotherapy. CONCLUSION The findings confirm that complete cytoreduction is the criterion standard of surgery in the management of advanced ovarian, peritoneal, and fallopian tube cancer, whatever the timing of surgery. With experienced teams, surgery was completed, without evident residual tumor in 71% of the cases.
Collapse
|
18
|
Diaphragmatic surgery during cytoreduction for primary or recurrent epithelial ovarian cancer: a review of the literature. Arch Gynecol Obstet 2013; 287:733-41. [PMID: 23341061 DOI: 10.1007/s00404-013-2715-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 01/10/2013] [Indexed: 10/27/2022]
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.
Collapse
|
19
|
Comparison of morbidity and survival between primary and interval cytoreductive surgery in patients after modified posterior pelvic exenteration for advanced ovarian cancer. Int J Gynecol Cancer 2012; 22:1349-54. [PMID: 22954783 DOI: 10.1097/igc.0b013e318265d358] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Surgical management of advanced ovarian cancer often requires low modified posterior pelvic exenteration (MPE) to achieved complete resection. The aim of this study was to evaluate the morbidity of MPE at the time of primary cytoreductive surgery (PCS) and interval cytoreductive surgery (ICS) after neoadjuvant chemotherapy. MATERIALS AND METHODS From 2001 to 2009, 63 patients underwent MPE for advanced ovarian cancer. We analyzed and compared surgical characteristics and postoperative courses between PCS and ICS. RESULTS Modified posterior pelvic exenteration was performed during PCS for 50 patients (79%) and during ICS for 13 patients (21%). Complete cytoreduction was achieved in 80% of patients (84% in the PCS group and 69% in the ICS group; ns). There was no significant difference between the PCS and ICS groups in the type and the rate of standards or radical surgical procedures. Patients with ICS had a shorter length of stay in the intensive care unit (0.9 vs 2.7 days; P = 0.009), but there was no difference in the total length of hospitalization (P = 0.94). The global rate of postoperative complications was 76%. No differences were found between the 2 groups in digestive or extradigestive complications, iterative surgery, or interventional radiology procedures. The median overall survival was 49.4 months in the PCS group and 27.1 months in the ICS group (P = 0.27), and the median progression-free survival time in both groups was 20 months. CONCLUSIONS There was no difference in the occurrence of postoperative complications between PCS and ICS, especially in morbidity related to MPE. The specific morbidity of this surgical procedure remained low compared with the overall morbidity in cases of extensive surgery.
Collapse
|
20
|
Pulmonary Complications following Cytoreductive Surgery and Perioperative Chemotherapy in 147 Consecutive Patients. Gastroenterol Res Pract 2012; 2012:635314. [PMID: 22927838 PMCID: PMC3425016 DOI: 10.1155/2012/635314] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 06/10/2012] [Indexed: 01/02/2023] Open
Abstract
Cytoreductive surgery (CRS) with hyperthermic perioperative chemotherapy (HIPEC) has become a treatment option for selected patients with peritoneal metastases (PMs) from gastrointestinal malignancies. The purpose of this study is to evaluate our most recent data regarding pulmonary complications (respiratory distress, pleural effusion, and pneumonia) and attempt to identify risk factors associated with this management plan. This study includes the most recent 4-year experience with appendiceal and colorectal carcinomatosis patients treated in a uniform manner between January 1, 2006 and December 31, 2009. A prospective morbidity and mortality database was maintained and pulmonary adverse events were analyzed with special attention to subphrenic peritonectomy. There were 147 consecutive patients with a mean age of 49.9 years. Fourteen patients (10%) presented grades I–IV pulmonary complications for a total of 26 events. The peritonectomy of right upper quadrant was performed in 74% and right plus left in 49% of the patients. Statistically, there were no more pulmonary complications among patients submitted to peritoneal stripping of right or right and left hemidiaphragm as compared to no subdiaphragmatic peritonectomy (P = 1.00 and P = 0.58, resp.). In an analysis of 18 quantitative indicators and clinical variables with pulmonary adverse events, only blood replacement greater than six units showed a significant correlation (P = 0.0062). Pulmonary adverse events were observed in 10% of patients having CRS and HIPEC. Subphrenic peritonectomy was not a specific risk factor for developing these adverse events.
Collapse
|
21
|
Rafii A, Stoeckle E, Jean-Laurent M, Ferron G, Morice P, Houvenaeghel G, Lecuru F, Leblanc E, Querleu D. Multi-center evaluation of post-operative morbidity and mortality after optimal cytoreductive surgery for advanced ovarian cancer. PLoS One 2012; 7:e39415. [PMID: 22844394 PMCID: PMC3402488 DOI: 10.1371/journal.pone.0039415] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 05/24/2012] [Indexed: 11/18/2022] Open
Abstract
PURPOSE While optimal cytoreduction is the standard of care for advanced ovarian cancer, the related post-operative morbidity has not been clearly documented outside pioneering centers. Indeed most of the studies are monocentric with inclusions over several years inducing heterogeneity in techniques and goals of surgery. We assessed the morbidity of optimal cytoreduction surgery for advanced ovarian cancer within a short inclusion period in 6 referral centers dedicated to achieve complete cytoreduction. PATIENTS AND METHODS The 30 last optimal debulking surgeries of 6 cancer centers were included. Inclusion criteria included: stage IIIc- IV ovarian cancer and optimal surgery performed at the site of inclusion. All post-operative complications within 30 days of surgery were recorded and graded using the Memorial secondary events grading system. Student-t, Chi2 and non-parametric statistical tests were performed. RESULTS 180 patients were included. There was no demographic differences between the centers. 63 patients underwent surgery including intestinal resections (58 recto-sigmoid resection), 24 diaphragmatic resections, 17 splenectomies. 61 patients presented complications; One patient died post-operatively. Major (grade 3-5) complications requiring subsequent surgeries occurred in 21 patients (11.5%). 76% of patients with a major complication had undergone an ultraradical surgery (P = 0.004). CONCLUSION While ultraradical surgery may result in complete resection of peritoneal disease in advanced ovarian cancer, the associated complication rate is not negligible. Patients should be carefully evaluated and the timing of their surgery optimized in order to avoid major complications.
Collapse
|
22
|
Chang SJ, Bristow RE. Evolution of surgical treatment paradigms for advanced-stage ovarian cancer: redefining 'optimal' residual disease. Gynecol Oncol 2012; 125:483-92. [PMID: 22366151 DOI: 10.1016/j.ygyno.2012.02.024] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 02/10/2012] [Accepted: 02/16/2012] [Indexed: 12/14/2022]
Abstract
Over the past 40 years, the survival of patients with advanced ovarian cancer has greatly improved due to the introduction of combination chemotherapy with platinum and paclitaxel as standard front-line treatment and the progressive incorporation of increasing degrees of maximal cytoreductive surgery. The designation of "optimal" surgical cytoreduction has evolved from residual disease ≤ 1 cm to no gross residual disease. There is a growing body of evidence that patients with no gross residual disease have better survival than those with optimal but visible residual disease. In order to achieve this, more radical cytoreductive procedures such as radical pelvic resection and extensive upper abdominal procedures are increasingly performed. However, some investigators still suggest that tumor biology is a major determinant in survival and that optimal surgery cannot fully compensate for tumor biology. The aim of this review is to outline the theoretical rationale and historical evolution of primary cytoreductive surgery, to re-evaluate the preferred surgical objective and procedures commonly required to achieve optimal cytoreduction in the platinum/taxane era based on contemporary evidence, and to redefine the concept of "optimal" residual disease within the context of future surgical developments and analysis of treatment outcomes.
Collapse
Affiliation(s)
- Suk-Joon Chang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea
| | | |
Collapse
|
23
|
Chéreau E, Rouzier R, Gouy S, Ferron G, Narducci F, Bergzoll C, Huchon C, Lécuru F, Pomel C, Daraï E, Leblanc E, Querleu D, Morice P. Morbidity of diaphragmatic surgery for advanced ovarian cancer: Retrospective study of 148 cases. Eur J Surg Oncol 2011; 37:175-80. [DOI: 10.1016/j.ejso.2010.10.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 09/19/2010] [Accepted: 10/26/2010] [Indexed: 11/29/2022] Open
|
24
|
Complications de la chirurgie radicale des cancers de l’ovaire de stade avancé. ACTA ACUST UNITED AC 2011; 39:21-7. [DOI: 10.1016/j.gyobfe.2010.08.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Accepted: 03/18/2010] [Indexed: 12/25/2022]
|
25
|
Gouy S, Chereau E, Custodio AS, Uzan C, Pautier P, Haie-Meder C, Duvillard P, Morice P. Surgical procedures and morbidities of diaphragmatic surgery in patients undergoing initial or interval debulking surgery for advanced-stage ovarian cancer. J Am Coll Surg 2010; 210:509-14. [PMID: 20347745 DOI: 10.1016/j.jamcollsurg.2010.01.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 01/05/2010] [Accepted: 01/07/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgical management of advanced-stage ovarian cancer (ASOC) can require diaphragmatic surgery (DS) to achieve complete cytoreduction. The aim of this study was to evaluate modalities and morbidities of DS at the time of initial surgery (INS) and interval debulking surgery (IDS; performed after neoadjuvant chemotherapy). STUDY DESIGN Retrospective review of patients undergoing (unilateral or bilateral) DS at the time of INS or IDS for ASOC. RESULTS Between 2005 and 2008, 63 patients were studied. Treatment of the diaphragm was unilateral in 31 patients and bilateral in 32 patients. DS was performed respectively at the time of INS in 22 patients (35%) and IDS in 41 (65%) patients. Complete cytoreductive surgery was achieved in 95% (21 of 22 in the INS group and 39 of 41 in the IDS group). Surgical procedures used during DS were (in the INS and IDS groups, respectively) stripping in 14 (64%) and 16 (39%), coagulation in 2 (9%) and 10 (24%), and both procedures in 6 (27%) and 15 (37%). An intraoperative chest tube was placed in 14% of patients in each group. Postoperative chest complications requiring treatment occurred in 6 cases: pulmonary embolism (3 cases), symptomatic pleural effusion requiring chest drainage (1 case), and pneumothorax necessitating chest drainage (2 cases). CONCLUSIONS Rate of overall morbidity related to DS was not statistically different in patients undergoing INS and IDS. Surgical treatment of this upper part of the abdomen is key to achieving complete cytoreductive surgery in ASOC.
Collapse
|
26
|
Fanfani F, Fagotti A, Gallotta V, Ercoli A, Pacelli F, Costantini B, Vizzielli G, Margariti PA, Garganese G, Scambia G. Upper abdominal surgery in advanced and recurrent ovarian cancer: Role of diaphragmatic surgery. Gynecol Oncol 2010; 116:497-501. [DOI: 10.1016/j.ygyno.2009.11.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Revised: 11/18/2009] [Accepted: 11/19/2009] [Indexed: 11/29/2022]
|