Feasibility of laparoscopic diaphragmatic peritonectomy during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer

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.

Pulmonary morbidity related to diaphragm surgery performed for gynecological cancers

Objective:

To evaluate pulmonary morbidity related to diaphragm surgery performed for gynecological cancers and to identify the impact of transdiaphragmatic thoracotomy.

Materials and Methods:

We reviewed clinical and pathologic data of 232 women who had undergone diaphragm surgery as a part of cytoreductive surgery procedures performed for gynecological cancers.

Results:

Transdiaphragmatic thoracotomy occurred in 52 patients (22.4%). Rate of pulmonary complications among patients who had a transdiaphragmatic thoracotomy was higher compared with patients who did not have a transdiaphragmatic thoracotomy (40.4% vs 20.6%, p=0.004). Transdiaphragmatic thoracotomy [odds ratio (OR), 2.66; 95% confidence interval (CI), 1.20-5.92; p=0.016], colon resection (OR, 5.21; 95% CI, 2.34-11.63; p<0.001), ileostomy (OR, 19.61; 95% CI, 1.64-250.0; p=0.019), and any extra-pulmonary complication occurrence (OR, 2.35; 95% CI, 1.13-4.88; p=0.023) were identified as independent predictors of pulmonary morbidity. Patients with transdiaphragmatic thoracotomy developed pleural effusion, pleural effusion necessitating drainage, pneumothorax, pneumonitis, and atelectasis more frequently compared with patients who did not have transdiaphragmatic thoracotomy. Rate of admission to postoperative intensive care of patients with transdiaphragmatic thoracotomy (30.8%) was significantly higher than that of patients without transdiaphragmatic thoracotomy (12.2%) (p=0.001).

Conclusion:

Transdiaphragmatic thoracotomy is an independent predictor of pulmonary morbidity among patients who underwent diaphragm surgery. Avoiding accidental transdiaphragmatic thoracotomies with maximal attention and performing full-thickness resection procedures with alternative surgical techniques preventing a thoracotomy may help decrease pulmonary morbidity rates and postoperative care costs.

Cytoreductive Surgery for Advanced Ovarian Cancer

The amount of the largest diameter of visible residual tumor after cytoreductive surgery remains one of the strongest prognostic factors In advanced ovarian cancer. The Implementation of a more aggressive surgical approach to Increase the proportion of patients without visible residual tumor Is, therefore, a rational concept. Thus, the surgical management of advanced ovarian, primary peritoneal and fallopian tube cancers now Incorporates more comprehensive surgical procedures. However, these more extensive surgical procedures are associated with an Increased risk of morbidity, which may have a negative Impact on the oncologic outcome. In addition, It Is unclear whether all patients benefit from a comprehensive surgical Intervention In the same way or If there are patients whose disease course will not be Influenced by this approach. The methodologic analysis of surgical effectiveness Is complex and controversial owing to a lack of prospective surgical trials. This review acknowledges controversies and alms to discuss novel developments In the field of cytoreductive surgery for patients with ovarian, primary peritoneal and fallopian tube cancers. The focus of the review Is to discuss the role of surgery at Initial diagnosis. The role of secondary and tertiary surgery In the recurrent setting Is beyond the scope of this review.

Human papillomavirus genotyping and integration in ovarian cancer Saudi patients

Background

Human papillomavirus (HPV) is associated with different malignancies but its role in the pathogenesis of ovarian cancer is controversial. This study investigated the prevalence, genotyping and physical state of HPV in ovarian cancer Saudi patients.

Methods

Hundred formalin fixed paraffin embedded (FFPE) ovarian carcinoma tissues and their normal adjacent tissues (NAT) were included in the study. HPV was detected by nested polymerase chain reaction (PCR) using degenerated HPVL1 consensus primer pairs MY09/MY11 and GP5+/GP6 + to amplify a broad spectrum of HPV genotypes in a single reaction. The HPV positive samples were further genotyped using DNA sequencing. The physical state of the virus was identified using Amplification of Papillomavirus Oncogene Transcripts (APOT) assay in the samples positive for HPV16 and/or HPV18.

Results

High percentage of HPV (42%) was observed in ovarian carcinoma compared to 8% in the NAT. The high-risk HPV types 16, 18 and 45 were highly associated with the advanced stages of tumor, while low-risk types 6 and 11 were present in NAT. In malignant tissues, HPV-16 was the most predominant genotype followed by HPV-18 and -45. The percentage of viral integration into the host genome was significantly high (61.1%) compared to 38.9% episomal in HPV positive tumors tissues. In HPV18 genotype the percentage of viral integration was 54.5% compared to 45.5% episomal.

Conclusion

The high risk HPV genotypes in ovarian cancer may indicate its role in ovarian carcinogenesis. The HPV vaccination is highly recommended to reduce this type of cancer.

Assessment of intraoperative tube thoracostomy after diaphragmatic resection as part of debulking surgery for primary advanced-stage Müllerian cancer

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.

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

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.

Surgical management of epithelial ovarian cancer

Ovarian cancer affects approximately 21,880 women and accounts for over 13,000 deaths annually in the United States. Although survival rates have improved over the past several decades, directly as a result of advances in chemotherapy and surgery, ovarian cancer continues to have high mortality rates. Understanding the multiple roles of surgery throughout the disease course is the focus of this review.

Diaphragmatic Surgery During Primary Cytoreduction for Advanced Ovarian Cancer: Peritoneal Stripping Versus Diaphragmatic Resection

Background

Standard approach for medically stable advanced ovarian cancer patients should be primary cytoreduction following platinum-based chemotherapy. The aim of surgical effort should be the complete removal of all visible disease. Our objective was to compare perioperative features, postoperative complications, and secondarily oncological outcomes of patients who underwent diaphragmatic stripping with those who underwent diaphragmatic resection for advanced ovarian cancer.

Methods

One hundred twelve cases were identified, among them 79 underwent diaphragmatic stripping and 33 underwent diaphragmatic full-thickness resection. Data collected included patients’ age, all perioperative details and pathological findings, International Federation of Gynecology and Obstetrics stage, adjuvant therapy, and follow-up data.

Results

Larger residual tumors (mean, 5.1 vs 1.6 mm, respectively;P< 0.01) but shorter operating time (25 minutes shorter operative time,P= 0.07) were observed in the stripping group. Higher postoperative pleural effusions rates (63.6% vs 37.9%,P= 0.01), but no differences in the remaining complications, were observed in the resection group. After a mean of 31 months of follow-up, disease-free survival rates were 27.8% in the stripping group and 39.4% in the resection group (P= 0.04). No significant differences were observed for overall survival.

Conclusions

Diaphragmatic surgery at the time of primary cytoreductive surgery for advanced ovarian cancer may contribute to the achievement of complete cytoreduction with low perioperative complication rate; full-thickness resection is preferable if peritoneum stripping will not achieve a complete removal of the disease.

Incidental events of diaphragmatic surgery in 82 patients with advanced ovarian, primary peritoneal and fallopian tubal cancer

Surgical resections, such as peritoneal stripping (peritonectomy) are performed for disseminated diaphragmatic lesions of advanced ovarian cancer. This study retrospectively investigated the incidental events of diaphragmatic surgery. The records of patients with advanced mullerian carcinomas, including ovarian, primary peritoneal and fallopian carcinomas, who underwent diaphragmatic surgery were reviewed. Based on our criteria, stripping was performed for surface disease on the diaphragm, and full-thickness resection was performed for bulky disease. In certain cases, both procedures were performed. We analyzed intra- and post-operative incidental events in 82 patients. The χ(2) and Fisher's exact tests were used in the statistical analysis. There were 82 stage III-IV cases of which 56 patients underwent stripping, 12 underwent full-thickness resection and 14 patients underwent both procedures. Unexpected open chest surgery following stripping occurred in 1 out of 63 patients (1.6%) in the primary, 4 out of 13 patients (30.8%) in the interval and 0 out of 6 patients (0.0%) in the secondary debulking surgery groups. The incidence of unexpected open chest surgery was high in the interval debulking surgery group (p<0.001). Regarding post-operative events, accumulation of pleural effusion was identified in 43 patients (52.4%). The incidence of pleural effusions was not significantly different between the two procedures. No complications were encountered, nor was a chest tube required, during unexpected open chest surgery and postoperative pleural effusions. Therefore, it was concluded that special attention should be paid during interval debulking surgery even though it was possible for surgical resections of diaphragmatic lesions to be performed safely.

Surgical technique of diaphragm full-thickness resection and trans-diaphragmatic decompression of pneumothorax during cytoreductive surgery for ovarian cancer

OBJECTIVE

To describe the technique and short-term post-operative outcomes associated with diaphragm full-thickness resection (FTR) and intraoperative trans-diaphragmatic decompression of the resultant pneumothorax (TDDP).

METHODS

All patients undergoing cytoreductive surgery for primary or recurrent ovarian cancer between 8/1/98 and 7/30/09 were retrospectively identified from the tumor registry database. Patients undergoing diaphragm FTR were selected for detailed review of the operative technique and post-operative outcomes. The operative technique of TDDP using a fenestrated Robinson catheter is described.

RESULTS

A total of 45 patients met study inclusion criteria. Diaphragm FTR surgery was performed exclusively by gynecologic oncologists in 73.3% of cases. The median patient age was 60 years, and the majority (75.6%) of cases were performed for primary cytoreduction of Stage IIIC (n=27) or Stage IV (n=18) disease. The two-dimensional surface area of tumor involvement ranged from 9 cm(2) to 192 cm(2). The right hemi-diaphragm alone was involved in 71.1% of cases, while both the right and left hemi-diaphragms were involved in 24.4%. TDDP was performed in 41 of the 45 patients undergoing diaphragm FTR, while 4 patients had intraoperative thoracostomy tubes placed. Among the 41 TDDP patients, post-operative days 3-4 radiographic imaging revealed that 56% had a small residual pleural effusion and 9.8% had a residual pneumothorax; however, only 2 patients (4.9%) required post-operative thoracostomy tube placement or thoracentesis.

CONCLUSION

The technique of TDDP eliminates the need of intraoperative and post-operative thoracostomy tube/thoracentesis in 95.1% of patients undergoing diaphragm FTR as a component of ovarian cancer cytoreductive surgery.

Surgical procedures and morbidities of diaphragmatic surgery in patients undergoing initial or interval debulking surgery for advanced-stage ovarian cancer

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.

Characteristics and management of diaphragm involvement in patients with primary advanced-stage ovarian, fallopian tube, or peritoneal cancer

OBJECTIVES

The aim of this study was to determine the frequency of diaphragm involvement (DI) in cases of International Federation of Gynecology and Obstetrics (FIGO) stage IIIC and IV primary epithelial ovarian, fallopian tube, or peritoneal cancer; the frequency of use of different surgical techniques in managing diaphragm implants; and the procedure-associated morbidity.

METHODS

A retrospective analysis of consecutive patients undergoing primary surgery by a single surgical team between January 2005 and June 2007 was accomplished. Patients with tumors of low malignant potential and nonepithelial histologic diagnosis and those who received neoadjuvant chemotherapy were excluded.

RESULTS

Thirty-three patients met the inclusion criteria. Diaphragm involvement was found in 91% of the cases. Whereas the left hemidiaphragm is never involved alone, the right side is significantly affected more extensively (P = 0.002) and frequently (alone, 20%; both sides, 80%). The frequency of use of procedures varies considerably in the literature, whereas full-thickness diaphragm resection (DR) had to be performed in 53% of our patients with DI. Diaphragm resection at the left hemidiaphragm and bilateral DRs are very rare in primary cases. A specific histopathologic examination of the DR preparation is desirable. A simple 4-tiered classification of the infiltration depth is proposed. The most frequent complication is serothorax, but a generous indication for intraoperative chest tube placement is solely recommended in cases of DR.

CONCLUSIONS

Surgical effort in achieving an optimum cytoreduction could be evaluated more precisely with parameters of DI and diaphragm-related treatment procedures. The usual quality criteria for ovarian cancer surgery, such as residual tumor state and morbidity, are more marked by subjectivity and inconsistent definitions.

Pulmonary morbidity of diaphragmatic surgery for stage III/IV ovarian cancer

OBJECTIVE

To determine the morbidity of diaphragmatic peritonectomy.

DESIGN

Prospective cohort study.

SETTING

A Gynecology Department of a University Hospital.

POPULATION

From 2005 to 2007, thirty-seven consecutive patients underwent surgery for stage IIIC or IV ovarian cancer.

METHODS

Patients were separated into a diaphragmatic surgery group (n = 18) and a control group (n = 19). Diaphragmatic surgery may consist of coagulation, stripping or muscle resection.

MAIN OUTCOME MEASURES

Postoperative course and outcome were analysed.

RESULTS

Patients in group 1 (diaphragmatic surgery) underwent more intestinal resection (89% versus 37%, P = 0.01) and pelvic (94% versus 63%, P = 0.02) or para-aortic lymphadenectomy (94% versus 53%, P = 0.04). Neither the mean estimated blood loss (960 ml versus 909 ml) nor the rates of intra-operative blood transfusion (11 versus 9) were significantly different between the two groups. The mean operative time was higher in group 1 (480 minutes versus 316 minutes, P < 0.05). There were thirteen postoperative complications in group 1 and eight in group 2 (P = 0.065). In group 1, the main complication was pleural effusion (seven cases): four patients required secondary pleural drainage, two required only pleural puncture and one had both procedures. There were more complete cytoreduction in group 1 than in group 2 (89% versus 63%, P = 0.068).

CONCLUSIONS

Diaphragm peritonectomies and resections are an effective way to cytoreduce diaphragm carcinomatosis and increase the rate of optimal debulking surgery. Such procedures frequently result in pleural effusion, but with no long-term morbidity.