The Role of Diaphragmatic Surgery During Interval Debulking After Neoadjuvant Chemotherapy An Analysis of 74 Patients With Advanced Epithelial Ovarian Cancer
ABSTRACT The purpose of this retrospective study was to evaluate diaphragmatic surgery in achieving optimal cytoreductive results and its associated complications during interval debulking surgery in patients with advanced ovarian cancer.
After retrospective review of medical records, diaphragmatic surgery was performed in 74 of 128 consecutive patients with advanced epithelial ovarian cancer who underwent interval debulking, between September 1993 and December 2007. Four different approaches were performed: coagulation (group 1), stripping (group 2), combination of stripping with coagulation (group 3), and diaphragm full-thickness resection including muscle with pleura (group 4). Cytoreductive outcome, morbidity, overall survival, and disease-free survival were analyzed.
Two patients (2.7%) had International Federation of Gynecology and Obstetrics stage IIIB disease; 46 (62.16%), stage IIIC; and 26 (35.13%), stage IV. After 3 to 4 cycles of neoadjuvant platinum-based chemotherapy, the diaphragmatic disease was coagulated in 43 patients (58.10%) and was only stripped in 10 (13.51%); in 19 patients (25.67%), a combination of these techniques was applied; and in 2 (2.70%), the disease was resected, with the adjacent infiltrated part of the diaphragmatic muscle and the pleura above it. Debulking to no residual was achieved in 95%, 100%, 100%, and 50% for groups 1, 2, 3, and 4, respectively. The median disease-free survival was 15, 14, and 14 months, and the median overall survival was 34, 30, and 51 months for groups 1, 2, and 3, respectively, and were not reached for group 4. Minor and major complications were comparable among the groups. Pleural effusions were the most frequent associated complication, and chest tube placement (1.3%) or thoracocentesis (4%) were necessary for the relief of respiratory distress. The perioperative mortality rate was 0%.
Diaphragmatic surgery during interval debulking enhances optimal cytoreduction rates and improves survival with acceptable and manageable morbidity. In patients with thick (>4 mm) or large (>1 cm) lesions, stripping the diaphragm or full-thickness resection of the diaphragmatic muscle is preferred.
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ABSTRACT: Ovarian cancer is the sixth most common cancer among women and the leading cause of death in women with gynaecological malignancies. Opinions differ regarding the role of ultra-radical (extensive) cytoreductive surgery in ovarian cancer treatment. To evaluate the effectiveness and morbidity associated with ultra-radical/extensive surgery in the management of advanced stage ovarian cancer. We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4), MEDLINE and EMBASE (up to November 2010). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. Randomised controlled trials (RCTs) or non-randomised studies, analysed using multivariate methods, that compared ultra-radical/extensive and standard surgery in adult women with advanced primary epithelial ovarian cancer. Two review authors independently assessed whether potentially relevant studies met the inclusion criteria, abstracted data and assessed the risk of bias. One non-randomised study was identified so no meta-analyses were performed. One non-randomised study met our inclusion criteria. It analysed retrospective data for 194 women with stage IIIC advanced epithelial ovarian cancer who underwent either ultra-radical (extensive) or standard surgery and reported disease specific overall survival and perioperative mortality. Multivariate analysis, adjusted for prognostic factors, identified better disease specific survival among women receiving ultra-radical surgery, although this was not statistically significant (Hazard ratio (HR) = 0.64, 95% confidence interval (CI): 0.40 to 1.04). In a subset of 144 women with carcinomatosis, those who underwent ultra-radical surgery had significantly better disease specific survival than women who underwent standard surgery (adjusted HR = 0.64, 95% CI 0.41 to 0.98). Progression-free survival and quality of life (QoL) were not reported and adverse events were incompletely documented. The study was at high risk of bias. We found only low quality evidence comparing ultra-radical and standard surgery in women with advanced ovarian cancer and carcinomatosis. The evidence suggested that ultra-radical surgery may result in better survival. It was unclear whether there were any differences in progression-free survival, QoL and morbidity between the two groups. The cost-effectiveness of this intervention has not been investigated. We are, therefore, unable to reach definite conclusions about the relative benefits and adverse effects of the two types of surgery.In order to determine the role of ultra-radical surgery in the management of advanced stage ovarian cancer, a sufficiently powered randomised controlled trial comparing ultra-radical and standard surgery or well-designed non-randomised studies would be required.Cochrane database of systematic reviews (Online) 01/2011; DOI:10.1002/14651858.CD007697.pub2 · 5.94 Impact Factor
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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.Archives of Gynecology 01/2013; 287(4). DOI:10.1007/s00404-013-2715-1 · 1.28 Impact Factor
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ABSTRACT: Primary cytoreductive surgery in patients with stage IIIC-IV epithelial ovarian cancer frequently includes diaphragm peritonectomy or resection, which can lead to symptomatic pleural effusions when the resection specimen is ≥10cm. Our objective was to evaluate whether the placement of an intraoperative thoracostomy tube decreased the incidence of symptomatic pleural effusions in these cases. We identified 156 patients who underwent primary debulking surgery involving diaphragm peritonectomy or resection for stage III-IV ovarian cancer from 1/01-12/09. Using standard statistical tests, the incidence of symptomatic pleural effusions and other variables were compared between patients who did and did not have intraoperative chest tubes placed. Forty-nine patients had a resected diaphragm specimen ≥10cm in largest dimension; 28 (57%) did not undergo chest tube placement (NCT group) while 21 (43%) did (CT group). Mediastinal lymph node dissection (0% vs 19%, P=0.028) and liver resections (11% vs 38%, P=0.037) were higher in the CT group. Postoperatively, 57% of the NCT group developed a moderate or large pleural effusion compared to 19% of the CT group (P=0.007). Thirteen patients (46%) in the NCT group developed respiratory symptoms requiring either placement of a postoperative chest tube or thoracentesis compared to 3 patients (14%) in the CT group (P=0.018). Diaphragm peritonectomy or resection can often lead to moderate or large pleural effusions that may become symptomatic. In these patients, intraoperative chest tube placement may be considered to decrease the incidence of symptomatic effusions and the need for postoperative chest tube placement or thoracentesis.Gynecologic Oncology 11/2013; 132(2). DOI:10.1016/j.ygyno.2013.11.026 · 3.69 Impact Factor