Diaphragm resection for ovarian cancer: technique and short-term complications
Introduction
Of the most relevant prognostic factors for ovarian cancer (OC) outcome, extent of surgical debulking is the sole factor under the control of the operating surgeon. Since Griffiths' [2] original report accurately correlating survival with residual disease, nearly every prospective or retrospective study to date documents that survival in advanced stage ovarian cancer is directly linked to the amount of residual disease present at the conclusion of primary cytoreductive surgery (reviewed in Refs. [3], [4]). Most recently, Eisenkop and Spirtos [5] demonstrated that this principle holds true in cases where radical procedures are required to achieve optimal debulking status; this suggests that even biologically aggressive tumors are best treated using a strategy of maximal effort at achieving optimal surgical cytoreduction.
In a recent survey of the membership of the Society of Gynecologic Oncologists (SGO), 76.3% of respondents cited bulky diaphragmatic disease as a factor precluding optimal cytoreduction, second only to portal triad disease [1]. In addition, only 24% of those surveyed utilized diaphragm resection (DR) and 30% were not experienced with the procedure [1]. These observations suggest that a major source of variation in the ability to achieve optimal surgical debulking is the ability to remove significant disease from the hemidiaphragm. In support of this view, fully 40.5% of 163 consecutive patients with Stages III/IV ovarian cancer required diaphragm stripping or resection to enable debulking to less than 1 cm in over 98% of patients [5]. Underscoring the importance of this site is the fact that bulky diaphragmatic disease may be the largest metastatic site in primary [6] or secondary disease [7]. The frequency of diaphragm involvement in recurrent disease suggests incomplete excision may be frequent at primary surgery.
Little literature exists regarding the specific morbidity associated with full-thickness resection of the diaphragm in cytoreductive surgery. Fiorica et al. [8] (2 cases), Montz et al. [9] (4 cases), and Kapnick et al. [10] (11 cases), and Deppe et al., [14] (14 cases) all reported small numbers of cases with morbidity confined to bleeding or pneumothorax. Eisenkop and Spirtos [5] reported on 27 patients who had undergone full-thickness DR as part of a large series of completely cytoreduced patients, but specific morbidity associated with DR was not discussed. Because of the lack of published experience with the procedure of full-thickness DR and the frequency in which diaphragmatic disease precludes successful cytoreductive surgery, we examined our own institutional experience with DR for ovarian cancer.
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Materials and methods
All investigations for these studies were approved by the Institutional Review Board of the Mayo Clinic. We retrospectively identified all patients undergoing surgery for ovarian cancer at our institution from January 1988 through December 2001. For this study, we identified those patients who underwent diaphragm resection as part of the surgical procedure. Charts were retrospectively reviewed for demographic data, surgical–pathological variables, type of surgery (primary vs. recurrent),
Results
We identified 41 women who underwent diaphragm resection for ovarian cancer at Mayo Clinic during the study period 1988–2001. Demographic characteristics, stage, and surgical–pathologic factors are shown in Table 1. The majority of DR occurred in women undergoing surgery for recurrent disease (35/41, 85%) and in 13 of these 35 cases, there had been at least one prior recurrence. The lesions were predominantly right-sided (80%) but bilateral resections were needed in two (5%) patients.
Discussion
Surgical cytoreduction of gross tumor remains one of the fundamental principals in the treatment of epithelial ovarian cancer. Numerous studies performed over time have repeatedly shown that the less tumor remaining at the conclusion of surgery, the better the prognosis for the patient (reviewed in Refs. [3], [4]). The ability to perform such surgery safely and meticulously truly distinguishes the specialty of gynecologic oncology. Despite this, the obstacles to achieving optimal cytoreduction
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