Diaphragmatic Surgery in Advanced Ovarian, Tubal and Peritoneal Cancer. A 7-Year Retrospective Analysis of the Tumor Bank Ovarian Cancer Network

Discussion

In the current study, we analyzed our results for all patients with stage III-IV ovarian cancer who underwent or did not undergo any diaphragmatic surgical intervention at the time of PCS between 2007 and 2013. To the best of our knowledge, this study is largest study of diaphragmatic surgery as a part of PCS for AOC.

In our current series, preoperatively apparent stage IV (pleura effusion) disease, a very high CA-125 value, serous papillary tumors and the presence of massive ascites (>500 ml) were statistically significant predictors of the need for diaphragmatic surgery in order to achieve CTR in the frame of PCS.

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Figure 2.

Overall survival (OS) in patients with advanced ovarian cancer who underwent primary cytoreductive surgery according to performance or not of diaphragmatic intervention (A), and to type of diaphragmatic intervention (B).

Unfortunately, we could not find any other study comparing PCS with and without diaphragmatic surgery, but only series, which studied PCS with different approaches to diaphragmatic surgery as one collective without a control group.

As our debulking operations always aimed to achieve CTR when possible, we found that diaphragmatic surgery was needed in almost half of all patients undergoing PCS. Furthermore, 60% of suboptimally debulked patients (residual tumor <10 mm) needed some kind of diaphragmatic surgery.

Performing a diaphragmatic surgery as a part of PCS correlated in our findings with a statistically significant increase of bowel resection, partial resection of liver capsule, cholecystectomy, splenectomy and partial stomach resection. This did increase the operating time or postoperative complications, but most of these complications were not directly related to the diaphragmatic intervention with only one exception (pleura effusion).

In our study, we noticed longer PFS and OS in the non-diaphragmatic surgery group in comparison to the diaphragmatic surgery group. These results were not statistically significant and they reflect more the difference between the two groups regarding the distribution of peritoneal carcinosis, which was clearly more massive in the diaphragmatic surgery group.

In our current series, we performed diaphragmatic stripping in 53%, diaphragmatic resection in 44.8% and infrared coagulation in only 2.2% of the patients. Zapardiel et al. reported diaphragmatic stripping in 70.5% and full-thickness resection in 29.5% of cases (13). In the study of Tsolakidis et al., diaphragmatic disease was coagulated in 22% of patients, stripped in 35%, in 35%, a combination of these techniques was applied, and in 8%, the disease was resected with the adjacent infiltrated part of the diaphragm muscle and the pleura above it (14). We achieved CTR in 73.3% and 61.3% in diaphragmatic resection and stripping groups, respectively. These rates were 63.6% and only 36.7% in the same groups in the study of Zapardiel et al. Fanfani et al. reported that in their whole study population, optimal residual disease at the end of surgery, defined as residual nodule less than 1 cm, for PCS was achieved (15).

The median OS and PFS in our current study were 47.1 and 43.9 months and 18 and 19 months for diaphragmatic resection and stripping, respectively. Median PFS in the study by Tsolakidis et al. was 15, 15, 17 months and median OS was 40, 42, and 50 months for groups of patients treated with coagulation, stripping, and combination stripping with coagulation, respectively (14).

PFS and OS rates were 27.8% and 58.2%, respectively, in the stripping group, and 39.4% and 78.8%, respectively, in the resection group of the study of Zapardiel et al. (13). Aletti et al. reported a survival advantage for treatment of diaphragmatic disease when considering either all patients with diaphragm disease (53% vs. 15%) or only the subset with diaphragmatic disease who were optimally cytoreduced – defined as less than 1 cm of residual tumor (55% vs. 28%) (16). For this subgroup of patients, we did not notice this benefit of diaphragmatic surgery in our patients.

Postoperative pleural effusion was the most frequent associated complication (16.9%), followed by pneumothorax (6.6%), and pneumonia (2.2%) in the study by Tsolakidis et al. (14). Focusing on complications directly related to diaphragmatic surgery, Chereau et al. reported 37% of pleural effusion, 5% of pulmonary embolism, 4% of pneumothorax, and 2% of pulmonary infection (17). Devolder et al. reported 59% pleural effusion rate in a group of 69 diaphragmatic surgeries, although none involved full-thickness resection of the diaphragm (18). Postoperative pleura effusion was the most commonly diagnosed complication in the diaphragmatic surgery group of our cohort (25.4%). The incidence of pneumonia and pneumothorax was 4.5% and 1.9%, respectively in the diaphragmatic surgery group, but it did not differ from the incidence rate in the control group. We did not find any statistically significant differences in terms of postoperative complications between the two major types of diaphragmatic surgery. In our series, the infrared contact coagulation group presented a worse complication rate, mortality and survival. This group was too small in our study to reveal any significant results. On the other hand, we tend to perform infrared coagulation only when we believe that achieving a CTR will be impossible or very risky in already morbid patients.

In conclusion, even within the limits of a retrospective study but taking into account the large cohort of patients we had, diaphragmatic surgery at the time of PCS for AOC may be needed in 50% of patients in order to be able to achieve a higher CTR rate. Our current findings support the results of other similar studies considering diaphragmatic surgery as acceptable, feasible and often as an essential intervention in order to achieve CTR or suboptimal debulking.