A Physician-matched Case Control Study Of Diaphragmatic Peritonectomy In Bulky Stages Ⅲ And Ⅳ Epithelial Ovarian Cancer

Objective Diaphragm involvement by ovarian cancer is often considered to be the secondary obstacle to successful cytoreductive surgery. This study was performed to assess the outcomes and associated morbidity in patients with advanced epithelial ovarian cancer undergoing diaphragmatic peritonectomy.Methods The patients from2009to2011of Fudan University Cancer Hospital with diaphragm metastasis were involved in this retrospective study. We performed a intention-to-cure case-control study, patients were divided into diaphragmatic peritonectomy group and control group. The clinical data were reviewed including the general information, surgical procedures, characteristics at the diagnosis, information of diaphragmatic peritonectomy and the survival data. Person X2test and One-way ANOVA was used to identify the baseline level difference between two groups. Overall survival was estimated by the Kaplan-Meier method and the difference was determined by the Log-Rank method. Cox proportion hazards regression was used to evaluate the prognostic factors.Results Cases comprised of32patients undergoing diaphragm peritonectomy treatment, while control group consisted of39patients from2009to2011. Person X2test and One-way ANOVA was used to identify the baseline level difference between two groups. We found the year of surgery, median age, internal disease, ASA score, histology type, neoadjuvant, CA125level before primary cytoreduction, ascites, bowel and mesenteric carcinomatosis are not significant difference between two groups. Diaphragmatic procedures performed including stripping of the diaphragmatic peritoneum, full or partial thickness diaphragm resection, excision of nodules.Mean operative time in diaphragmatic peritonectomy group is214.5minutes and the control group is136.7minutes, P=0.000; Median blood loss in diaphragmatic peritonectomy group is1000ml and the control group is600ml, P=0.000; Median blood transfusion in diaphragmatic peritonectomy group is800ml and the control group is400ml, P=0.000;There is13patients received intraperitoneal chemotherapy and3patients in control group, P=0.001;13(40.6%) patients had no residual disease in diaphragmatic, P=0.000. Mean hospitalization in diaphragmatic peritonectomy group is22days and control group is15days, P=0.007.The median follow-up time was21.7months. Up to the last follow-up, one patient(3.1%) in diaphragmatic peritonectomy group was lost and one patients (2.6%) in control group was lost.19patients (59.4%) was recurrence in diaphragmatic and median PFS is19.9months while29patients (74.4%) was recurrence in control group and median PFS is15.4months, P=0.092,HR:0.609,95%CI(0.34-1.091). The median survival is not reached.4patients (12.5%) and11patients (28.8%) died of cancer in diaphragmatic peritonectomy group and control group, respectively. Mean survival was33.7months in diaphragmatic surgery group and27.1months in control group, P=0.081, HR:0.374,95CI(0.118-1.181). Logistics regression revealed that diaphragmatic treatment outcome was significantly prolonged compared the control group.2year cancer-specific survival was88.7%and64.2%in study group and control group, respectively.1year caner-specific survival was96.8%in diaphragmatic group and84.6%in the control group.Conclusions Diaphragmatic peritonectomy can prolong overall survival and significantly improve complete resection rate. In our study, the main complication was pulmonary morbidity:chest tube/pleural puncture with an acceptable range. The diaphragmatic surgical skills should be mastered by gynecological oncologist and we still need further follow-up and large sample size randomized controlled clinical trials are expected to establish the value of diaphragmatic peritonectomy.