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Characteristics and Management of Diaphragm Involvement in Patients With Primary Advanced-Stage Ovarian, Fallopian Tube, or Peritoneal Cancer
  1. Jens Einenkel, MD*,
  2. Rudolf Ott, MD, PhD,
  3. Romy Handzel, MD*,
  4. Ulf-Dietrich Braumann, PhD and
  5. Lars-Christian Horn, MD, PhD§
  1. *Departments of Obstetrics and Gynecology, and
  2. Departments of Visceral Surgery, and
  3. Departments of Interdisciplinary Centre for Bioinformatics, Translational Centre for Regenerative Medicine, and
  4. §Departments of Division of Perinatal and Gynecologic Pathology, Institute of Pathology, Leipzig University, Leipzig, Germany.
  1. Address correspondence and reprint requests to Jens Einenkel, MD, Zentrum für Frauen- und Kindermedizin der Universität Leipzig, Liebigstraße 20a, 04103 Leipzig, Germany. E-mail: jens{at}


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.

  • Ovarian carcinoma
  • Diaphragm
  • Surgery

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