Pounds Rachel, Phillips Andrew, Kehoe Sean, Nevin James, Sundar Sudha, Elattar Ahmed, Teo Hong Giap, Singh Kavita, Balega Janos
Institute of Cancer and Genomic Sciences, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, United Kingdom.
Department of Obstetrics and Gynaecology, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, United Kingdom.
Eur J Obstet Gynecol Reprod Biol. 2018 Jul;226:47-53. doi: 10.1016/j.ejogrb.2018.05.024. Epub 2018 May 18.
To establish the positive predictive values of pre-operative identification with CT imaging of metastatic diaphragm disease in surgically managed cases of advanced ovarian cancer (AOC). Additionally, we have assessed the post-operative morbidity and survival following diaphragmatic surgical intervention in a large regional cancer centre in the United Kingdom.
A retrospective review of all cases of AOC with metastatic diaphragm disease surgically treated at the Pan-Birmingham Gynaecological Cancer Centre, UK between 1st August 2007 and 29th February 2016.
A total of 536 women underwent surgery for primary AOC. Diaphragm disease was evident intra-operatively in 215/536 (40.1%) and 85/536 women (15.9%) underwent a procedure involving their diaphragm. Of these 85 cases, 38 peritoneal strippings (38/85, 44.7%), 31 partial diaphragmatic resections (31/85, 35.6%) and 16 electro-surgical ablations (16/85, 18.9%) were performed. There were no significant differences in post-operative complications between the three different diaphragmatic surgical groups. Of those patients who underwent peritoneal stripping or partial diaphragm resection, 12% were upstaged to stage 4A by virtue of pleural invasion. The positive predictive value for pre-operative radiological identification of diaphragmatic disease was 78.6%. CT imaging failed to detect diaphragmatic involvement despite obvious diaphragm disease during surgery in 29.4% of cases, giving a low negative predictive value of 64.8%. The sensitivity and specificity for CT imaging in detecting diaphragm disease was 44.3% and 93.8%, respectively.
Diaphragmatic disease is often discovered in AOC. However, pre-operative assessment with CT imaging is not reliable in accurately detecting diaphragm involvement. Therefore, all patients with AOC should be regarded as in potential need for diaphragm surgery and their operation undertaken in cancer centres with adequate expertise in upper abdominal surgery. If there is a suspicion of diaphragm muscle invasion during diaphragmatic peritonectomy, the muscle should be partially resected. This will lead to potential upstaging of disease to stage 4A and therefore, to suitability for targeted therapy. In our Centre, the surgical removal of diaphragmatic disease did not significantly increase surgical morbidity.
确定在接受手术治疗的晚期卵巢癌（AOC）病例中，术前通过CT成像识别转移性膈肌疾病的阳性预测值。此外，我们评估了英国一家大型地区癌症中心在进行膈肌手术干预后的术后发病率和生存率。
对2007年8月1日至2016年2月29日期间在英国伯明翰妇科癌症中心接受手术治疗的所有伴有转移性膈肌疾病的AOC病例进行回顾性研究。
共有536名女性接受了原发性AOC手术。术中发现215/536（40.1%）存在膈肌疾病，85/536名女性（15.9%）接受了涉及膈肌的手术。在这85例病例中，进行了38例腹膜剥脱术（38/85，44.7%）、31例部分膈肌切除术（31/85，35.6%）和16例电外科消融术（16/85，18.9%）。三个不同膈肌手术组之间的术后并发症无显著差异。在接受腹膜剥脱术或部分膈肌切除术的患者中，12%因胸膜侵犯而被上调至4A期。术前影像学识别膈肌疾病的阳性预测值为78.6%。在29.4%的病例中，尽管术中膈肌疾病明显，但CT成像未能检测到膈肌受累，阴性预测值低至64.8%。CT成像检测膈肌疾病的敏感性和特异性分别为44.3%和93.8%。
AOC患者常发现膈肌疾病。然而，术前通过CT成像评估在准确检测膈肌受累方面并不可靠。因此所有AOC患者都应被视为可能需要进行膈肌手术，手术应在具备足够上腹部手术专业知识的癌症中心进行。如果在膈肌腹膜切除术中怀疑膈肌肌肉受侵，应部分切除肌肉。这可能会导致疾病上调至4A期，从而适合进行靶向治疗。在我们中心，手术切除膈肌疾病并未显著增加手术发病率。
