Cytoreductive surgery with hyperthermic thoracoabdominal chemotherapy in stage IV ovarian cancer - a technical description

Abstract

Systemic chemotherapy for peritoneal disease in ovarian carcinoma is associated with a recurrence rate of more than 75%, and most of the cases are confined to the peritoneal cavity. The propensity of locoregional treatment failure has paved the way for the discovery of cytoreductive surgery with intra-cavitary chemotherapy. Cytoreductive surgery (CRS) is the present-day treatment modality for a variety of peritoneal carcinomatosis including ovarian cancer, and multi-visceral resection is critical for completion of CRS. In cases of diaphragmatic infiltration by tumor deposits, partial resection leads to a diaphragmatic rent, which can be used for the perfusion of chemotherapeutic drugs into the pleural cavity. Disease transmission from the peritoneal to pleural cavity is a poor prognostic factor however. Hence, intrathoracic hyperthermic chemotherapy may be a reasonable treatment option for ovarian carcinoma with malignant pleural effusion or pleural deposits. Hyperthermic intraperitoneal chemotherapy (HIPEC) is added to the treatment plan in cases of complete CRS but this is a technically demanding procedure. Therefore, performing hyperthermic intrathoracic chemotherapy on top of CRS and HIPEC may be even more complicated for such advanced cancers. The technique of combining HIPEC and hyperthermic intrathoracic chemotherapy is also commonly known as hyperthermic thoracoabdominal chemotherapy (HITAC). The perioperative morbidity and mortality may be remarkably high in such scenarios. We describe our CRS technique with HITAC, which was performed in three FIGO stage IVA ovarian carcinoma patients with metastatic pleural effusion after complete CRS. The patients were retrospectively identified from a prospectively maintained database. All had partial diaphragmatic resection followed by HITAC as part of CRS treatment. Surgical techniques are outlined along with accompanying intra-operative images. Patient demographics, clinical and follow-up details were also described briefly. No comparative analysis with control patients was done. Adjustments in chemotherapy dose are not mandatory for HITAC. Of three patients, one had intrathoracic recurrence on follow-up; no mortality was recorded HITAC is a complex and potentially harmful procedure whose toxicity profile is still poorly known. Morbidity was not life-threatening and survival was acceptable.

Keywords

Hyperthermic intraperitoneal chemotherapy / hyperthermic intrathoracic chemotherapy / ovarian carcinoma / cytoreduction surgery / peritoneal carcinoma index

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