Roberto Tozzi; Federico Ferrari; Joost Nieuwstad; Riccardo Garruto Campanile; Hooman Soleymani Majd

doi:10.3802/jgo.2020.31.e14

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Tozzi, Ferrari, Nieuwstad, Campanile, and Majd: Tozzi classification of diaphragmatic surgery in patients with stage IIIC–IV ovarian cancer based on surgical findings and complexity

Original Article

J Gynecol Oncol 2020;31(2):e14.

Published online: 4 March 2020

DOI: https://doi.org/10.3802/jgo.2020.31.e14

Tozzi classification of diaphragmatic surgery in patients with stage IIIC–IV ovarian cancer based on surgical findings and complexity

Roberto Tozzi, Federico Ferrari, Joost Nieuwstad, Riccardo Garruto Campanile, Hooman Soleymani Majd

Department of Gynaecologic Oncology, Oxford Cancer Centre, Churchill Oxford University Hospital, Oxford, United Kingdom

Correspondence to Roberto Tozzi Department of Gynaecologic Oncology, Oxford Cancer Centre, Churchill Oxford University Hospital, Old Road OX3 7LJ, Oxford, United Kingdom. E-mail: roberto.tozzi@obs-gyn.ox.ac.uk

Received 6 March 2019 Revised 12 June 2019 Accepted 18 August 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

To introduce a systematic classification of diaphragmatic surgery in patients with ovarian cancer based on disease spread and surgical complexity.

Methods

For all consecutive patients who underwent diaphragmatic surgery during Visceral-Peritoneal debulking (VPD) in the period 2009–2017, we extracted: initial surgical finding, extent of liver mobilization and type of procedure. Combining these features, we aimed to classify the surgical procedures necessary to tackle different presentation of diaphragmatic disease. We also report histology, intra- and post-operative specific complication rate based on the classification.

Results

A total of 170 patients were included in this study, 110 (64.7%) had a peritonectomy, while 60 (35.3%) had a full thickness resection with pleurectomy. We identified 3 types of surgical procedures. Type I treated 28 out of 170 patients (16.5%) who only had anterior diaphragm disease, needed no liver mobilization, included peritonectomy and had no morbidity recorded. Type II pertained to 105 out of 170 patients (61.7%) who had anterior and posterior disease, needed partial and sometimes full liver mobilization, had a mix of peritonectomy and full thickness resection, and experienced 10% specific morbidity. Type III included 37 out of 170 patients (21.7%) who needed full mobilization of the liver, always had full thickness resection, and suffered 30% specific morbidity.

Conclusion

Diaphragmatic surgery can be classified in 3 types. The adoption of this classification can facilitate standardization of the surgery, comparison of data and define the expertise required. Finally, this classification can be a benchmark to establish the training required to treat diaphragmatic disease.

Keywords: Diaphragm, Liver, Peritoneal Neoplasm/Surgery, Peritoneum/Surgery, Classification, Ovarian Cancer

References

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Fig. 1.

Type I diaphragmatic surgery according to Tozzi classification, initial finding (A) and final outcome (B).

Fig. 2.

Type II diaphragmatic surgery according to Tozzi classification, initial finding (A) and open diaphragm (B).

Table 1.

Inclusion and exclusion criteria for VPD

Inclusion criteria	Exclusion criteria
• Preoperative – Histology proven or suspected stage IIIC–IV ovarian cancer – Performance status (ECOG) <2- Post chemotherapy patients with stabile disease or response at 3 or 6 cycles	• Preoperative – CT scan showing presence of lung metastases, 3 or more liver segments involvement and/or disease progression on chemotherapy
	• Intraoperative – Explorative laparoscopy showing diffuse small bowel serosal deposit, porta hepatis encasement

CT, computed tomography; ECOG, Eastern Cooperative Oncology Group; VPD, Visceral-Peritoneal debulking.

Table 2.

Eleven steps of diaphragmatic surgery in patients with stage IIIC–IV ovarian cancer according to Tozzi classification

Step	Description	Type I	Type II	Type III
1	Resection of the falciform ligament 3–4 cm ventral to the out spring from the liver	R	R	R
2	Resection of the membranous part of the falciform ligament towards the insertion in the diaphragm	R	R	R
3	Resection of anterior part of the right coronary ligament until the suprarenal impression of the liver		R	R
4	Resection of the posterior part of the right coronary, right triangular and hepato-renal ligament		R	R
5	Resection of the dorsal ligament (hepato-caval) until the inset of the hepatic vein			R
6	Exposure of right and middle hepatic veins +/− encirclement with vessel loop			R
7	Marking the peritoneal disease below the ribs to start ventral peritonectomy	R	R	R
8	Marking the peritoneal disease from the upper part of the paracolic gutter and over the right kidney to start dorsal peritonectomy	R	R	R
9	Incision of the muscle tailored to the extent of the disease			R
10	Repair of the defect with or without a mesh, with a Foley catheter and a Valsalva manoeuvre to restore the negative pressure			R
11	Test to prove the integrity of the diaphragm			R

R, required; VPD, Visceral-Peritoneal debulking.

Table 3.

Patients and tumor characteristics in group 1 (primary VPD) and group 2 (neo-adjuvant VPD)

Characteristics	Group 1 (n=93)	Group 2 (n=77)	Total (n=170)	p-value (group 1 vs. group 2)
Age	63 (52–72)	66 (51–79)	65 (51–79)	–
Previous treatment			NA	–
None	93 (54.7)	–
Chemotherapy	–	77 (45.2)
FIGO stage
IIIC	68 (73.1)	65 (84.4)	133 (78.2)	0.86
IV	25 (26.9)	12 (15.6)	37 (21.8)	0.65
Histology type
HGSC	80 (86.2)	66 (85.7)	146 (85.8)	0.90
Others	13 (13.8)	11 (14.2)	24 (14.2)	0.91
Tumor grade
G1	7 (7.5)	5 (6.5)	12 (12.7)	0.88
G2	12 (12.9)	3 (3.9)	15 (5.3)	0.64
G3	74 (79.5)	69 (89.6)	143 (82)	0.72

Data are presented as number (range) or number (rate).

FIGO, International Federation of Gynecology and Obstetrics; HGSC, High Grade Serous Cancer; NA, not available; VPD, Visceral-Peritoneal debulking.

Table 4.

Tozzi classification of diaphragmatic surgery based on disease findings, liver mobilization and procedure with size of specimen and morbidity rate

Characteristics	Type I (n=28)	Type II (n=105)	Type III (n=37)	p-value
Disease findings	Anterior	Anterior/posterior	Anterior/posterior/abutting the hepatic veins	–
Liver mobilization	None	Partial without dorsal ligament	Full including dorsal ligament	–
Procedure	Peritonectomy P	Peritonectomy/resection	n Resection	–
Maximum size of the	11 (5–18)	19 (12–29)	23 (15–36)	0.05 (I vs. II)
specimen in cm				0.03 (I vs. III)
				0.52 (II vs. III)
Morbidity	–	9 (9.5)	11 (29.7)	0.02 (II vs. III)

Data are presented as number (range) or number (rate).

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