Journal List > J Gynecol Oncol > v.31(2) > 1148327

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

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.

References

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Fig. 1.
Type I diaphragmatic surgery according to Tozzi classification, initial finding (A) and final outcome (B).
jgo-31-e14f1.tif
Fig. 2.
Type II diaphragmatic surgery according to Tozzi classification, initial finding (A) and open diaphragm (B).
jgo-31-e14f2.tif
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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