Transdiaphragmatic cardiophrenic lymph node resection for Stage IV ovarian cancer

Objective: For Stage IV epithelial ovarian cancer, the extent of surgical debulking is one of the main prognostic factors under the control of the surgeon. For this group of patients, no gross residual disease is associated with the most favorable progression-free survival and overall survival [1]. One of the most commonly cited factors precluding the obtainment of zero visible disease is bulky upper abdominal disease [2]. Previously, we described a surgical technique used to perform full-thickness diaphragm resection and cardiophrenic lymph node dissection [3]. This video displays this technique in one of our recent patients. Methods: The patient was a 57-year-old female with a CA-125 of 2675 and a pre-operative CT scan showing a 10 cm adnexal mass, ascites, carcinomatosis, and 1.6 cm right cardiophrenic lymph node without pleural effusion. Primary cytoreductive surgery was undertaken with exploratory laparotomy, type 2 radical oophorectomy (en bloc modified radical abdominal hysterectomy, bilateral salpingo-oophorectomy, pan-pelvic peritonectomy, rectosigmoid colectomy), left hemicolectomy with en bloc omentectomy, splenectomy, distal pancreatectomy, right diaphragm peritonectomy and full-thickness resection with transdiaphragmatic resection of right cardiophrenic lymph nodes, and primary closure of diaphragmatic defect with placement of right thoracostomy tube. Results: The operative time was 464 min with an estimated blood loss of 800 ml. The patient was discharged home on postoperative day 8 in stable condition and initiated systemic chemotherapy on postoperative day 21. Conclusion: Transdiaphragmatic resection of cardiophrenic lymph nodes is a feasible surgical technique to achieve complete cytoreduction in carefully selected cases of Stage IV ovarian cancer.