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Cytoreduction of diaphragmatic metastases using the Cavitron Ultrasonic Surgical Aspirator
GYNECOLOGIC
ONCOLOGY
41, 220-222
(1991)
Cytoreduction of Diaphragmatic Metastases Using the Cavitron Ultrasonic Surgical Aspirator MARK D. ADELSON, M.D. Division
of Gynecologic
Oncology,
Department of Obstetrics Crouse Irving Memorial Received
and Gynecology, State University of New Hospital, Syracuse, New York 13210 December
Health
Science
Center
and
10, 1990
sented in 1987 [9], and the preliminary experience was first published in 1988 by Adelson et al. [lo]. This prospective evaluation of cytoreduction of diaphragm metastases was conducted as part of a larger evaluation of the use of the Cavitron in gynecology. The purpose was to evaluate the completion and safety of cytoreduction of diaphragm disease.
The Cavitron Ultrasonic Surgical Aspirator was used to reduce the volume of diaphragmatic metastases in 33 patients. Thirty patients had epithelial carcinoma of the ovary and one each had tubal adenocarcinoma, papillary peritoneal tumor, and mesothelioma. Twenty-seven patients had Stage IIIC disease, and six had Stage IV. Initially, 13 patients had diaphragmatic disease greater than 15 mm diameter (of any single nodule), and 2 had disease 6-15 mm diameter. After cytoreduction using standard means, 11 patients had disease greater than 15 mm diameter and 2 patients had disease from 6 to 15 mm in greatest diameter. After using the Cavitron, 1 patient had no gross diaphragmatic residual disease+ and 30 patients had disease l-5 mm diameter. No complication resulted from the cytoreduction of diaphragm disease using the Cavitron. The Cavitron Ultrasonic Surgical Aspirator is invaluable to obtain minimal residual disease of diaphragmatic metastases. o 1%~ Academic press, IN.
MATERIALS
AND METHODS
From September 1986 to August 1990, 33 patients with intraperitoneal malignancy and metastases to the diaphragm underwent primary surgical cytoreduction. The goal of the cytoreduction was to reduce all tumor masses to less than 6 mm greatest diameter (defined as optimal residual disease). Standard techniques were first employed, which included manual blunt removal of tumor and sharp knife and cautery excision. All patients were operated upon using a midline incision, extended to the xyphoid process if needed for exposure of the diaphragm. Cytoreduction of difficult sites, such as the diaphragm, was performed last, after completion of cytoreduction in the rest of the peritoneal cavity, using standard techniques. Further access to the diaphragm was obtained by mobilizing the liver dorsally, by resecting the falciform, triangular, and coronary ligaments, as needed. To shorten the length of the procedure, the Cavitron was used at full power. A dragging technique, moving the handpiece tip in a plane parallel to the surface of the diaphragm, provides the greatest security against fullthickness injury to the diaphragm. Muscle fiber bundles can be seen as tumor is removed. Very fibrotic tumors, and tumors invading the muscle which are subperitoneal, must be approached using a thrusting motion, moving the handpiece in a plane perpendicular to the surface of the
INTRODtiCTION Cytoreduction plays an important role in the treatment of ovarian cancer [l]. Because most patients present with extensive disease, complete cytoreduction is not always accomplished using standard techniques [2,3]. Cancer in certain upper abdominal sites, such as the diaphragm, has often been considered unresectable [ 1,3]. The Cavitron Ultrasonic Surgical Aspirator was introduced in 1967 for the phacoemulsification of cataracts [4], and a more powerful version was approved for use in neurosurgery in 1976 [5]. Demonstrated advantages of using this technique, compared with cold knife or cautery resection, include reduced blood loss, reduced tissue injury, and improved visibility. The majority of published experience has been with hepatic, splenic, and renal resection [6-S]. Use of the Cavitron for cytoreduction of gynecologic intraperitoneal malignancy was first pre220 0090-8258/91 $1.50 Copyright 0 1991 by Academic Press, Inc. All rights of reproduction in any form reserved.
York
ULTRASONIC TABLE
ASPIRATION
OF DIAPHRAGMATIC
1
Largest Diaphragmatic Tumor Diameter by Stage of Surgery (N = 33) Stage of surgery (No. of patients) Tumor diameter (mm)
Initial findings
Before Cavitron
After Cavitron
0 l-5 6-15 >15
0 18 2 13
0 20 2 11
1 30 1 1
diaphragm. Alternatively, the peritoneum and fibrous tissue can be opened sharply or using cautery, to gain access to the tumor. Hemostasis was obtained using cautery coagulation. RESULTS Thirty of thirty-three patients had adenocarcinoma of the ovary. One patient each had adenocarcinoma of the fallopian tube, papillary peritoneal tumor, and peritoneal mesothelioma. Twenty-seven patients had Stage IIIC disease, and six had Stage IV disease. Forty-five percent of these patients had diaphragmatic disease greater than 5 mm (suboptimal) as the initial finding at exploration, and in 87% of this group the diaphragmatic disease was greater than 15 mm (Table 1). The maximal disease diameter ranged from 1 to 300 mm. After applying standard techniques and before using the Cavitron, 39% still had suboptimal diaphragmatic disease, most of which (85?’o) was greater than 15 mm diameter. After using the Cavitron, optimal cytoreduction to less than 6 mm residual was achieved in 94% of cases. Only one patient (3% of all patients) had diaphragmatic disease greater than 15 mm (100 mm residual). The mean residual disease diameter at the end of operation was 5 mm (2 mm after excluding the outlying value of 100 mm). No complications attributable to diaphragmatic cytoreduction were seen. No patient developed pneumothorax or interference with diaphragmatic function. DISCUSSION The technique of cytoreduction using the Cavitron Ultrasonic Surgical Aspirator permits completion of the cytoreduction of diaphragmatic disease in a greater proportion of patients, compared with using standard to techniques alone. It also facilitates cytoreduction smaller residual disease diameter than is feasible without use of the Cavitron. Of 33 patients treated, 97% had residual diaphragmatic disease less than 16 mm, and 94%
METASTASES
221
had residual less than 6 mm. Considering all sites of abdominal disease, optimal cytoreduction (~16 mm residual) was achieved in 94% of patients, and 91% had residual less than 6 mm. The literature supports that only 40-70% of patients presenting with extensive disease can be cytoreduced to less than 16 mm [l,ll], and only in 15-56% can cytoreduction to less than 6 mm be achieved [1,12,13]. Few studies and a small number of patients with diaphragmatic disease have been reported. Two reports gave no initial or residual size measurements [14,15]. Patsner reported only 3 patients with bulky diaphragmatic disease ablated with the CO* laser [16]. Fiorica et al. [17] and Montz et al. [18] reported a total of 16 patients with diaphragmatic disease, initially greater than 5 mm, resected sharply. The reported complication rate from this technique was high, as was operative time and blood loss. In 6 patients the pleural space was entered, in 2 the mediastinum was entered, an additional patient had a postoperative pneumothorax, and the procedure had to be terminated prior to completion in 1 patient, because of excessive bleeding. Optimal cytoreduction is essential, since response to chemotherapy and survival is proportional to residual disease diameter [ 11. The definition of optimal is often stated as less than 15 or 20 mm, but survival has been shown to improve as residual disease decreases below this level, approaching zero [1,3,12,13]. In addition to being a predictor of survival after standard intravenous cytotoxic therapy, cytoreduction below 6 mm is crucial for the success of other therapies, such as intraperitoneal immunoand chemotherapy and abdominal radiation therapy [19,20]. The high rate of optimal cytoreduction to minimal residual disease in this study resulted from the selective action of the Cavitron. This instrument acts as an acoustic vibrator and selectively fragments and aspirates tissue of high water and low collagen content (i.e., tumor). Tissues with a high collagen content, such as blood vessels, peritoneum, and muscle, can be spared [7,8]. Selective removal of numerous small tumor nodules and debulking of large nodules can be performed without undue injury to surrounding structures. The irrigation and aspiration functions of the instrument preserve visual control during the cytoreduction, and unlike cautery or laser techniques, tactile feedback is preserved, increasing the safety and operator control. Selective and complete cytoreduction of diaphragmatic metastases can be performed with the Cavitron. Adherence to proper technique should ensure minimal morbidity, as compared to other techniques. Use of this technique, by virtue of the increased rate of complete cytoreduction possible, may improve response to therapy and may improve survival.
222
MARK
D. ADELSON
REFERENCES 1. Hacker, N. F., Berek, J. S., and Lagasse, L. D. Primary cytoreductive surgery for epithelial ovarian cancer, O&et. Gynecol. 61, 413 (1983). 2. Eddy, G. L., Copeland, L. J., and Gershenson, D. M. Fallopian tube carcinoma, Obstet. Gynecol. 64, 546 (1984). 3. Richardson, G. S., Scully, R. E., and Nikrui, N. Common epithelial cancer of the ovary, N. Engl. J. Med. 312, 415 (1985). 4. Kelman, C. D. Phaco-emulsion and aspiration: A report of 500 consecutive cases, Am. J. Ophthalmol. 75, 764 (1973). 5. Fasano, V. A., Zeme, S., and Frego, L. Ultrasonic aspiration in the surgical treatment of intracranial tumors, J. Neurosurg. Sci. 25, 35 (1981). 6. Andrus, C. H., and Kaminski, D. L. Segmental hepatic resection utilizing the ultrasonic dissector, Arch. Surg. 121, 515 (1986). 7. Chopp, R. T., Shah, B. B., and Addonizio, J. C. Use of ultrasonic surgical aspirator in renal surgery, Urology 77, 157 (1983). 8. Hodgson, W. J., and McElhinney, A. J. Ultrasonic partial splenectomy, Surgery 91, 346 (1982). 9. Adelson, M. D., and Thompson, M. A. The Cavitron Ultrasonic Surgical Aspirator for cytoreduction of ovarian cancer, presented at the Felix Rutledge Society, University of Texas, Houston, May 8, 1987. 10. Adelson, M. D., Baggish, M. S., Seifer, D. B., Cassel, S. L., and Thompson, M. A. Cytoreduction of ovarian cancer with the Cavitron ultrasonic surgical aspirator, Obstet. Gynecof. 72, 140-143 (1988). 11. Piver, M. S. Cytoreductive surgery in gynecologic malignancies, ht. Adv. Surg. Oncol. 6, 65 (1983).
12. Griffiths, C. T. Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma, Natl. Cancer Inst. Monogr. 42,101 (1975). 13. Heintz, A. P., Hacker, N. F., and Berek, J. S. Cytoreductive surgery in ovarian carcinoma: Feasibility and morbidity, Obstet. Gynecol. 67, 783 (1986). 14. Deppe, G., Malviya, V. K., Boike, G., and Hampton, A. Surgical approach to diaphragmatic metastases from ovarian cancer, Gynecol. Oncol. 24, 2.58260 (1986). 15. Deppe, G., Malviya, V. K., Boike, G., and Malone, J. M. Jr. Use of cavitron surgical aspirator for debulking of diaphragmatic metastases in patients with advanced carcinoma of the ovaries, Surg. Gynecol. Obstet. 168, 455-456 (1989). 16. Patsner, B. Carbon dioxide laser vaporization of diaphragmatic metastases for cytoreduction of ovarian epithelial cancer, Obstet. Gynecol. 76, 724-727 (1990). 17. Fiorica, J. V., Hoffman, M. S., LaPolla, J. P., Roberts, W. S., and Cavanagh, D. The management of diaphragmatic lesions in ovarian carcinoma, Obstet. Gynecol. 74, 927-929 (1989). 18. Montz, F. J., Schlerth, J. B., and Berek, J. S. Resection of diaphragmatic peritoneum and muscle: Role in cytoreductive surgery for ovarian cancer, Gynecol. Oncol. 35, 338-340 (1989). 19. Berek, J. S., Hacker, N. F., and Lichtenstein, A. Intraperitoneal recombinant alpha interferon for “salvage” immunotherapy in stage III epithelial ovarian cancer: A Gynecologic Oncology Group study, Cancer Res. 45, 4447 (1985). 20. Peters, W. A., Blasko, J. C., and Bahgley, C. M. Salvage therapy with whole-abdominal irradiation in patients with advanced carcinoma of the ovary previously treated by combination chemotherapy, Cancer 58, 880 (1986).
ONCOLOGY
41, 220-222
(1991)
Cytoreduction of Diaphragmatic Metastases Using the Cavitron Ultrasonic Surgical Aspirator MARK D. ADELSON, M.D. Division
of Gynecologic
Oncology,
Department of Obstetrics Crouse Irving Memorial Received
and Gynecology, State University of New Hospital, Syracuse, New York 13210 December
Health
Science
Center
and
10, 1990
sented in 1987 [9], and the preliminary experience was first published in 1988 by Adelson et al. [lo]. This prospective evaluation of cytoreduction of diaphragm metastases was conducted as part of a larger evaluation of the use of the Cavitron in gynecology. The purpose was to evaluate the completion and safety of cytoreduction of diaphragm disease.
The Cavitron Ultrasonic Surgical Aspirator was used to reduce the volume of diaphragmatic metastases in 33 patients. Thirty patients had epithelial carcinoma of the ovary and one each had tubal adenocarcinoma, papillary peritoneal tumor, and mesothelioma. Twenty-seven patients had Stage IIIC disease, and six had Stage IV. Initially, 13 patients had diaphragmatic disease greater than 15 mm diameter (of any single nodule), and 2 had disease 6-15 mm diameter. After cytoreduction using standard means, 11 patients had disease greater than 15 mm diameter and 2 patients had disease from 6 to 15 mm in greatest diameter. After using the Cavitron, 1 patient had no gross diaphragmatic residual disease+ and 30 patients had disease l-5 mm diameter. No complication resulted from the cytoreduction of diaphragm disease using the Cavitron. The Cavitron Ultrasonic Surgical Aspirator is invaluable to obtain minimal residual disease of diaphragmatic metastases. o 1%~ Academic press, IN.
MATERIALS
AND METHODS
From September 1986 to August 1990, 33 patients with intraperitoneal malignancy and metastases to the diaphragm underwent primary surgical cytoreduction. The goal of the cytoreduction was to reduce all tumor masses to less than 6 mm greatest diameter (defined as optimal residual disease). Standard techniques were first employed, which included manual blunt removal of tumor and sharp knife and cautery excision. All patients were operated upon using a midline incision, extended to the xyphoid process if needed for exposure of the diaphragm. Cytoreduction of difficult sites, such as the diaphragm, was performed last, after completion of cytoreduction in the rest of the peritoneal cavity, using standard techniques. Further access to the diaphragm was obtained by mobilizing the liver dorsally, by resecting the falciform, triangular, and coronary ligaments, as needed. To shorten the length of the procedure, the Cavitron was used at full power. A dragging technique, moving the handpiece tip in a plane parallel to the surface of the diaphragm, provides the greatest security against fullthickness injury to the diaphragm. Muscle fiber bundles can be seen as tumor is removed. Very fibrotic tumors, and tumors invading the muscle which are subperitoneal, must be approached using a thrusting motion, moving the handpiece in a plane perpendicular to the surface of the
INTRODtiCTION Cytoreduction plays an important role in the treatment of ovarian cancer [l]. Because most patients present with extensive disease, complete cytoreduction is not always accomplished using standard techniques [2,3]. Cancer in certain upper abdominal sites, such as the diaphragm, has often been considered unresectable [ 1,3]. The Cavitron Ultrasonic Surgical Aspirator was introduced in 1967 for the phacoemulsification of cataracts [4], and a more powerful version was approved for use in neurosurgery in 1976 [5]. Demonstrated advantages of using this technique, compared with cold knife or cautery resection, include reduced blood loss, reduced tissue injury, and improved visibility. The majority of published experience has been with hepatic, splenic, and renal resection [6-S]. Use of the Cavitron for cytoreduction of gynecologic intraperitoneal malignancy was first pre220 0090-8258/91 $1.50 Copyright 0 1991 by Academic Press, Inc. All rights of reproduction in any form reserved.
York
ULTRASONIC TABLE
ASPIRATION
OF DIAPHRAGMATIC
1
Largest Diaphragmatic Tumor Diameter by Stage of Surgery (N = 33) Stage of surgery (No. of patients) Tumor diameter (mm)
Initial findings
Before Cavitron
After Cavitron
0 l-5 6-15 >15
0 18 2 13
0 20 2 11
1 30 1 1
diaphragm. Alternatively, the peritoneum and fibrous tissue can be opened sharply or using cautery, to gain access to the tumor. Hemostasis was obtained using cautery coagulation. RESULTS Thirty of thirty-three patients had adenocarcinoma of the ovary. One patient each had adenocarcinoma of the fallopian tube, papillary peritoneal tumor, and peritoneal mesothelioma. Twenty-seven patients had Stage IIIC disease, and six had Stage IV disease. Forty-five percent of these patients had diaphragmatic disease greater than 5 mm (suboptimal) as the initial finding at exploration, and in 87% of this group the diaphragmatic disease was greater than 15 mm (Table 1). The maximal disease diameter ranged from 1 to 300 mm. After applying standard techniques and before using the Cavitron, 39% still had suboptimal diaphragmatic disease, most of which (85?’o) was greater than 15 mm diameter. After using the Cavitron, optimal cytoreduction to less than 6 mm residual was achieved in 94% of cases. Only one patient (3% of all patients) had diaphragmatic disease greater than 15 mm (100 mm residual). The mean residual disease diameter at the end of operation was 5 mm (2 mm after excluding the outlying value of 100 mm). No complications attributable to diaphragmatic cytoreduction were seen. No patient developed pneumothorax or interference with diaphragmatic function. DISCUSSION The technique of cytoreduction using the Cavitron Ultrasonic Surgical Aspirator permits completion of the cytoreduction of diaphragmatic disease in a greater proportion of patients, compared with using standard to techniques alone. It also facilitates cytoreduction smaller residual disease diameter than is feasible without use of the Cavitron. Of 33 patients treated, 97% had residual diaphragmatic disease less than 16 mm, and 94%
METASTASES
221
had residual less than 6 mm. Considering all sites of abdominal disease, optimal cytoreduction (~16 mm residual) was achieved in 94% of patients, and 91% had residual less than 6 mm. The literature supports that only 40-70% of patients presenting with extensive disease can be cytoreduced to less than 16 mm [l,ll], and only in 15-56% can cytoreduction to less than 6 mm be achieved [1,12,13]. Few studies and a small number of patients with diaphragmatic disease have been reported. Two reports gave no initial or residual size measurements [14,15]. Patsner reported only 3 patients with bulky diaphragmatic disease ablated with the CO* laser [16]. Fiorica et al. [17] and Montz et al. [18] reported a total of 16 patients with diaphragmatic disease, initially greater than 5 mm, resected sharply. The reported complication rate from this technique was high, as was operative time and blood loss. In 6 patients the pleural space was entered, in 2 the mediastinum was entered, an additional patient had a postoperative pneumothorax, and the procedure had to be terminated prior to completion in 1 patient, because of excessive bleeding. Optimal cytoreduction is essential, since response to chemotherapy and survival is proportional to residual disease diameter [ 11. The definition of optimal is often stated as less than 15 or 20 mm, but survival has been shown to improve as residual disease decreases below this level, approaching zero [1,3,12,13]. In addition to being a predictor of survival after standard intravenous cytotoxic therapy, cytoreduction below 6 mm is crucial for the success of other therapies, such as intraperitoneal immunoand chemotherapy and abdominal radiation therapy [19,20]. The high rate of optimal cytoreduction to minimal residual disease in this study resulted from the selective action of the Cavitron. This instrument acts as an acoustic vibrator and selectively fragments and aspirates tissue of high water and low collagen content (i.e., tumor). Tissues with a high collagen content, such as blood vessels, peritoneum, and muscle, can be spared [7,8]. Selective removal of numerous small tumor nodules and debulking of large nodules can be performed without undue injury to surrounding structures. The irrigation and aspiration functions of the instrument preserve visual control during the cytoreduction, and unlike cautery or laser techniques, tactile feedback is preserved, increasing the safety and operator control. Selective and complete cytoreduction of diaphragmatic metastases can be performed with the Cavitron. Adherence to proper technique should ensure minimal morbidity, as compared to other techniques. Use of this technique, by virtue of the increased rate of complete cytoreduction possible, may improve response to therapy and may improve survival.
222
MARK
D. ADELSON
REFERENCES 1. Hacker, N. F., Berek, J. S., and Lagasse, L. D. Primary cytoreductive surgery for epithelial ovarian cancer, O&et. Gynecol. 61, 413 (1983). 2. Eddy, G. L., Copeland, L. J., and Gershenson, D. M. Fallopian tube carcinoma, Obstet. Gynecol. 64, 546 (1984). 3. Richardson, G. S., Scully, R. E., and Nikrui, N. Common epithelial cancer of the ovary, N. Engl. J. Med. 312, 415 (1985). 4. Kelman, C. D. Phaco-emulsion and aspiration: A report of 500 consecutive cases, Am. J. Ophthalmol. 75, 764 (1973). 5. Fasano, V. A., Zeme, S., and Frego, L. Ultrasonic aspiration in the surgical treatment of intracranial tumors, J. Neurosurg. Sci. 25, 35 (1981). 6. Andrus, C. H., and Kaminski, D. L. Segmental hepatic resection utilizing the ultrasonic dissector, Arch. Surg. 121, 515 (1986). 7. Chopp, R. T., Shah, B. B., and Addonizio, J. C. Use of ultrasonic surgical aspirator in renal surgery, Urology 77, 157 (1983). 8. Hodgson, W. J., and McElhinney, A. J. Ultrasonic partial splenectomy, Surgery 91, 346 (1982). 9. Adelson, M. D., and Thompson, M. A. The Cavitron Ultrasonic Surgical Aspirator for cytoreduction of ovarian cancer, presented at the Felix Rutledge Society, University of Texas, Houston, May 8, 1987. 10. Adelson, M. D., Baggish, M. S., Seifer, D. B., Cassel, S. L., and Thompson, M. A. Cytoreduction of ovarian cancer with the Cavitron ultrasonic surgical aspirator, Obstet. Gynecof. 72, 140-143 (1988). 11. Piver, M. S. Cytoreductive surgery in gynecologic malignancies, ht. Adv. Surg. Oncol. 6, 65 (1983).
12. Griffiths, C. T. Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma, Natl. Cancer Inst. Monogr. 42,101 (1975). 13. Heintz, A. P., Hacker, N. F., and Berek, J. S. Cytoreductive surgery in ovarian carcinoma: Feasibility and morbidity, Obstet. Gynecol. 67, 783 (1986). 14. Deppe, G., Malviya, V. K., Boike, G., and Hampton, A. Surgical approach to diaphragmatic metastases from ovarian cancer, Gynecol. Oncol. 24, 2.58260 (1986). 15. Deppe, G., Malviya, V. K., Boike, G., and Malone, J. M. Jr. Use of cavitron surgical aspirator for debulking of diaphragmatic metastases in patients with advanced carcinoma of the ovaries, Surg. Gynecol. Obstet. 168, 455-456 (1989). 16. Patsner, B. Carbon dioxide laser vaporization of diaphragmatic metastases for cytoreduction of ovarian epithelial cancer, Obstet. Gynecol. 76, 724-727 (1990). 17. Fiorica, J. V., Hoffman, M. S., LaPolla, J. P., Roberts, W. S., and Cavanagh, D. The management of diaphragmatic lesions in ovarian carcinoma, Obstet. Gynecol. 74, 927-929 (1989). 18. Montz, F. J., Schlerth, J. B., and Berek, J. S. Resection of diaphragmatic peritoneum and muscle: Role in cytoreductive surgery for ovarian cancer, Gynecol. Oncol. 35, 338-340 (1989). 19. Berek, J. S., Hacker, N. F., and Lichtenstein, A. Intraperitoneal recombinant alpha interferon for “salvage” immunotherapy in stage III epithelial ovarian cancer: A Gynecologic Oncology Group study, Cancer Res. 45, 4447 (1985). 20. Peters, W. A., Blasko, J. C., and Bahgley, C. M. Salvage therapy with whole-abdominal irradiation in patients with advanced carcinoma of the ovary previously treated by combination chemotherapy, Cancer 58, 880 (1986).