Objective: Diaphragmatic resection is frequently required to achieve optimal cytoreduction with no residual disease in patients with advanced ovarian cancer. Pleural effusion and pneumothorax are known short-term postoperative complications of diaphragmatic resection; however, few studies have reported intraoperative and long-term postoperative complications of this procedure. We investigated the intraoperative, as well as short- and long-term postoperative complications of diaphragmatic resection. Methods: Of the patients with stage III/IV ovarian cancer, who were initially treated at our hospital between 2008 and 2020, 267 patients who underwent diaphragmatic resection were included in this study. We recorded details regarding the type of diaphragmatic resection, type of closure, and intraoperative, as well as short- and long-term postoperative complications. Results: Of the 264 patients who underwent right-sided diaphragmatic resection, 235 underwent full-thickness resection and 29 underwent peritoneal stripping. Of the 118 patients who underwent left-sided diaphragmatic resection, 23 underwent full-thickness resection and 95 underwent peritoneal stripping. Intraoperative complications occurred in 5 patients (massive bleeding from the right hepatic vein [n=1], massive bleeding during excision of the liver adherent to the diaphragm [n=1], and lung injury [n=3]). Short-term complications included pleural effusion that necessitated drainage in 2 and pneumothorax after drain removal in 1 patient. Long-term complications included right diaphragmatic hernia in 1, left diaphragmatic hernia in 2, and pancreaticopleural fistula in 1 patient. Conclusion Diaphragmatic resection was associated with a low incidence of intra- and postoperative complications, which highlights the safety of this approach for management of advanced ovarian cancer.

Objective: Splenectomy with or without distal pancreatectomy is occasionally performed during cytoreductive surgery for advanced ovarian cancer. We investigated pre-, intra-, postoperative risk factors and predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) in patients who underwent cytoreductive surgery for advanced ovarian cancer. Methods: We investigated 165 consecutive patients with ovarian, fallopian tube, and peritoneal carcinoma categorized as stage III/IV disease, who underwent splenectomy with or without distal pancreatectomy as a component of cytoreductive surgery performed as initial treatment at Chiba University Hospital. Patient characteristics, clinical factors, and surgical outcomes were compared between those with and without CR-POPF. Results: CR-POPF occurred in 20 patients (12%). There were no significant intergroup differences in the characteristics between patients with CR-POPF and patients without CR-POPF except for operative time, intraoperative blood loss, amylase (AMY) levels in drain fluid on postoperative day (POD)1 and POD3, and pancreatic stump thickness. Multivariate analysis showed that the POD3 drain fluid AMY level was the only significant risk factor and predictor of CR-POPF in patients who underwent cytoreductive surgery for advanced ovarian cancer. The receiver operating characteristic curve of the POD3 drain fluid AMY level, which predicted development of CR-POPF showed an area under the curve of 0.77, and the optimal cut-off value of AMY was 808 U/L. A pancreatic fistula did not occur in patients with POD3 drain fluid AMY levels <130 U/L. Conclusion The POD3 drain fluid AMY level can be early diagnostic predictor CR-POPF after splenectomy with or without distal pancreatectomy for advanced ovarian cancer.

Objective: We investigated the efficacy and toxicity of tailored-dose chemotherapy with gemcitabine and irinotecan for platinum-refractory/resistant ovarian or primary peritoneal cancer. Methods: We enrolled patients with ovarian or primary peritoneal cancer who received ≥2 previous chemotherapeutic regimens but developed progressive disease during platinumbased chemotherapy or within 6 months post-treatment. All patients received gemcitabine (500 mg/m 2 ) and irinotecan (50 mg/m 2 ) on days 1 and 8 every 21 days at the starting dose. The dose was increased or decreased by 4 levels in subsequent cycles based on hematological or non-hematological toxicities observed. The primary endpoint was progression-free survival (PFS), and secondary endpoints were disease control rate (DCR), overall survival (OS), and adverse events. Results: We investigated 25 patients who received 267 cycles (median 8 cycles/patient) between October 2008 and May 2011. Tailored-dose gemcitabine was administered up to the 5th cycle as follows: 1,000 mg/m 2 in 1 (4%), 750 mg/m 2 in 16 (64%), 500 mg/m 2 in 6 (24%), and 250 mg/m 2 in 2 patients (8%). The median PFS and OS were 6.2 months (95% confidence interval [CI]=2.7–10.7) and 16.8 months (95% CI=9.4–30.7), respectively. The DCR was 76%, and PFS was >6 months in 12 of 25 patients (48%). Grade 3 hematological toxicities included leukopenia (9.4%), neutropenia (11.2%), anemia (9.8%), and thrombocytopenia (1.1%).Grade 3/4 non-hematological toxicities did not occur except for fatigue in one patient. Conclusions Tailored-dose chemotherapy with gemcitabine and irinotecan was effective and well tolerated in patients with platinum-refractory/resistant ovarian or primary peritoneal cancer.