Table 1.

Review of literature: CPLN in ovarian cancer

Studies	Patients (n)	Patients group	Objective	Result
Chi et al23	465	FIGO IIIC	Analyse survival rates at very specific residual disease diameters to determine the optimal goal of primary cytoreduction for bulky stage IIIC EOC	Amount of residual disease as a significant prognostic factor (P<0.001) Median overall survival in relation to the five residual disease categories was: no gross residual, 106 months; gross ≤0.5 cm, 66 months; 0.6–1.0 cm, 48 months; 1–2 cm, 33 months; >2 cm, 34 months. Removal of all evidence of macroscopic disease is associated with prolonged survival and should be the goal of primary cytoreductive surgery.
Bristow et al24	84	FIGO IV	Survival impact of surgical cytoreduction and of debulking extrahepatic disease in the subgroup of patients with liver metastasis	Median survival of optimally cytoreduced patients was 38.4 months compared with 10.3 months for patients with suboptimal residual disease. Optimal resection of both extrahepatic and hepatic disease had a median survival of 50.1 months, compared with a median survival of 27.0 months for the patients with optimal extrahepatic disease but suboptimal residual hepatic tumour.
Bristow et al25	81 cohorts, 6885	FIGO III and IV	Relative effect of per cent maximal cytoreductive surgery and other prognostic variables on survival	Each 10% increase in maximal cytoreduction was associated with a 5.5% increase in median survival time. When actuarial survival was estimated, cohorts with <25% or =25% maximal cytoreduction had a mean weighted median survival time of 22.7 months, whereas cohorts with more than 75% maximal cytoreduction had a mean weighted median survival time of 33.9 months—an increase of 50%.
Chang et al18	18 relevant studies, 13 257 patients	FIGO IV	To quantify the impact of complete cytoreduction to no gross residual disease on overall survival among patients with advanced-stage ovarian cancer	Each 10% increase in the proportion of patients undergoing complete cytoreduction to no gross residual disease was associated with a significant and independent 2.3-month increase (95% CI0.6 to4.0, P=0.011) in cohort median survival compared with a 1.8-month increase (95% CI 0.6 to 3.0, P=0.004) in cohort median survival for optimal cytoreduction (residual disease ≤1 cm).
Raban et al11	72	FIGO IIIC	Comparison between patients with CPLN at initial diagnosis and controls	CPLN were related with lower cytoreduction rate, shorter DFI and OS.
Holloway et al6	78	Recurrence	Detection of enlarged CPLN on CT scan	Enlarged CPLN detected in 28% cases. Detection is a significant adverse prognostic factor for OS and PFS.
Kolev et al14	212	FIGO III–IV	Retrospective revision of supradiaphragmatic LN and OS	Cut-off ≥5 mm largest axis 50-month median survival without adenopathy versus 45 months with adenopathy. All underwent attempted primary cytoreduction followed by systemic chemotherapy. None had any supradiaphragmatic nodes removed at primary cytoreduction.
Prader et al9	196	FIGO IIIC-IVB	Surgical management of CPLN	Cut-off ≥10 mm shortest axis 90% histologically positive Transdiaphragmatic excision of CPLN is a feasible part of cytoreductive surgery.
Kim et al29	31	FIGO IV	Whether the preoperative diameter of CPLN along the short and long axes, determined via CT scan predicts CPLN metastasis in patients with advanced epithelial ovarian cancer.	The probability of detecting CPLN metastasis in patients with advanced ovarian cancer was approximately 85% when the short axis of the CPLN was >7 mm in preoperative CT scans. Patients with CPLNs of this size may be candidates for CPLN dissection to confirm the pathological diagnosis.
Perri et al27	218	FIGO IIIC-IV	Rates of optimal abdominopelvic cytoreduction and the sites of recurrence Potential impact of thoracic cytoreduction on treatment results in patients with intrathoracic spread	Optimal abdominopelvic cytoreduction was achievable in stage IV patients, although in significantly fewer patients than in stage IIIC. Sites of recurrence were rarely thorax alone (6.8%). Thoracic debulking is likely to change the course of disease in only a few patients and thus should be carefully individualised.
Eisenkop 42	24	FIGO IIIC and IV	To determine possible benefits of thoracoscopy for the management of patients with advance epithelial ovarian cancer	The median and estimated 5-year survival for the entire cohort was 28.9 months and 42%, respectively. Log-rank analysis revealed the probability of survival to be improved by the performance of thoracoscopy (performed versus not performed, P=0.05). Permits complete cytoreduction for some patients who might otherwise have unrecognised macroscopic residual intrathoracic disease.
Yoo et al 32	11	FIGO IV	Feasibility of the transabdominal CPLN dissection via incised diaphragm in patients with ovarian cancer by gynaecological oncologists instead of the conventional VATS	Metastasis was identified in 45% (5/11) of ≥5 mm CPLN on preoperative CT. There was no significant morbidity related to CPLN dissection and mortality associated with surgery. Ten patients achieved the no gross residual disease and one patient accomplished gross residual 1 (residual disease measuring ≤1 cm in maximal diameter).
Garbi et al33	22	FIGO IVB	To define the safety and feasibility of surgical transdiaphragmatic resection of enlarged CPLN as a part of upfront debulking surgery	All patients who underwent CPLN resection had an extensive disease (median peritoneal cancer index, 18), and more than 77% required complex surgical procedures (complexity score, 3). No residual abdominal disease less than 5 mm at the end of surgery was described in 20 (90%) out of 22. Transdiaphragmatic enlarged CPLN resection seems to be safe and feasible procedure when indicated to achieve no or minimal tumour residual disease.
LaFargue et al30	11	FIGO IVB	To further define the preoperative, intraoperative and postoperative characteristics of patients undergoing transdiaphragmatic resection of CPLNs in advanced gynaecological cancer and delineate the associated short-term morbidities	Malignancy was identified in 86% of lymph node submitted. The overall postoperative morbidity associated with CPLN resection was low, with the most common finding being a small pleural effusion present on chest X-ray between POD 3 and 5 (55%). Transdiaphragmatic CPLN resection is a feasible procedure with relatively minor short-term postoperative morbidities that can be used to achieve cytoreduction to no gross residual disease.

Some part of this table is reproduced from Prader et al⁹ with permission from Elsevier.

CPLN, cardiophrenic lymph node; EOC, epithelial ovarian cancer; DFI, disease-free interval; OS, overall survival; PFS, progression-free survival; POD, postoperative day; VATS, video-assisted thoracic surgery.