Intraoperative Ultrasound-Guided Excision of Cardiophrenic Lymph Nodes in an Advanced Ovarian Cancer Patient.

Abstract

Ovarian cancer is commonly diagnosed at an advanced stage. Complete macroscopic eradication of the disease is associated with improved prognosis. In this setting, the surgical resection of enlarged cardiophrenic lymph nodes (CPLNs) can help to achieve cytoreduction to no gross residual disease. During surgery, CPLN removal is usually performed either via video-assisted thoracic surgery or through a large transdiaphragmatic or subxiphoid incision. In the present case, we propose the use of an intraoperative transdiaphragmatic ultrasound to confirm preoperative imaging and to obtain a precise localization of the suspicious CPLNs. A 50-year-old woman without peritoneal carcinomatosis was diagnosed with bilateral ovarian cancer and enlarged inguinal, pelvic, aortic, and cardiophrenic nodes. She underwent primary debulking surgery, including radical hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal biopsies, and bulky nodes resection, at the iliac, inguinal, and lumboaortic regions. After obtaining complete abdominal cytoreduction, an intraoperative ultrasound scan was performed. Two enlarged CPLNs were ultrasonographically visualized using a convex contact probe through a transhepatic window, and their exact location was identified. After complete mobilization of the right liver, the right diaphragm was incised, proximal to the site of the lymphadenopathies. The 2 lymph nodes were identified, grasped, and removed by transdiaphragmatic approach. Absence of other residual disease was confirmed by thoracic inspection, palpation, and by a subsequent intraoperative ultrasound control. At final histology, CPLNs were positive for infiltration of high-grade serous ovarian carcinoma. Intraoperative transdiaphragmatic ultrasound represents a possible approach to localize suspicious CPLNs and to guide their surgical eradication.