Histotopographical Features of the Diaphragm in Normal Conditions and with its Metastatic Lesions

The study of regional histotopographic features of the diaphragm in normal conditions and in various types of metastatic lesions is of practical importance in abdominal oncology when planning cytoreductive surgical interventions and diaphragmatic peritonectomy.

The aim was to study the histotopographic structure of the diaphragm in normal and peritoneal carcinomatosis.

Material and methods. 40 non-embalmed preparations of the cadaveric diaphragm were used to prepare histotopograms of their various parts. The surgical material of 77 patients who underwent cytoreductive intervention and diaphragmatic peritonectomy of various volumes was also studied and histological preparations were made. Regional histotopographic features of the diaphragm in normal and metastatic lesions were studied. A correlation analysis of the size of carcinomatous nodes and the depth of tumor invasion was carried out.

Results. It was found that the histotopographic structure in various parts of the diaphragm is normally specific and has a number of differences. Metastatic damage to the diaphragm in peritoneal carcinomatosis differs in size of tumor nodes, in depth of tumor invasion, and in combined lesion of adjacent anatomical structures. In most cases, the size of carcinomatous lesions directly correlated with the depth of tumor invasion, however, it was found that a number of large tumor nodes do not have such   a   depth   of   germination,   but   affect   only   the   superficial   layers of   the   diaphragm (peritoneum and  diaphragmatic fascia).

Conclusion. The results of studying the depth of tumor invasion, which is often associated with the size of carcinomatous nodes, can be implemented in clinical practice when planning cytoreductive surgical interventions and performing diaphragmatic peritonectomy.

1. Gantsev ShKh., Solomenny SV, Gantsev KSh, Kzyrgalin ShR, Minigazimov RS, Loginova MV. Assessment Of Serous Lymph Hatches In Peritoneal Carcinomatosis (Diaphragmatic Peritoneum) By Scanning Electron Microscopy. Creative surgery and oncology. 2021;11(2):149-156. (In Russ.)

2. Gantsev SK, Gantsev KS, Kzyrgalin SR, Ishmuratova KR. Peritoneal Canceromatosis in Malignant Tumors of Various Localizations. Achievements and Prospects. Creative surgery and oncology. 2021;11(2):149-156. (In Russ.) doi: 10.24060/2076-3093-2021-11-2-149-156

3. Craus-Miguel A, Segura-Sampedro JJ, González-Argenté X, Morales-Soriano R. Diaphragmatic Peritonectomy and Full-Thickness Resection in CRS/HIPEC May Allow Higher Completeness of Cytoreduction Rates with a Low Rate of Respiratory Complications. Ann Surg Oncol. 2021 Aug;28(8):4676–82. doi: 10.1245/s10434-020-09505-3. Epub 2021 Jan 6. PMID: 33409735.

4. Halkia E, Efstathiou E, Spiliotis J, Romanidis K, Salmas M. Management of diaphragmatic peritoneal carcinomatosis: surgical anatomy guidelines and results. J BUON. 2014 Jan-Mar;19(1):29-33. PMID: 24659639.

5. Ishii T, Seo S, Ito T, Ogiso S, Fukumitsu K, Taura K, Kaido T, Uemoto S. Structure and surgical dissection layers of the bare area of the liver. BMC Surg. 2020 Jul 31;20(1):172. doi: 10.1186/s12893-020-00830-8. PMID: 32736550; PMCID: PMC7393883.

6. Papadia A, Morotti M. Diaphragmatic surgery during cytoreduction for primary or recurrent epithelial ovarian cancer: a review of the literature. Arch Gynecol Obstet. 2013 Apr;287(4):733-41. doi: 10.1007/s00404-013-2715-1. Epub 2013 Jan 23. PMID: 23341061.

7. Stepanyan A, Zhirayr Malakyan, Alaverdyan A, Davtyan H, Hovhannisyan T. Right upper quadrant peritonectomy. Answering frequently asked questions. Int J Gynecol Cancer. 2021 Sep 1;31(9):1305–6. doi: 10.1136/ijgc-2021-002695

8. Tozzi R, Ferrari F, Joost Nieuwstad, Riccardo Garruto Campanile, Hooman Soleymani Majd. Tozzi classification of diaphragmatic surgery in patients with stage IIIC–IV ovarian cancer based on surgical findings and complexity. J Gynecol Oncol. 2020 Jan 1;31(2):2. doi: 10.3802/jgo.2020.31.e14

9. Zapardiel I, Peiretti M, Zanagnolo V, Biffi R, Bocciolone L, Landoni F, et al. Diaphragmatic Surgery During Primary Cytoreduction for Advanced Ovarian Cancer: Peritoneal Stripping Versus Diaphragmatic Resection. International Journal of Gynecologic Cancer. 2011 Nov;21(9):1698–703. Doi Nov;21(9):1698–703. doi: 10.1097/igc.0b013e31822f65c3