Impact and safety of pregnancy on desmoid fibromatosis management in the era of active surveillance. An international multicenter retrospective observational study

AIM

To evaluate desmoid fibromatosis (DF) progression and obstetric outcomes during and after pregnancy, providing evidence to inform clinical decision-making and counseling.

METHODS

This international, multicenter, retrospective observational study included data from 157 women with DF, contributing 177 pregnancies. Women were classified into three groups: DF diagnosed during pregnancy (Group A), pregnancy occurring after the diagnosis of DF (Group B: DF in situ during pregnancy), or pregnancy in previously resected DF (Group C). Logistic regression and tumor size trend analyses were conducted.

RESULTS

Among 177 pregnancies, Group A exhibited the highest rates of DF progression (68.7 % during pregnancy, 40.6 % postpartum), while Groups B and C had lower progression rates (9.5 % during pregnancy, 8.3 % postpartum). Active treatment was required in 5.6 % of cases. Spontaneous regression occurred in 23.7 % of pregnancies, particularly following progression. Obstetric complications were comparable to those in the general population.

CONCLUSION

Pregnancy is generally safe for women with DF, particularly after prolonged disease stability. Individualized counseling is essential for managing risks of progression and recurrence, supporting informed fertility decisions. Referral to specialized centers is recommended to optimize DF management during family planning and pregnancy.

Contrast enhanced ultrasound versus MRI for response assessment of extra-abdominal desmoid Fibromatosis- A feasibility study

BACKGROUND

Desmoid Fibromatosis (DF) is a locally aggressive soft tissue tumor which was traditionally managed with surgical excision. However due to high rates of local recurrence and insights about its behavior, there is now a paradigm shift towards active surveillance and medical management. Imaging plays a crucial role in surveillance and treatment response; however, conventional RECIST criteria are not adequate for DF. MRI is the preferred modality but faces limitation in availability and uniformity. Although ultrasound (US) is not optimal for evaluation, contrast enhanced US has shown promising results in many solid tumors.

OBJECTIVES

To explore the role of Contrast Enhanced Ultrasound (CEUS) as a response assessment tool in DF.

MATERIALS AND METHODS

This was a prospective study conducted between March 2022 and December 2023 and included 21 adults with DF who received medical line of treatment. A combination of clinical evaluation for symptom relief, and imaging modalities using MRI and CEUS, were utilized for response assessment. Statistical analysis was performed using non parametric tests.

RESULTS

Out of 21, 19 patients underwent pre as well as post-treatment evaluation. Clinical improvement was reported by 73.68 % while MRI indicated response only in 41.18 %; whereas only 29.41 % met the criteria for partial response according to RECIST 1.1. All responders on MRI exhibited continued enhancement on CEUS with a significant decrease in Mean Transit Time (MTT, p = 0.047).

CONCLUSION

CEUS demonstrates potential as an effective treatment response tool in DF, providing real-time information of microvascular changes within the mass.

A Clinical Pharmacological Perspective on Intraperitoneal Chemotherapy

Peritoneal metastases (PM), frequently observed in malignancies such as ovarian, colorectal, pancreatic, and gastric cancers, present a significant therapeutic challenge due to poor prognosis and limited effectiveness to systemic chemotherapy. The peritoneal-plasma barrier reduces effective drug transfer from plasma to the peritoneal cavity, reducing cytotoxic effects on PM. Intraperitoneal (IP) chemotherapy offers a locoregional approach, enabling high local drug concentrations that can enhance therapeutic efficacy while limiting systemic toxicity. The three major methods for IP administration-hyperthermic intraperitoneal chemotherapy (HIPEC), pressurized intraperitoneal aerosol chemotherapy (PIPAC), and catheter-based IP (CBIP) chemotherapy-each provide unique pharmacokinetic (PK) advantages for PM treatment. This review provides a comprehensive update on the pharmacological rationale of IP chemotherapy, focusing on drug characteristics that support extended IP retention and effective tumor targeting. The effects of administration variables are discussed, highlighting their role in optimizing IP drug exposure. Additionally, recent PK data on commonly used drugs in IP therapy, including platinum-based agents, taxanes, and novel nanoparticle formulations, will be evaluated. While PK rationale supports the administration of IP chemotherapy, further efficacy results from ongoing clinical trials are still awaited. Innovations in nanoparticle-based formulations and controlled-release systems offer substantial potential for improving both drug retention and targeted delivery, enhancing treatment precision and minimizing systemic toxicity. Continued exploration in these areas, along with optimization of IP administration protocols, is vital for advancing patient outcomes, refining therapeutic strategies, and maximizing the benefits of IP chemotherapy in clinical practice.

What is the accuracy, sensitivity and specificity of the radiological peritoneal cancer index in repeat cytoreductive surgery: a retrospective study

BACKGROUND

Repeat cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) (rCRS-HIPEC) has improved the long-term survival of select patients with acceptable perioperative morbidity and mortality. The pattern of peritoneal disease recurrence is critical in determining eligibility for rCRS-HIPEC. This study evaluated the accuracy, sensitivity and specificity of the radiological peritoneal cancer index (PCI) across different imaging modalities in rCRS-HIPEC patients.

METHODS

This was a retrospective study on patients with peritoneal disease recurrence who underwent rCRS-HIPEC between January 2022 to December 2023. The accuracy, sensitivity, and specificity of the radiological PCI in predicting the surgical PCI was calculated overall and for each imaging modality at each abdominal region.

RESULTS

32 patients were included in this study. The accuracy, sensitivity and specificity of the overall radiological PCI was 63.0%, 30.8% and 79.9%, respectively. Accuracy (67.5 vs. 62.6%) and specificity (84.8% vs. 75.8%) were higher in FDG-PET versus CT. The sensitivities of all imaging modalities were low (CT 34.9%, FDG-PET 33.3%). FDG-PET and CT had high sensitivities in detecting pelvic disease (80% and 87.5%) but low sensitivities in identifying small bowel (25-33.3% for both modalities) and epigastric disease (25% and 0%). For each abdominal region, the difference between radiological and surgical PCI did not differ significantly based on imaging modality.

CONCLUSIONS

Overall, the radiological PCI has a good specificity in rCRS-HIPEC patients and should be used to guide perioperative decision-making. FDG-PET had superior accuracy and specificity in comparison to CT in detecting peritoneal disease recurrence.

Effect of CDX2 on proliferation, invasion, migration, and apoptosis of duodenal cancer cells

This study investigates the expression and biological role of caudal homologous transcription factor 2 (CDX2) in duodenal carcinoma. Paraffin-embedded samples from 40 duodenal carcinoma cases were analyzed using immunohistochemistry on a tissue microarray to assess CDX2 expression and its prognostic significance. CDX2 overexpression plasmids and CDX2-siRNA were transfected into colon and duodenal cancer cells. Transfection efficiency was confirmed by RT-PCR and Western blotting. Cell proliferation was assessed using CCK8 assay, migration via scratch assay, and cell cycle and apoptosis by flow cytometry. CDX2 staining was primarily nuclear, with a positive rate of 65% in duodenal carcinoma tissues, significantly lower than in adjacent non-tumor tissues (p<0.05). CDX2-positive patients had better prognoses than negative patients (p<0.05). Reduced CDX2 expression significantly enhanced the proliferation of CaCO2 and HuTu-80 cells (p<0.001), whereas CDX2 overexpression suppressed proliferation (p<0.001). CDX2 knockdown increased migration, while its overexpression reduced migration (p<0.05). CDX2 overexpression led to a significant increase in G0/G1 phase cells and a decrease in S phase cells (p<0.05), whereas knockdown reduced G0/G1 phase cells and increased S and G2/M phase cells (p<0.05). Apoptosis was significantly increased following CDX2 overexpression (p<0.001) and decreased after CDX2 knockdown (p<0.001). CDX2 expression is downregulated or lost in duodenal carcinoma, acting as a tumor suppressor. CDX2 may serve as a crucial biomarker for predicting the onset, progression, and treatment of duodenal carcinoma.

Abdominal and concomitant thoracic HIPEC, named HITAC : Technique and post-operative courses

INTRODUCTION

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is the preferred treatment for selected patients with carcinomatosis. When diaphragmatic involvement occurs, partial diaphragm resection (DR) is necessary to achieve complete cytoreduction (CC-0). In cases of macroscopic pleural invasion detected during CRS, abdominal and intrathoracic HIPEC (HITAC) through the diaphragm may be considered if pleural and peritoneal CC0 can be obtained.

OBJECTIVES

To report the combined procedure technique, postoperative course, morbidity, and long-term outcomes.

METHODS

A monocentric database was used to identify cases.

RESULTS

Seven synchronous HITAC cases were identified. Median PCI was 12 (3-39). Inflow catheter placement was behind the spleen, with outflow in the right thorax. Four patients had anastomosis and two splenectomy. Oxaliplatin was used in 4 HITAC, mitomycin in 1, and cisplatin in 2. Surgery lasted a median of 580mins (300-720), with extubation 2-4h post-op, or on day 1. Median thoracic drainage on day 1 was 657mL (300-1600), decreasing by day 3. Median drain removal was on day 8 (7-17), with hospital stay of 12 days (8-16). One patient had a postoperative pancreatic fistula and pneumonia, while the remaining 6 had no major complications. One-month residual pleural effusion was noted in one case. No pleural recurrence was observed for PMP, with a median follow-up of 88 months (30-166).

CONCLUSIONS

Combined HIPEC and intrathoracic chemotherapy is feasible without major risks. Thoracic drainage can produce high volumes postoperatively. Favorable long-term outcomes are observed in low-grade PMP.

The Role of Prophylactic or Adjuvant Hyperthermic Intraperitoneal Therapy in Appendiceal and Colorectal Cancer Peritoneal Metastasis

Appendiceal neoplasms and colorectal cancer have a propensity to develop peritoneal metastases. Despite advancements in systemic therapy and surgical management, the development and management of peritoneal metastases remains a challenging problem. Utilization of adjuvant or prophylactic hyperthermic intraperitoneal chemotherapy has been described, with varying quality of data and reported outcomes. The utilization of prophylactic or adjuvant hyperthermic intraperitoneal chemotherapy in patients with appendiceal neoplasms and colorectal cancer remains an active area of exploration.

Hyperthermic Intraperitoneal Chemotherapy in the Management of Ovarian, Fallopian Tube and Peritoneal Carcinomas

Ovarian cancer (OC) is a leading cause of gynecologic cancer-related deaths. Despite improvements, the 10-year survival rate has remained relatively unchanged in recent years. Disease recurrence occurs in nearly 80% of patients with advanced disease symptoms. Hyperthermic intraperitoneal chemotherapy (HIPEC) is a therapy that targets common sites of OC recurrence with heated chemotherapy during surgery, which promotes either direct cell death, heightened deoxyribonucleic acid damage, or increased tumor susceptibility to chemotherapeutics. Clinical trials utilizing HIPEC have shown promising results. This paper aims to provide an overview of HIPEC, including historical trials, mechanistic insights, recent advances, and ongoing clinical trials.

Peritoneal Cancer Index Correlates with Radiographic Assessment of Colorectal Carcinomatosis

BACKGROUND

The Peritoneal Cancer Index (PCI), calculated intraoperatively, has previously yielded mixed results when correlated with computed tomography. This study aimed to quantify variation in this scoring method comparing radiologists' and surgeons' radiologic PCI (rPCI) assessment.

METHODS

The rPCI of 104 patients treated at a single institution for peritoneal carcinomatosis was calculated by an abdominal radiologist and a surgeon. An additional 36-patient cohort was studied to compare preoperative rPCI with intraoperative gold standard PCI. Agreement was compared using kappa statistics.

RESULTS

The rPCI of the 104 patients studied ranged from 2 to 39 (median, 12; interquartile range [IQR], 6-23) by the radiologist's analysis and 2 to 37 (median, 9; IQR, 6-15) by the surgeon's analysis. There was good agreement for PCI cutoffs of 15 (77.48%; kappa, 0.40) and 20 (78.63%; kappa, 0.24). The 36-patient cohort undergoing surgical exploration showed a median rPCI of 4 (IQR, 2-5.75) and a median intraoperative PCI of 11 (IQR, 6-12), with a significant difference in score by method (p < 0.001, Wilcoxon signed-rank test).

CONCLUSIONS

For rPCI cutoffs greater than 15 and 20, the surgeon's and radiologist's rPCI showed strong concordance, denoting the interobserver reproducibility of rPCI. Moreover, concordance with intraoperative PCI translated to radiographic assessment. The rPCI consistently underestimated intraoperative PCI, suggesting that rPCI may be a useful conservative tool for assessing peritoneal burden. Although surgical exploration is needed to "rule in" patients as candidates for CRS, the authors suggest that rPCI can be used to "rule out" patients as CRS candidates based on institutional PCI cutoffs.

Baseline Inflammatory Burden Index Predicts Primary Resistance to Combinations of ICIs With Chemotherapy in Patients With HER-2-Negative Advanced Gastric Cancer

PURPOSE

Combinations of immune checkpoint inhibitors (ICIs) and chemotherapy have become the standard first-line treatment for human epidermal growth factor receptor 2 (HER-2)-negative advanced gastric cancer. However, primary resistance remains a challenge, with no effective biomarkers available for its prediction. This retrospective study explores the relationship between the baseline inflammatory burden index (IBI) and primary resistance in such context.

MATERIALS AND METHODS

We analyzed 62 patients with HER-2-negative advanced gastric cancer who received ICIs and chemotherapy as their first-line treatment. The IBI was calculated as follows: C-reactive protein (mg/L) × neutrophil count (10³/mm³)/lymphocyte count (10³/mm³). Based on disease progression within 6 months, patients were categorized into the primary resistant or the control group. We compared baseline characteristics and IBI scores between the groups and assessed the predictive value of the IBI using the receiver operating characteristic curve. Both univariate and multivariate binary logistic regression analyses were conducted to identify factors influencing primary resistance.

RESULTS

Nineteen patients were included in the primary resistance group, and forty-three patients were included in the control group. The IBI was significantly higher in the resistant group compared to the control group (P<0.01). The area under the curve for the IBI was 0.82, indicating a strong predictive value. Multivariate analysis identified the IBI as an independent predictor of primary resistance (P=0.014).

CONCLUSIONS

The baseline IBI holds promise as a predictor of primary resistance to combined ICIs and chemotherapy in patients with HER-2-negative advanced gastric cancer.

Giant Intra-Abdominal Desmoid Tumor in a Young Man: A Case Report and Literature Review

INTRODUCTION

Desmoid tumors are rare soft-tissue tumors with a high recurrence rate; however, histologically, these tumors are benign. We describe a case in which a giant desmoid tumor was resected in a young man without any apparent causative factors.

CASE PRESENTATION

A 21-year-old man was referred to our hospital for treatment after presenting to a nearby hospital with right inguinal pain. Abdominal magnetic resonance imaging showed an intra-abdominal mass measuring 34 × 15 × 8 cm with partial signal hyperintensity on T2-weighted imaging and hypointensity on T1-weighted imaging, extending from the left abdominal cavity to the pelvic region. Although no definitive diagnosis was obtained preoperatively, surgery was performed under suspicion of gastrointestinal stromal tumor or other significant disease. A mass was identified firmly adherent to the transverse colon, gastric wall, and diaphragm, and these organs were partially resected. The excised specimen measured 38 × 21 × 8 cm and weighed 6400 g. Macroscopically, the tumor showed a smooth surface and homogeneous interior. Pathological examination revealed atypical cells with spindle-shaped nuclei and collagen fiber hyperplasia in the stroma, and immunostaining was negative for c-kit, CD34, desmin, S-100, and positive for β-catenin, leading to a confirmed diagnosis of desmoid tumor. Fifteen months after surgery, a local recurrence with a diameter of 3.0 cm was identified, and the patient remains under careful follow-up.

CONCLUSIONS

Intra-abdominal desmoid tumors larger than 30 cm are extremely rare. When encountering a young patient with a large intra-abdominal tumor, the possibility of desmoid tumor should be considered.

Mesh-reinforced reconstruction after abdominal wall desmoid tumor resection: a retrospective analysis of 16 cases

PURPOSE

Managing the defect after abdominal wall desmoid tumor resection is challenging due to the wide excision required. This report aims to review our institutional experience with mesh-reinforced reconstruction following desmoid tumor resection in the abdominal wall.

METHODS

We retrospectively reviewed patients who underwent abdominal wall desmoid tumor resection with mesh-reinforced reconstruction between April 2014 and January 2019. Patient records were analyzed to collect data on demographic characteristics, surgical procedures, and complications.

RESULTS

Sixteen eligible patients were identified, including one patient who underwent simultaneous resection of affected intra-abdominal organs. The mean size of the abdominal wall defect was 88.1 ± 71.6 cm², and the mean mesh size was 160.3 ± 56.5 cm². The mean operative time was 87.5 ± 41.4 min, the mean hospital stay was 15.7 ± 6.0 days, and the mean follow-up period was 83.8 ± 18.0 months. Complications included seroma (n = 1) and abnormal sensation (n = 2). Tumor recurrence was observed in 1 patient, who died due to cancer progression (lung cancer). No surgical site infections or mesh infections were observed. Additionally, no patients developed ventral hernias or abdominal bulging.

CONCLUSION

Mesh-reinforced reconstruction is a feasible and effective approach for patients requiring abdominal wall desmoid tumor resection.

The Histomorphology to Molecular Transition: Exploring the Genomic Landscape of Poorly Differentiated Epithelial Endometrial Cancers

The peremptory need to circumvent challenges associated with poorly differentiated epithelial endometrial cancers (PDEECs), also known as Type II endometrial cancers (ECs), has prompted therapeutic interrogation of the prototypically intractable and most prevalent gynecological malignancy. PDEECs account for most endometrial cancer-related mortalities due to their aggressive nature, late-stage detection, and poor response to standard therapies. PDEECs are characterized by heterogeneous histopathological features and distinct molecular profiles, and they pose significant clinical challenges due to their propensity for rapid progression. Regardless of the complexities around PDEECs, they are still being administered inefficiently in the same manner as clinically indolent and readily curable type-I ECs. Currently, there are no targeted therapies for the treatment of PDEECs. The realization of the need for new treatment options has transformed our understanding of PDEECs by enabling more precise classification based on genomic profiling. The transition from a histopathological to a molecular classification has provided critical insights into the underlying genetic and epigenetic alterations in these malignancies. This review explores the genomic landscape of PDEECs, with a focus on identifying key molecular subtypes and associated genetic mutations that are prevalent in aggressive variants. Here, we discuss how molecular classification correlates with clinical outcomes and can refine diagnostic accuracy, predict patient prognosis, and inform therapeutic strategies. Deciphering the molecular underpinnings of PDEECs has led to advances in precision oncology and protracted therapeutic remissions for patients with these untamable malignancies.

Appendiceal adenocarcinoma-patterns of tumor spread and prognosis

INTRODUCTION

Appendiceal adenocarcinoma represents a diagnostic and therapeutic challenge since it is prone to early lymphatic and peritoneal spread. We aimed to analyze the proportion of lymph node metastases in completion right hemicolectomy specimens, risk factors for peritoneal metastases (PM), and prognosis after definitive treatment.

METHODS

Ninety-three patients with appendiceal adenocarcinoma scheduled for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) in Uppsala 2004-2020 were identified from a prospectively maintained registry. Risk factors for PM were assessed based on the presence (CT + group, n = 55) or absence (CT - group, n = 37) of visible PM at baseline CT scan. Prognostic factors were analyzed based on the actual presence (PM group, n = 66) or absence (no PM group, n = 27) of PM.

RESULTS

The median age was 60 (26-78). Forty-eight patients were women. Resection of PM at initial surgery indicated an 80 % risk of finding PM at a follow-up exploration. R1 appendectomy and perforated appendix had a similar risk for PM (24 %,26 %) which increased to 38 % if both were present. Regional lymph node metastases occurred in 31 % in the CT + group vs. 14 % in the CT - group (p = 0.005) and was associated with poor survival HR 5.16 (1.49-17.81). The 5-year OS and DFS rates were 54 % and 29 % in the PM group.

CONCLUSIONS

Patients with certain risk factors have a high likelihood of PM despite a normal CT scan, which justifies selective exploration at a HIPEC center. Regional lymph node spread supports the current practice of completion right hemicolectomy and is a significant prognostic factor.

Intraperitoneal chemotherapy is now back for ovarian cancer

The Intraperitoneal Carboplatin for Ovarian Cancer (iPocc) trial demonstrated that intraperitoneal (IP) administration of carboplatin is more effective than intravenous (IV) administration for advanced ovarian cancer, especially in cases with large residual tumors, challenging previous assumptions that IP chemotherapy is only beneficial for small residual tumors. Additionally, the iPocc trial showed that IP chemotherapy has a comparable safety profile to IV chemotherapy, with the exception of port-related toxicities. This review summarizes the principles, development, and significance of IP chemotherapy and discusses its future potential in light of recent studies. Notably, the iPocc trial, conducted under Japan's new clinical trial regulations, achieving regulatory approval based on investigator-initiated results. The iPocc regimen offers a viable treatment option for patients with advanced ovarian cancer (stages II-IV). However, bevacizumab is recommended for later-line treatments rather than combining it with IP chemotherapy until further trials support such combinations. Future studies are needed to identify biomarkers that predict response to the iPocc regimen. The trial's success underscores the dedication of patients and families who contributed to this groundbreaking research.

Role of Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) in the Treatment of Peritoneal Carcinomatosis From Small Bowel Adenocarcinoma-A Systematic Review and Meta-Analysis

INTRODUCTION

While systemic chemotherapy (SC) is the mainstay of treatment of peritoneal carcinomatosis from small bowel adenocarcinomas (SBA-PC), its efficacy and outcomes remain poor. Therefore, the role of curative-intent surgery needs to be better defined. Using a systematic review and meta-analysis, this study aims to define the role of CRS/HIPEC in patients with SBA-PC.

METHODS

A systematic literature search was performed using PubMed and MEDLINE following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies published between 1990 and 2023. Articles were scored and incorporated within approximate normality of means/proportions formulae to compare outcomes of CRS/HIPEC and SC alone.

RESULTS

Ten studies with 461 patients undergoing CRS/HIPEC and seven studies with 285 patients undergoing SC alone were identified. In the CRS/HIPEC group, 215 (46.6%) were male and the median age was 46.5-66 years. The primary tumor was located mostly in the duodenum (n = 169, 36.7%) and ileum (n = 108, 23.4%). Grade was unspecified in most patients (n = 232, 50.3%). Median Peritoneal Cancer Index (PCI) ranged between 10 and 12, and 93.1% underwent complete cytoreduction (CC 0/1). CRS/HIPEC-related major morbidity and mortality was 20.7% (SD = 2.5, 95% CI 15.6-25.6) and 1.7% (SD = 0.8, 95% CI 0.1-3.3), respectively. With a median follow-up of 21.1 (SD = 1.1, 95% CI 18.9-23.3) months, CRS/HIPEC demonstrated median overall survival of 32.3 (SD = 1.19, 95% CI 30-34.6) versus 14.5 (SD = 0.19, 95% CI 14.1-14.9) months for SC alone (p < 0.0003).

CONCLUSION

In comparison to SC alone, CRS/HIPEC may result in long-term survival with acceptable perioperative morbidity, in select SBA-PC patients with low-volume disease undergoing complete cytoreduction.

Efficacy of Cytoreductive Surgery and Hyperthermic Intrathoracic Chemotherapy (HITHOC) in Thymic Neoplasia: A Systematic Review and Single-Arm Meta-analysis

INTRODUCTION

The study was designed to evaluate the efficacy and safety of hyperthermic intrathoracic chemotherapy (HITHOC) as an adjuvant treatment for thymic epithelial tumors, including thymomas and thymic carcinomas.

METHODS

A systematic review of PubMed, Embase, and Cochrane Library databases was conducted from inception to July 30, 2024. The analysis included retrospective studies and case series involving patients undergoing cytoreductive surgery combined with HITHOC for thymomas. The treatment effects for binary endpoints were assessed using proportion rates with 95% confidence intervals (CIs). Statistical analyses were performed using R software.

RESULTS

Fifteen studies comprising 248 patients were included. The mean age of patients was 56 years. Thymomas represented 92% of cases, thymic carcinomas 7%, and other thymic neoplasms 1%. Operative mortality was 2.42% (95% CI 1.09-5.28), and overall mortality was 8.32% (95% CI 4.25-15.65). The disease recurrence rate was 25.99% (95% CI 14.04-43.02). The incidence of pneumonia was 1.96% (95% CI 0.45-8.16), and acute kidney injury (AKI) was 2.83% (95% CI 0.94-8.20).

CONCLUSIONS

The combination of cytoreductive surgery with HITHOC in patients with thymomas resulted in low operative and overall mortality, as well as low rates of AKI. However, the high recurrence rate presents a challenge for long-term disease control. This study provides the most up-to-date evidence on the safety and efficacy of HITHOC for thymomas, contributing valuable insights for clinical practice.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews; No.: CRD42024566953; URL: https://www.crd.york.ac.uk/prospero/ .

Contemporary Management of Malignant Ascites

INTRODUCTION

Malignant ascites (MA) develops when malignant disease of the peritoneum causes excess fluid to accumulate in the abdominal cavity. It portends a poor prognosis and is associated with debilitating symptoms. While several palliative therapies exist, none have proven curative or free from side effects and complications. This review article describes experimental therapies on the horizon and the contemporary management of MA.

MATERIALS AND METHODS

A literature review was performed using MEDLINE/PubMed, in which studies of emerging or experimental therapies under investigation for the management of MA were reviewed. Current therapies were also reviewed to provide important context. Data, including study design, sample size, primary and secondary outcomes, and side effects were recorded and described. Studies were then categorized into distinct sections and subsections, with tables corresponding to each section.

RESULTS

Five current therapies, including paracentesis, diuretics, peritoneovenous shunting, permanent catheters, and intraperitoneal chemotherapy, are described. Their limitations in effectively managing MA are highlighted. The "Experimental therapies" section is subsectioned into several categories, with the major studies corresponding to each section thoroughly described regarding methods, results, and validity. A final section describes treatments for mucinous ascites, which has distinct characteristics.

CONCLUSIONS

While each of the experimental therapies described offers unique benefits and has demonstrated some promise in managing MA, they all have limitations that have thus far prevented any one of them from being routinely used in practice. MA remains a challenging condition to treat, warranting further research into novel therapies.

A novel nebulized drug delivery system based on an innovative high-pressure peristaltic pump availably applied to pressurized intraperitoneal aerosol chemotherapy

Background

Management of peritoneal carcinomatosis (PC) remains a significant clinical challenge due to a lack of effective therapies. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has been identified as a safe and efficacious treatment for PC. However, despite the observed high potential for PIPAC in treating numerous PC cases, the technology is still limited in China. To address this deficit, we developed a novel nebulized drug delivery system (NDDS) and evaluated it in this study.

Methods

The NDDS was developed and was systematically assessed through tests of mechanical properties, granulometric analyses, sprayed distribution tests, and gravimetric analyses; moreover, drug penetration and distribution were examined in vitro and in a porcine model (female Tibetan pig).

Results

The NDDS, which included a high-pressure peristaltic pump, demonstrated a pressure initiation time of 5 s and a spray angle of 70°. Nebulization was consistent from the fifth second onward, with a median droplet diameter of 25.0-26.5 µm. The diameters of the sprayed intensive and expanded area were 26.1±1.4 and 48.5±1.0 cm at the vertical distance of 15 cm, and the stress generated was ≤3.790 Pa. Intraluminal drug distribution was extensive but heterogeneity, with 100- to 400-µm drug penetration depth (PD), and the optimal drug PD was observed in locations directly opposite to or adjacent surrounding the nozzle.

Conclusions

The developed NDDS demonstrated promising mechanical properties, effective granulometric characteristics, extensive spray coverage, and satisfactory drug penetration and distribution. It offers a practicable solution for the application of PIPAC and will hopefully improve the current dilemma in PC therapy.

Chemotherapy Options for Locally Advanced Gastric Cancer: A Review

Cancers represent a significant global health burden, affecting millions of individuals each year [...].

Management of Peritoneal Metastasis in Patients with Pancreatic Ductal Adenocarcinoma

The peritoneum is the second most common site of metastasis in patients with pancreatic ductal adenocarcinoma (PDAC). Up to half of all patients that undergo curative-intent resection eventually develop peritoneal metastasis (PM), which accounts for significant morbidity and drives mortality. Despite recent advances in management, PM is associated with very poor prognosis, which is often measured in weeks to months. Clinical manifestations including bowel obstruction, ascites, and urinary obstruction have profound impact on quality of life. Even with relatively advanced disease, PM often remains occult on imaging and thus tend to be underdiagnosed and understudied. Many patients with peritoneal-only PM are excluded from clinical trials because response cannot be measured by standard radiographic criteria. Furthermore, as patients with PM are not eligible for surgical resection and low-volume peritoneal disease is often not amenable to percutaneous biopsy, tissue samples for peritoneal-specific translational studies are limited. Intraperitoneal therapeutics have been proposed as an attractive option for PM, as better penetration of tumor tissue can be achieved with less systemic toxicity compared with intravenous chemotherapy. Heated intraperitoneal chemotherapy (HIPEC), typically combined with cytoreductive surgery (CRS), is an option for select patients with PM from gynecologic or gastrointestinal primary, and for patients with primary peritoneal mesothelioma. However, the incorporation of locoregional therapy for PM in patients with PDAC has been poorly studied given the aggressive nature of pancreatic cancer and overall poor prognosis. With recent advances in existing treatment options, there may be a subset of patients who may derive benefits from locoregional control with cytoreduction and/or intraperitoneal chemotherapy. Critically, additional work is needed to determine PM-favorable clinical and tumoral predictive biomarkers to identify patients who may benefit from a more aggressive approach. We describe the current state of management of patients with peritoneal metastasis from PDAC and review the available data exploring peritoneal-directed therapy with cytoreductive surgery and/or intraperitoneal chemotherapy.

Molecular and Functional Characterization of the Peritoneal Mesothelium, a Barrier for Solute Transport

Peritoneal dialysis (PD) is an increasingly needed, life-maintaining kidney replacement therapy; efficient solute transport is critical for patient outcome. While the role of peritoneal perfusion on solute transport in PD has been described, the role of cellular barriers is uncertain, the mesothelium has been considered irrelevant. We calculated peritoneal blood microvascular endothelial surface area (BESA) to mesothelial surface area (MSA) ratio in human peritonea in health, chronic kidney disease, and on PD, and performed molecular transport related gene profiling and single molecule localization microscopy in two mesothelial (MC) and two endothelial cell lines (EC). Molecular-weight dependent transport was studied in-vitro, ex-vivo and in mice. Peritoneal BESA is 1-3-fold higher than MSA across age groups, and increases with PD, while the mesothelium is preserved during the first 2 years of PD. Tight junction, transmembrane and transcytotic transporter expression are cell-type specifically expressed. At nanoscale, tight junction anchoring protein Zonula occludens-1 is more abundant and more continuously expressed along the MC than the EC. Ionic conductance is 3-fold lower across the MC than human microvascular EC, as is the permeability for creatinine, 4- and 10-kDa, but not for 70-kDa dextran. MC removal from sheep peritoneum abolishes ionic barrier function. Short term intraperitoneal LPS exposure in mice selectively affects peritoneal mesothelial integrity and increases transperitoneal solute transport. We provide molecular correlates and consistent functional evidence for the mesothelium as a barrier for peritoneal solute transport, ie, essential information on peritoneal transport modeling, and for interventions to improve PD efficiency and biocompatibility, and beyond.

INDEPSO-ISPSM consensus on peritoneal malignancies - Enhanced recovery after surgery in cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC)

Background

The role of enhanced recovery after surgery (ERAS) in cytoreductive surgery and/or Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is evolving, with promising results that improve patient outcomes. This consensus exercise was carried out to address and standardize components of the ERAS protocol pertinent to the Indian context.

Method

The modified Delphi method was employed with two rounds of voting. All fifty invited specialists agreed to vote. There were 30 questions addressing the key elements of ERAS protocols. They were broadly distributed across four sections: Prehabilitation, Preoperative, Intraoperative, and Postoperative elements. A consensus was achieved if any one option received > 70 % votes (strong consensus > 90 %). If consensus was not achieved in round 1, the question was moved to round 2.

Results

After rounds I and II, 48/50 (95.8%) of invited panelists voted for the questions. The highest rate of 'skipped question' was 6% in both rounds. A consensus was obtained for 28/30 (93.33%) questions, and strong consensus was obtained for 5/30 (16.6%) questions. No consensus was obtained for two questions. Some of the panelists' recommendations contradicted the standard ERAS guidelines, such as using intraperitoneal drains in all patients and mechanical bowel preparation for left-sided colonic or rectal resections.

Conclusion

Despite some limitations, this consensus exercise represents a significant step toward advancement and pioneering efforts to improve patient outcomes by implementing and standardizing ERAS protocols in CRS and/or HIPEC tailored for India.

Solitary Myofibroma of the oral and maxillofacial regions in pediatric patients: A clinicopathological analysis of ten patients and review of 75 cases

BACKGROUND

The imaging manifestations of oral and maxillofacial myofibroma/myofibromatosis can vary among patients. Although many clinical cases have been reported, a consensus on the clinicopathological features of and treatment principles for this disease is lacking.

PURPOSE

This study aimed to summarize the clinicopathological features of solitary myofibroma of the oral and maxillofacial regions in pediatric patients.

METHODS

The clinical data, histological features, and immunohistochemical characteristics of ten pediatric patients who underwent surgical removal and subsequent pathological diagnosis of myofibroma were collected and retrospectively and cross-sectionally analyzed.

RESULTS

Seven patients were male, and 3 were female, with ages ranging from 3 months to 6 years (mean: 2.6 years). The patients presented with solitary lesions involving the mandibular gingiva and adjacent mandible (4 patients), mandible (2 patients), oral floor and submandibular area and adjacent mandible (1 patient), gingiva (1 patient), maxilla (1 patient), and oropharynx (1 patient). Light microscopy revealed spindle-shaped tumor cells organized in bundles or vortex patterns, forming a hemangiopericytoma-like perivascular pattern, whereas immunohistochemical staining revealed diffuse smooth muscle actin (SMA) positivity. All patients underwent surgical resection, and none experienced recurrence over the 12- to 82-month follow-up.

CONCLUSIONS

Solitary myofibroma in the oral and maxillofacial regions is predominantly observed in infants and young children, with a higher incidence among males. The prognosis is favorable following localized lesion resection or curettage of jawbone lesions. Accurate recognition of the clinical, radiological, and pathological features of the disease will reduce the misdiagnosis rate.

Secondary cytoreductive surgery in platinum-sensitive relapsed ovarian cancer: a meta-analysis of randomized controlled trials

PURPOSE

To evaluate the role of secondary cytoreduction in patients with platinum-sensitive recurrent ovarian cancer.

METHODS

The PubMed, Medline, Embase, Cochrane Library and Web of Science databases were searched. Randomized controlled trials (RCTs) that compare secondary cytoreduction plus chemotherapy with chemotherapy alone in patients with platinum-sensitive relapsed ovarian cancer were selected. Pooled hazard ratios (HR) with 95% confidence intervals (CIs) were calculated.

RESULTS

There was no difference in overall survival (OS) between the surgery group and no surgery group (HR = 0.89; 95% CI 0.77, 1.04; p = 0.14), but secondary cytoreduction showed a significant improvement in progression-free survival (PFS) (HR = 0.67; 95% CI 0.54, 0.76; p < 0.00001). A subgroup analysis comparing the complete gross resection subpopulation with the no surgery group achieved a significant longer OS (HR = 0.70, 95% CI 0.58-0.85; p = 0.0003) and a greater PFS benefit (HR = 0.56, 95% CI 0.48-0.66; p < 0.00001). In addition, as compared with incomplete resection, the OS benefit of complete gross resection was more evident (HR = 0.51, 95% CI 0.37-0.69; p < 0.0001).

CONCLUSIONS

In women with platinum-sensitive recurrent ovarian cancer, although secondary cytoreduction followed by chemotherapy resulted in longer PFS than chemotherapy alone, it did not lead to significant benefit in OS. However, when complete gross resection was achieved, it significantly prolonged OS and provided a greater PFS benefit.

Computational Evaluation of Improved HIPEC Drug Delivery Kinetics via Bevacizumab-Induced Vascular Normalization

Background: Oxaliplatin-based hyperthermic intraperitoneal chemotherapy (HIPEC) using the original 30 min protocol has shown limited benefits in patients with peritoneal metastasis of colorectal cancer (PMCRC), likely due to the short duration, which limits drug penetration into tumor nodules. Bevacizumab, an antiangiogenic antibody that modifies the tumor microenvironment, may improve drug delivery during HIPEC. This in silico study evaluates the availability of oxaliplatin within tumor nodules when HIPEC is performed after bevacizumab treatment. Methods: Using a computational fluid dynamics (CFD) model of HIPEC, the temperature and oxaliplatin distribution within the rat abdomen were calculated, followed by a model of drug transport within tumor nodules located at various sites in the peritoneum. The vascular normalization effect of the bevacizumab treatment was incorporated by adjusting the biophysical parameters of the tumor nodules. The effective penetration depth values, including the thermal enhancement ratio of cytotoxicity, were then compared between HIPEC alone and HIPEC combined with the bevacizumab treatment. Results: After bevacizumab treatments at doses of 0.5 mg/kg and 5 mg/kg, the oxaliplatin availability increased by up to 20% and 45% when HIPEC was performed during the vascular normalization phase, with the penetration depth increasing by 1.5-fold and 2.3-fold, respectively. Tumors with lower collagen densities and larger vascular pore sizes showed higher oxaliplatin enhancement after the combined treatment. Bevacizumab also enabled a reduction in the oxaliplatin dose (up to half at 5 mg/kg bevacizumab) while maintaining effective drug levels in the tumor nodules, potentially reducing systemic toxicity. Conclusions: These findings suggest that administering oxaliplatin-based HIPEC during bevacizumab-induced vascular normalization could significantly improve drug penetration and enhance treatment efficacy.

Iterative Intraperitoneal Chemotherapy in Gastric Cancer Peritoneal Carcinomatosis

Background/objectives: Despite the incremental improvement of survival with systemic therapy in metastatic gastric cancer (GC), the outcomes of patients with peritoneal carcinomatosis (PC) remain poor. The limited effectiveness of systemic therapy is attributed to the blood-peritoneal barrier and anarchic intra-tumoral circulation, which reduce the penetration of systemic therapy. Approaches that incorporate intraperitoneal (IP) chemotherapy, in addition to systemic therapies, may be a viable alternate strategy. Therefore, we provide a review of biology of gastric cancer peritoneal metastasis and evidence for bidirectional iterative IP chemotherapy in GCPC. Methods: A comprehensive search in PubMed, Scopus, Embase, Web of Science, Google Scholar, and ClinicalTrials.gov was performed to find the relevant articles and ongoing phase II/III clinical trials in iterative IP chemotherapy in GCPC. Results: Intraperitoneal (IP) chemotherapy leverages the blood-peritoneal barrier to allow for the administration of high concentrations of chemotherapy directly to the peritoneal metastases, with a significant reduction in the systemic toxicity and enhanced drug efficacy against peritoneal metastasis. This pharmacokinetic advantage of IP chemotherapy can be further enhanced by additional measures such as heat or aerosolization. There are three IP chemotherapy approaches, namely, heated intraperitoneal chemotherapy (HIPEC), pressurized intraperitoneal aerosolized chemotherapy (PIPAC), and normothermic intraperitoneal chemotherapy (NIPEC). Recent evidence suggests that iterative IP chemotherapy combined with systemic therapy may offer significant survival benefits for patients with peritoneal metastasis. Furthermore, bidirectional treatment approaches may also increase the chances of surgical resection and survival. Conclusions: IP chemotherapy plays a pivotal role in the management of gastric carcinomatosis, particularly in combination with cytoreduction in highly selected patients. The combination of systemic and regional control may increase the chances of surgical resection and may ultimately lead to significant survival benefits.

Peritoneal chemotherapy delivery systems for ovarian cancer treatment: systematic review of animal models

Introduction

Intraperitoneal chemotherapy for ovarian cancer treatment has controversial benefits as most methodologies are associated with significant morbidity. We carried out a systematic review to compare tumor response, measured by tumor weight and volume, between intraperitoneal chemotherapy delivered via drug delivery systems (DDSs) and free intraperitoneal chemotherapy in animal models of ovarian cancer. The secondary aim was to assess the toxicity of DDS-delivered chemotherapy, based on changes in animal body weight.

Methods

Based on PRISMA and SYRCLE guidelines, we identified 38 studies for review, of which 20, were used in the meta-analysis. We evaluated outcome, through tumor volume and tumor weight and, toxicity, through animal weight. Analysis was based on drugs employed and treatment duration.

Results

Most studies were performed on mice. Ovarian cancer cell lines most commonly used to induce xenografts were SKOV3 (19 studies) and A2780 (6 studies). Intraperitoneal device, also known as drug delivery systems (DDS), consisted in nanoparticles, hydrogels, lipid polymer and others. The most commonly used drugs were paclitaxel and cisplatin. Most studies used as the control treatment the same chemotherapy applied free intraperitoneally and tumor response/animal weight were evaluated weekly. There was a small benefit in overall tumor reduction in animals treated with intraperitoneal chemotherapy applied through the slow release device compared with animals treated with intraperitoneal free chemotherapy, as evaluated through tumor weight - results in standardized mean difference. (-1.06; 95% CI: -1.34, -0.78) and tumor volume (-3.72; 95% CI: -4.47, -2.97), a benefit that was seen in most weekly evaluations and for most chemotherapy drugs, such as carboplatin (tumor weight: -5.60; 95% CI: -7.83, -3.37), paclitaxel (tumor weight: -1.18; 95% CI: -1.52, -0.83), and cisplatin (tumor volume: -2.85; 95% CI: -3.66, -2.04) carboplatin (tumor volume: -12.71; 95% CI: -17.35, -8.07); cisplatin (tumor volume: -7.76; 95% CI: -9.88, -5.65); paclitaxel (tumor volume: -2.85; 95% CI: -3.66, -2.04). Regarding animal weight, there was no weight reduction in animals treated with intraperitoneal chemotherapy applied through the slow-release device compared with animals treated with intraperitoneal free chemotherapy. However, significant heterogeneity was observed in some comparisons.

Conclusion

slow-release devices are overall safe and effective in animal models of ovarian cancer. It was not possible to evaluate which one is the most promising device to treat ovarian cancer, because many different types were used to apply chemotherapy intraperitoneally.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021224573.

Emerging Trends in the Management of Gastric Malignancy with Peritoneal Dissemination: Same Disease, Heterogeneous Prognosis

Gastric cancer is a significant global contributor to cancer-related mortality. Stage IV gastric cancer represents a significant percentage of patients in Western countries, with peritoneal dissemination being the most prevalent site. Peritoneal disease comprises two distinct entities, macroscopic (P1) and microscopic (P0CY1), which are associated with poor long-term survival rates. Although the present standard of treatment is palliative chemotherapy, a global controversy has arisen concerning specific patients with limited disease burden or conversion to negative lavage cytology following chemotherapy. Available approaches include systemic or intraperitoneal chemotherapy, upfront gastrectomy, and conversion surgery. This review consolidated the current evidence regarding multimodal management, indicating prolonged survival for this distinct subgroup of patients. Considering the complexity of peritoneal metastases, the potential of the multimodal approach unveils promising prospects for identifying the optimal treatment for this particular subset of stage IV patients and thus enhancing their survival outcomes.

Insight into Predictors of Cytoreduction Score Following Cytoreductive Surgery-Hyperthermic Intraperitoneal Chemotherapy for Gastric Peritoneal Carcinomatosis Improves Patient Selection and Prognostic Outcomes

BACKGROUND

Peritoneal metastases due to gastric adenocarcinoma (GCPM) carry a dismal prognosis. A promising treatment strategy is cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), but clear eligibility criteria for GCPM are lacking. We sought to identify factors associated with overall survival (OS) following CRS-HIPEC for GCPM to help optimize patient selection and clinical outcomes.

PATIENTS AND METHODS

In this single-center retrospective cohort study, we examined CRS-HIPEC outcomes for patients with GCPM between 2001 and 2021. After analyzing patient demographic, clinicopathologic, and perioperative variables, we applied multivariable Cox hazard models to assess factors associated with OS. We then assessed associations between baseline predictors and prognostically important variables using multivariable logistic regression.

RESULTS

We analyzed 55 patients with GCPM who underwent CRS-HIPEC. Median age was 54 years and 42% were female. Median peritoneal carcinomatosis index (PCI) was 8, and 75% of patients achieved a cytoreduction completeness score (CC score) of 0. Median progression-free survival (PFS) was 6.9 months, and median OS was 14.1 months. On adjusted analysis, a CC score > 0 (HR 2.3, p = 0.02) was significantly associated with worse OS. A peritoneal carcinomatosis index greater than 13 (OR 52.6, p = 0.001) and fewer lymph nodes (especially < 18) resected with the primary tumor (OR 0.86, p = 0.042) in the metachronous setting were significantly associated with incomplete macroscopic cytoreduction (CC score > 0).

CONCLUSIONS

We demonstrated that PCI > 13 and primary lymph nodes harvested < 18 in metachronous tumors are associated with CC score > 0, which in turn portends a worse OS. Although these results warrant prospective validation, they provide insight into improved selection of patients with GCPM for CRS-HIPEC.

Pharmacokinetics of cisplatin in the systemic versus hyperthermic intrathoracic or intraperitoneal chemotherapy

OBJECTIVE

To compare the pharmacokinetics and adverse effects of cisplatin administered via intravenous infusion for systemic chemotherapy (SC) versus injection into the perfusate during hyperthermic intrathoracic chemotherapy (HITHOC) or hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

Total 60 patients who received SC, HITHOC, or HIPEC in the Department of Oncology, Tangdu Hospital, were enrolled into this study. After administering same dose of cisplatin (40 mg) via either intravenous infusion (SC group) or injection into the perfusate during the HITHOC or HIPEC procedure, concentration of cisplatin in the plasma as well as in the hyperthermic perfusate at various time points was quantified by HPLC analysis. The area under the plasma or perfusate concentration-time curve over the last 24h dosing interval (AUC0-24h), mean residence time over the 24 h (MRT0-24h), terminal elimination half-life (t1/2z), time to peak concentration (Tmax), apparent clearance (Clz/F), and peak concentration (Cmax) in the perfusate and plasma were compared.

RESULTS

In the perfusate, the AUC0-24h (64.32 ± 27.12 µg/mL·h) and Cmax (21.62 ± 5.88 µg/mL) were significantly higher in the HITHOC group compared to that in the HIPEC group (31.68 ± 13.29 µg/mL·h and 16.96 ± 5.54 µg/mL, respectively, p ≤ 0.01). In contrast, MRT0-∞, t1/2z, and Clz/F were significantly lower in the HITHOC group compared to that in the HIPEC group (p < 0.01). In the plasma, average AUC0-24h and Cmax of the HITHOC group were 2.57 ± 0.55 µg/mL·h and 0.26 ± 0.08 µg/mL, respectively, which were significantly lower than that of systemic chemotherapy (SC) group (3.26 ± 0.56 µg/mL·h and 0.69 ± 0.14 µg/mL, respectively, p < 0.01), but no difference compared to that of HIPEC group (3.02 ± 0.52 µg/mL·h and 0.40 ± 0.15 µg/mL, respectively, p > 0.05). In contrast, MRT0-24h and Tmax in the plasma of HITHOC group were significantly longer compared to that of SC group (p < 0.05), but no significant difference compared to that of HIPEC group (p > 0.05). Absolute bioavailability of cisplatin in the thoracic (HITHOC group) and abdominal (HIPEC group) cavities was 20 and 10 times higher than that in the blood administered intravenously (SC group), respectively. There was no significant difference in the incidence of adverse events among the three groups (p < 0.05).

CONCLUSION

The current study demonstrated that, in the perfusate, AUC0-24h and Cmax of cisplatin was significantly higher in the group of HITHOC compared to that of HIPEC, and that, in the plasma, AUC0-24h and Cmax of cisplatin was lower in the group of HITHOC compared to that of HIPEC or SC group. This study provided pharmacokinetic evidence to further support the concept that topical application of chemotherapeutic drug through minimally invasive HITHOC or HIPEC may enhance local exposure compared to systemic chemotherapy for the patients with malignant pleural effusion or ascites.

A super-giant basal cell carcinoma of the scalp

Basal cell carcinoma is a malignant skin cancer, originating from basal cells. However, it is regarded more benign than other skin cancers, in the majority of the cases. If left untreated, it can lead to various complications, degradation of quality of life and even mortality to the patient. A basal cell carcinoma with one dimension more than 20 cm, is defined as super-giant. In this report, we present a case of a super-giant basal cell carcinoma occupying most of the scalp in an elderly patient, causing him severe anemia and general malaise.

Cryoablation in Extra-Abdominal Desmoid Tumors: A 10-Year Experience in Pediatric and Young Adult Patients

PURPOSE

To determine the efficacy and safety of cryoablation in pediatric and young adult patients with desmoid tumors (DTs) retrospectively over a 10-year period.

MATERIALS AND METHODS

Twenty-one patients (age 2-22 years; median 14 years), with 21 desmoid tumors, underwent a total of 34 percutaneous cryoablation procedures between August 2013 and August 2023. All patients, excluding two, had surgical resection, chemotherapy, or a combination of these therapies with failed or suboptimal response. Clinical and imaging outcomes were analyzed for technical success, change in tumor volume, and recurrence of tumor, symptom improvement or recurrence, and procedure-related complications.

RESULTS

All procedures were technically successful. The median follow-up duration was 9 months (range, 3-32 months); total symptomatic improvement was achieved in 90% (19/21) patients, noticeable pain relief was seen in 100% (18/18) and 90% (9/10) patients had improved range of motion (ROM), discomfort resolved in 66.7% (2/3) patients. Of the treated tumors, 43% (9/21) showed greater than 75% tumor volume reduction of which 44% (4/9) had no evidence of viable residual tumor at follow-up, and 33% (7/21) had 50-75% volume reduction and 14% (3/21) had greater than 40-50% tumor volume reduction. According to modified response evaluation criteria in solid tumors (mRECIST), 71%( 15/21) had partial response (PR), 19% (4/21) had complete response (CR), and 10% (2/21) had stable disease. Four (12%) treatments were associated with minor complications, which self-resolved.

CONCLUSION

In this, predominantly pediatric patient cohort, cryoablation was effective and safe for the local control of extra-abdominal desmoid tumors in short-term follow-up.

The journey of nanoparticles in the abdominal cavity: Exploring their in vivo fate and impact factors

Peritoneal carcinomatosis (PC) is caused by metastasis of primary tumor cells from intra-abdominal organs to the peritoneal surface. Intraperitoneal (IP) chemotherapy allows close contact of high concentrations of therapeutic agents with cancer cells in the peritoneal cavity to prolong patient survival. However, conventional IP chemotherapy is prone to rapid elimination from the peritoneal cavity and lacks specificity towards cancer cells. To address these challenges, there is an imperative demand for exploiting novel drug delivery systems to enhance drug retention in the peritoneal cavity and target PC cells. Therefore, in this review, we first recapitulate the physiological structures and barriers associated with IP drug delivery, highlighting the in vivo fate of nanoparticles (NPs) after IP administration. Furthermore, the influence of physicochemical properties (particle size, charge, surface modification, and carrier composition) on the in vivo fate of NPs is discussed. Perspectives on the rational design of NPs for IP therapy and recent clinical progress are also provided.

Robotic Recto-Sigmoid Resection with Total Intracorporeal Colorectal Anastomosis (TICA) in Recurrent Ovarian Cancer

BACKGROUND

About 70% of women affected by ovarian cancer experience relapse within 2 years of diagnosis. Traditionally, the standard treatment for recurrent ovarian cancer (ROC) has been represented by systemic chemotherapy.1 Recently, several retrospective studies have suggested that secondary cytoreductive surgery could provide better clinical outcomes than chemotherapy alone, in the case of complete tumor cytoreduction.2,3 About 50% of patients with ROC have a pelvic component of the disease and 22% of patients present isolated pelvic recurrence, often involving the rectum.4,5 Minimally invasive secondary cytoreductive surgery is a feasible option and is associated with favorable perioperative outcomes.6-8 It is crucial to fully explore the peritoneal cavity before starting cytoreductive procedures in order to confirm the absence of carcinomatosis.9 The robotic system facilitates the identification of anatomical structures and makes it easier to perform complex surgical steps in narrow spaces. It also allows the integrated use of surgical tools such as intraoperative ultrasound and indocyanine green application.

METHODS

In this video, we present the case of a 64-year-old woman who experienced a rectal recurrence of ovarian cancer after a platinum-free interval of 12 months. We describe, in a step-by-step manner, the surgical procedure of a robotic rectosigmoid resection with totally intracorporeal colorectal anastomosis (TICA).10-12 RESULTS: Robotic secondary cytoreduction with complete gross resection was achieved. The patient did not report any intraoperative or postoperative complications. Final histology confirmed ROC.

CONCLUSION

Totally robotic rectosigmoid resection is a feasible option in isolated bowel recurrences. Thanks to continuous technical evolution, robot-assisted surgery has the potential to have a central role in the fight against solid tumors. Integration of multiple pre- and intraoperative technologies allows personalized surgery to be performed for each different patient.13,14.

The role of multimodality imaging in the selection and management of patients treated with cytoreductive surgery and HIPEC

Cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) is the mainstay of potentially curative surgical treatment for malignancies that have spread to peritoneal surfaces. This surgical procedure is however associated with high morbidity and appropriate patient selection and planning is therefore essential. Available multimodality imaging techniques include CT with oral and intravenous contrast, MRI including use of dedicated peritoneal protocol and FDG-PET/CT. These used with the correct technique, read by specialist radiologists and discussed under the auspices of a dedicated multidisciplinary team, can help to improve outcomes. We demonstrate that imaging not only provides information about peritoneal disease burden but more importantly want to shift the reader's focus to disease distribution. Our examples highlight how imaging helps avoid futile surgery by identifying patients with disease in unfavourable sites and show the strength and limitations of the various imaging modalities. We share how MR imaging can help identify multifocal and often occult sites including widespread miliary disease. Our examples provide a comprehensive overview demonstrating how imaging can help plan surgery by identifying patients who may need splenic vaccinations, counselling for stoma, egg harvesting and input from surgeons with other specialist expertise greatly increasing likelihood of achieving complete cytoreduction.

Primary signet ring cell carcinoma of the small intestine with abdominal pain and ascites as main symptoms: A rare case report and literature review

BACKGROUND

Primary small bowel adenocarcinoma (SBA) is an extremely rare malignant tumor of the digestive tract. Small bowel signet ring cell carcinoma, a form of SBA, is even more rare. According to epidemiological statistics, SBA only accounts for 2%-3% of all gastrointestinal malignancies, and the disease is hidden in the early stage, which is easy to miss or misdiagnose, and clinicians need to conduct in-depth identification before diagnosis.

CASE SUMMARY

This paper describes a rare case of SBA, characterized by chronic abdominal pain with ascites as the main symptoms, which was finally diagnosed by histopathology and immunohistochemistry obtained through percutaneous intraperitoneal target puncture guided by external abdominal ultrasound. Through genetic testing, personalized immunotherapy was selected. The patient was followed for half a year, and no symptoms such as abdominal pain and ascites were found.

CONCLUSION

The present case stresses the importance of in-depth diagnosis and timely treatment of SBA accompanied by abdominal pain and ascites, which is expected to increase the overall understanding of SBA and improve the clinical diagnosis of this rare disease.

Imaging of Peritoneal Surface Malignancies

Management of peritoneal surface malignancies is currently entrusted to a multimodality approach. Computed tomography (CT) scan remains the first imaging method despite the limitations in identifying small implants in critical regions. Magnetic resonance imaging is usually recommended for its performance in small implants, mesentery, and small bowel assessment. Positron emission tomography/CT plays an important role only in pseudomyxoma peritonei. Thus, becoming aware of the imaging strengths and drawbacks and having a multimodality imaging approach might be the best option for the patients.

Clinicopathological analysis of small intestinal metastasis from extra-abdominal/extra-pelvic malignancy

BACKGROUND

The metastatic tumors in the small intestine secondary to extra-abdominal/extra-pelvic malignancy are extremely rare. However, the small intestine metastases are extremely prone to misdiagnosis and missed diagnosis due to the lack of specific clinical manifestations and examination methods, thus delaying its treatment. Therefore, in order to improve clinical diagnosis and treatment capabilities, it is necessary to summarize its clinical pathological characteristics and prognosis.

AIM

To summarize the clinicopathological characteristics of patients with small intestinal metastases from extra-abdominal/extra-pelvic malignancy, and to improve the clinical capability of diagnosis and treatment for rare metastatic tumors in the small intestine.

METHODS

The clinical data of patients with small intestinal metastases from extra-abdominal/extra-pelvic malignancy were retrieved and summarized, who admitted to and treated in the Air Force Medical Center, Chinese People’s Liberation Army. Then descriptive statistics were performed on the general conditions, primary tumors, secondary tumors in the small intestine, diagnosis and treatment processes, and prognosis.

RESULTS

Totally 11 patients (9 males and 2 females) were enrolled in this study, including 8 cases (72.3%) of primary lung cancer, 1 case (9.1%) of malignant lymphoma of the thyroid, 1 case (9.1%) of cutaneous malignant melanoma, and 1 case (9.1%) of testicular cancer. The median age at the diagnosis of primary tumors was 57.9 years old, the median age at the diagnosis of metastatic tumors in the small intestine was 58.81 years old, and the average duration from initial diagnosis of primary tumors to definite diagnosis of small intestinal metastases was 9 months (0-36 months). Moreover, small intestinal metastases was identified at the diagnosis of primary tumors in 4 cases. The small intestinal metastases were distributed in the jejunum and ileum, with such clinical manifestations as hematochezia (5, 45.4%) and abdominal pain, vomiting and other obstruction (4, 36.4%). In addition, 2 patients had no obvious symptoms at the diagnosis of small intestinal metastases, and 5 patients underwent radical resection of small intestinal malignancies and recovered well after surgery. A total of 3 patients did not receive subsequent treatment due to advanced conditions.

CONCLUSION

Small intestinal metastases of extra-abdominal/extra-pelvic malignancy is rare with high malignancy and great difficulty in diagnosis and treatment. Clinically, patients with extra-abdominal/extra-pelvic malignancy should be alert to the occurrence of this disease, and their prognosis may be improved through active surgery combined with standard targeted therapy.

Adjuvants restore colistin sensitivity in mouse models of highly colistin-resistant isolates, limiting bacterial proliferation and dissemination

Antimicrobial resistance (AMR) has led to a marked reduction in the effectiveness of many antibiotics, representing a substantial and escalating concern for global health. Particularly alarming is resistance in Gram-negative bacteria due to the scarcity of therapeutic options for treating infections caused by these pathogens. This challenge is further compounded by the rising incidence of resistance to colistin, an antibiotic traditionally considered a last resort for the treatment of multi-drug resistant (MDR) Gram-negative bacterial infections. In this study, we demonstrate that adjuvants restore colistin sensitivity in vivo. We previously reported that the salicylanilide kinase inhibitor IMD-0354, which was originally developed to inhibit the human kinase IKKβ in the NFκB pathway, is a potent colistin adjuvant. Subsequent analog synthesis using an amide isostere approach led to the creation of a series of novel benzimidazole compounds with enhanced colistin adjuvant activity. Herein, we demonstrate that both IMD-0354 and a lead benzimidazole effectively restore colistin susceptibility in mouse models of highly colistin-resistant Klebsiella pneumoniae and Acinetobacter baumannii-induced peritonitis. These novel adjuvants show low toxicity in vivo, significantly reduce bacterial load, and prevent dissemination that could otherwise result in systemic infection.

Genomic landscape defines peritoneal metastatic pattern and related target of peritoneal metastasis in colorectal cancer

The primary objective of this study is to develop a prediction model for peritoneal metastasis (PM) in colorectal cancer by integrating the genomic features of primary colorectal cancer, along with clinicopathological features. Concurrently, we aim to identify potential target implicated in the peritoneal dissemination of colorectal cancer through bioinformatics exploration and experimental validation. By analyzing the genomic landscape of primary colorectal cancer and clinicopathological features from 363 metastatic colorectal cancer patients, we identified 22 differently distributed variables, which were used for subsequent LASSO regression to construct a PM prediction model. The integrated model established by LASSO regression, which incorporated two clinicopathological variables and seven genomic variables, precisely discriminated PM cases (AUC 0.899; 95% CI 0.860-0.937) with good calibration (Hosmer-Lemeshow test p = .147). Model validation yielded AUCs of 0.898 (95% CI 0.896-0.899) and 0.704 (95% CI 0.622-0.787) internally and externally, respectively. Additionally, the peritoneal metastasis-related genomic signature (PGS), which was composed of the seven genes in the integrated model, has prognostic stratification capability for colorectal cancer. The divergent genomic landscape drives the driver genes of PM. Bioinformatic analysis concerning these driver genes indicated SERINC1 may be associated with PM. Subsequent experiments indicate that knocking down of SERINC1 functionally suppresses peritoneal dissemination, emphasizing its importance in CRCPM. In summary, the genomic landscape of primary cancer in colorectal cancer defines peritoneal metastatic pattern and reveals the potential target of SERINC1 for PM in colorectal cancer.

A multi-nozzle nebuliser does not improve tissue drug delivery during PIPAC

BACKGROUND

Multi-nozzle nebulisers for pressurised intraperitoneal aerosol chemotherapy (PIPAC) are implemented in clinical practice to improve the homogeneity of tissue drug delivery. Nonetheless, the advantages of such devices over one-nozzle nebulisers have not been demonstrated thus far. In this study, we compared the performance of multi- and one-nozzle nebulisers by conducting physical and ex vivo pharmacological experiments.

METHODS

The one-nozzle nebuliser Capnopen® and the multi-nozzle nebuliser were the subjects of this study. In physical experiments, the aerosol droplet size was measured by laser diffraction spectroscopy. Spatial spray patterns were depicted on blotting paper. Pharmacological experiments were performed on the enhanced inverted bovine urinary bladder model, demonstrating real-time tissue drug delivery, aerosol sedimentation and homogeneity of doxorubicin and cisplatin tissue distribution.

RESULTS

The multi-nozzle nebuliser had a sixfold greater aerosolisation flow and a threefold greater angle of aerosolisation than Capnopen®. The aerosol particle size and distribution range were higher than that of Capnopen®. Spray patterns on blotting paper were more extensive with the multi-nozzle nebuliser. Real-time tissue drug delivery with the multi-nozzle nebuliser was over 100 ml within 1 min, and the aerosol sedimentation was 48.9% ± 21.2%, which was not significantly different from that of Capnopen®. The doxorubicin and cisplatin tissue concentrations were greater with Capnopen®. Although there was no significant difference in the homogeneity of doxorubicin distribution between the two devices, the homogeneity of cisplatin distribution was significantly higher with Capnopen®.

CONCLUSION

The multi-nozzle PIPAC nebuliser did not fulfil expectations. Even though the surface spray patterns were broader with the multi-nozzle nebuliser, the tissue drug homogeneity and concentration were greater with Capnopen®.

The 2022 PSOGI International Consensus on HIPEC Regimens for Peritoneal Malignancies: HIPEC Technologies

This manuscript reports the results of an international consensus on technologies of hyperthermic intraperitoneal perioperative chemotherapy (HIPEC) performed with the following goals: To provide recommendations for the technological parameters to perform HIPEC. To identify the role of heat and its application forms in treating peritoneal metastases. To provide recommendations regarding the correct dosimetry of intraperitoneal chemotherapy drugs and their carrier solutions. To identify for each intraperitoneal chemotherapy regimen the best dosimetry and fractionation. To identify areas of future research pertaining to HIPEC technology and regimens. This consensus was performed by the Delphi technique and comprised two rounds of voting. In total, 96 of 102 eligible panelists replied to both Delphi rounds (94.1%) with a consensus of 39/51 questions on HIPEC technical aspects. Among the recommendations that met with the strongest consensus were those concerning the dose of HIPEC drug established in mg/m2, a target temperature of at least 42°C, and the use of at least three temperature probes to pursue hyperthermia. Ninety minutes as the ideal HIPEC duration seemed to make consensus. These results should be considered when designing new clinical trials in patients with peritoneal surface malignancies.

Assessment of Intraoperative Scoring Systems for Predicting Cytoreduction Outcome in Peritoneal Metastatic Disease: A Systematic Review and Meta-analysis

BACKGROUND

Cytoreductive surgery (CRS) is a widely acknowledged treatment approach for peritoneal metastasis, showing favorable prognosis and long-term survival. Intraoperative scoring systems quantify tumoral burden before CRS and may predict complete cytoreduction (CC). This study reviews the intraoperative scoring systems for predicting CC and optimal cytoreduction (OC) and evaluates the predictive performance of the Peritoneal Cancer Index (PCI) and Predictive Index Value (PIV).

METHODS

Systematic searches were conducted in Embase, MEDLINE, and Web of Science. Meta-analyses of extracted data were performed to compare the absolute predictive performances of PCI and PIV.

RESULTS

Thirty-eight studies (5834 patients) focusing on gynecological (n = 34; 89.5%), gastrointestinal (n = 2; 5.3%) malignancies, and on tumors of various origins (n = 2; 5.3%) were identified. Seventy-seven models assessing the predictive performance of scoring systems (54 for CC and 23 for OC) were identified with PCI (n = 39/77) and PIV (n = 16/77) being the most common. Twenty models (26.0%) reinterpreted previous scoring systems of which ten (13%) used a modified version of PIV (reclassification). Meta-analyses of models predicting CC based on PCI (n = 21) and PIV (n = 8) provided an AUC estimate of 0.83 (95% confidence interval [CI] 0.79-0.86; Q = 119.6, p = 0.0001; I2 = 74.1%) and 0.74 (95% CI 0.68-0.81; Q = 7.2, p = 0.41; I2 = 11.0%), respectively.

CONCLUSIONS

Peritoneal Cancer Index models demonstrate an excellent estimate of CC, while PIV shows an acceptable performance. There is a need for high-quality studies to address management differences, establish standardized cutoff values, and focus on non-gynecological malignancies.

Multifunctional targeting of docetaxel plus bakuchiol micelles in the treatment of invasion and metastasis of ovarian cancer

The invasion and metastasis of tumors pose significant challenges in the treatment of ovarian cancer (OC), making it difficult to cure. One potential treatment approach that has gained attention is the use of matrix metalloproteinase reactive controlled release micelle preparations. In this study, we developed a novel PEG5000-PVGLIG-hyaluronic acid docetaxel/bakuchiol (PP-HA-DTX/BAK) micelles formulation with desirable characteristics such as particle size, narrow polydispersity index, and a ZETA potential of approximately -5 mV. The surface modification with HA facilitates tumor penetration into the tumor interior, while the incorporation of DSPE-PEG2000-PVGLIG-PEG5000helps conceal DSPE-PEG2000-HA, reducing off-target effects and prolonging drug circulation timein vivo. Bothin vitroandin vivoexperiments demonstrated that these micelles effectively inhibit proliferation, invasion, and metastasis of OC cells while promoting apoptosis. Therefore, our findings suggest that PP-HA-DTX/BAK micelles represent a safe and effective therapeutic strategy for treating OC.

First-line palliative systemic therapy alternated with oxaliplatin-based pressurized intraperitoneal aerosol chemotherapy for unresectable colorectal peritoneal metastases: A single-arm phase II trial (CRC-PIPAC-II)

BACKGROUND

Palliative systemic therapy alternated with electrostatic precipitation oxaliplatin-based pressurized intraperitoneal aerosol chemotherapy (ePIPAC) has never been prospectively investigated in patients with unresectable colorectal peritoneal metastases (CPM). The CRC-PIPAC-II study aimed to assess safety, feasibility and efficacy of such bidirectional therapy.

METHODS

This two-center, single-arm, phase II trial enrolled chemotherapy-naïve patients to undergo three treatment cycles, consisting of systemic therapy (CAPOX, FOLFOX, FOLFIRI, or FOLFOXIRI, all with bevacizumab) and oxaliplatin-based ePIPAC (92 mg/m2) with intravenous leucovorin (20 mg/m2) and 5-fluorouracil (400 mg/m2). Primary outcome were major treatment-related adverse events. Secondary outcomes included minor events, tumor response, progression-free survival (PFS) and overall survival (OS).

RESULTS

Twenty patients completed 52 treatment cycles. Fifteen major events occurred in 7 patients (35 %): 5 events (33 %) related to systemic therapy; 5 (33 %) related to ePIPAC; and 5 (33 %) were biochemical events. No treatment-related deaths occurred. All patients experienced minor events, mostly abdominal pain, nausea and peripheral sensory neuropathy. After treatment, radiological, pathological, cytological, and biochemical response was observed in 0 %, 88 %, 38 %, and 31 % of patients respectively. Curative surgery was achieved in one patient. Median PFS was 10.0 months (95 % confidence interval [CI] 8.0-13.0) and median OS was 17.5 months (95 % CI 13.0-not reached).

CONCLUSIONS

Combining palliative systemic therapy with oxaliplatin-based ePIPAC in patients with unresectable CPM was feasible and showed an acceptable safety profile. Treatment-induced response and survival are promising, yet further research is required to determine the additional value of ePIPAC to systemic therapy.

Motherhood on a precarious path: Pregnancy following breast carcinoma - Case report

Women of childbearing age frequently express a desire for pregnancy even after a diagnosis of breast cancer and after undergoing treatment. The average age of primiparous women is rising and gynecologists and oncologists are faced with inquiries about pursuing childbearing after the diagnosis of breast cancer. We present a case of a 39 year old women who came to our clinic in 39th week of gestation, gave vaginal birth to a vigorous neonatus and underwent into dyspnea just two hours after the delivery. She voluntarily disclosed her advanced stage of breast cancer diagnosis, as she feared it could lead to the termination of her pregnancy. After she was released from the hospital, she did not attend any follow-up appointments at our clinic, hence we have no knowledge whether she contacted her oncologist or the outcome of her primary disease.