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Golse N, Bakrin N, Passot G, Mohamed F, Vaudoyer D, Gilly FN, Glehen O, Cotte E. Iterative procedures combining cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal recurrence: postoperative and long-term results. J Surg Oncol 2012; 106:197-203. [PMID: 22331814 DOI: 10.1002/jso.23062] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 01/21/2012] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is the best treatment of several peritoneal surface malignancies. Isolated peritoneal recurrence may be treated by iterative procedures. The aim of this study was to evaluate immediate postoperative and long-term results after iterative CRS-HIPEC. METHODS From 1990 to 2010, 30 patients with isolated peritoneal recurrence underwent iterative procedures combining CRS-HIPEC. RESULTS Origins of peritoneal carcinomatosis were ovarian, colorectal, pseudomyxoma peritonei, peritoneal mesothelioma, gastric cancer, cholangiocarcinoma, leiomyosarcoma, and primary peritoneal serous carcinoma. Median recurrence-free survival (RFS) was 16.2 months from the first procedure. After the second procedure, one (3.3%) postoperative death occurred. Severe morbidity following the second procedure was 40% versus 30% after the first procedure (P = 0.37). At most recent follow up, 11 patients were disease-free, 10 were alive with recurrence, and 9 were dead with recurrence. Five-year overall survival after initial CRS with HIPEC was 65%, and overall median survival from diagnosis was 140 months. CONCLUSION Iterative procedures combining CRS-HIPEC are feasible and allow long-term survival but may result in significant morbidity and mortality. Patients must be carefully selected, based on the following criteria: Origin of carcinomatosis, magnitude of first procedure, length of RFS, physiological age, co-morbidity, and possibility of complete cytoreduction.
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Affiliation(s)
- Nicolas Golse
- Hospices Civils de Lyon, Service de Chirurgie Générale Thoracique et Endocrinienne, Centre Hospitalier Lyon Sud, Pierre Bénite, France
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Mohr Z, Hirche C, Klein T, Kneif S, Hünerbein M. Vacuum-assisted minimally invasive biopsy of soft-tissue tumors. J Bone Joint Surg Am 2012; 94:103-9. [PMID: 22257995 DOI: 10.2106/jbjs.j.00764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although exact histological characterization of soft-tissue tumors is essential for determining the appropriate therapy, the quality of the histological assessment is often limited by the size of the tissue samples. Incisional biopsy and core needle biopsy have been the most effective techniques for obtaining tissue samples from soft-tissue tumors. This study was performed to investigate whether vacuum-assisted biopsy can serve as a new diagnostic tool for soft-tissue neoplasms. METHODS This retrospective study compared the characterization made with use of vacuum-assisted biopsy of soft-tissue tumors in seventy-five patients between 2004 and 2006 and the characterization made with use of incisional biopsy of tumors in a comparison group of seventy-four patients between 2000 and 2005 with the final characterization made after radical tumor excision. All vacuum-assisted and incisional biopsies were performed by the same experienced surgeons and evaluated by the same experienced pathologists at a single tumor center. The sensitivity, specificity, positive and negative predictive values, and accuracy of the preliminary characterization made with use of each method were calculated on the basis of the final characterization made after excision. RESULTS The vacuum-assisted biopsy procedure was performed successfully in seventy-four (99%) of the seventy-five patients. The accuracy of vacuum-assisted biopsy (96%) was comparable with that of incisional biopsy (99%). Vacuum-assisted biopsy correctly characterized the tumor as benign or malignant in 96% (95% confidence interval [CI], 92% to 100%) of the seventy-five patients compared with 99% (95% CI, 96% to 100%) of the seventy-four patients who underwent incisional biopsy. Vacuum-assisted biopsy correctly characterized the tumor diagnosis in 95% (95% CI, 90% to 100%) of the patients compared with 95% (95% CI, 89% to 100%) for incisional biopsy. Vacuum-assisted biopsy correctly characterized the tumor grade in 89% (95% CI, 82% to 96%) of the patients compared with 88% (95% CI, 80% to 95%) for incisional biopsy. The sensitivity of vacuum-assisted biopsy was 93% (95% CI, 71% to 100%), the specificity and the positive predictive value were both 100%, and the negative predictive value was 91% (95% CI, 85% to 98%). The overall accuracy of vacuum-assisted biopsy was 96% (95% CI, 92% to 100%). CONCLUSIONS Vacuum-assisted biopsy appears to be safe and provides a new tool for the diagnosis of soft-tissue tumors. One advantage of vacuum-assisted biopsy is that it can be performed with use of local anesthesia in an outpatient setting.
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Affiliation(s)
- Zarah Mohr
- Department of General Surgery and Surgical Oncology, HELIOS Hospital Berlin-Buch, Berlin, Germany.
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Arjona-Sánchez Á, Muñoz-Casares FC, Rufián-Peña S, Díaz-Nieto R, Casado-Adam Á, Rubio-Pérez MJ, Ortega-Salas R. Pseudomyxoma peritonei treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: results from a single centre. Clin Transl Oncol 2011; 13:261-7. [PMID: 21493187 DOI: 10.1007/s12094-011-0651-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pseudomyxoma peritonei (PMP) is a rare, slowly progressive disease whose prognosis depends primarily on the completeness of cytoreduction. The value of intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) and of additional factors predicting long-term outcome and disease-free survival (DFS) remains poorly understood. This study aims to analyse survival rates and prognostic factors in patients undergoing maximal cytoreduction and HIPEC. METHODS Thirty patients were selected from a prospective database of records for patients undergoing cytoreduction and HIPEC with mitomycin C or paclitaxel. Overall survival (OS), DFS, and the prognostic factors influencing them, were examined using multivariate analysis. RESULTS Median follow-up was 44 months (range, 8-144). Histological classification of PMPs was DPAM in 6/30 of cases, PMCA-I in 10/30 and PMCA in 14/30. Complete cytoreduction (CC-0 and CC-1) was achieved in 28/30 of patients and CC-2 in 2/30. Median OS was 111 months (range 0-230) and five-year OS rate was 67%. Median DFS was 53.5 months (range 0-120) and 5-year DFS rate was 44%. Incomplete cytoreduction, lymph node involvement and PCI>20 were associated with poor prognosis for OS, while lymph node involvement, elevated CA-125 levels, unfavourable histology and previous chemotherapy were associated with poor outcomes for DFS. There was morbidity of Grade 3 or higher in 9/30. Post-operative mortality occurred in 1 case. CONCLUSION Cytoreduction plus peritonectomy procedures combined with HIPEC is a safe treatment and could improve survival rates. Since the optimal cytoreduction is the primary prognostic factor, patients should be centralised under the care of experienced teams.
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Affiliation(s)
- Álvaro Arjona-Sánchez
- Department of General Surgery, Unit of Surgical Oncology, Hospital Universitario Reina Sofía, Córdoba, Spain
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Cyto-reductive Surgery combined with Hyperthermic Intra-peritoneal Chemotherapy for Peritoneal Surface Malignancies: current treatment and results. Cancer Treat Rev 2011; 38:258-68. [PMID: 21807464 DOI: 10.1016/j.ctrv.2011.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 07/03/2011] [Accepted: 07/06/2011] [Indexed: 02/06/2023]
Abstract
Cyto-reductive Surgery (CS) combined with Hyperthermic Intra-peritoneal Chemotherapy (HIPEC) as loco-regional treatment of Peritoneal Surface Malignancies (PSM) has increasingly gained acceptance in clinical practice. This review summarizes the more relevant studies on this topic. Indications, pre-operative work-up, technical aspects, outcome and future directions of this combined approach in the treatment of Peritoneal Surface Malignancies are discussed here and proposed in an informative and didactic manner.
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Perioperative fast track program in intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery in advanced ovarian cancer. Eur J Surg Oncol 2011; 37:543-8. [DOI: 10.1016/j.ejso.2011.03.134] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 01/13/2011] [Accepted: 03/17/2011] [Indexed: 01/31/2023] Open
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Mancebo-González A, Díaz-Carrasco MS, Cascales-Campos P, de la Rubia A, Gil Martínez J. [Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy associated toxicity in treatment of peritoneal carcinomatosis]. FARMACIA HOSPITALARIA 2011; 36:60-7. [PMID: 21514864 DOI: 10.1016/j.farma.2011.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 01/11/2011] [Accepted: 01/18/2011] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Peritoneal carcinomatosis is a form of intra-abdominal dissemination of several tumours, which is associated with a poor prognosis. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is an alternative treatment. The aim of this study is to describe the toxicity associated with this procedure in patients with peritoneal carcinomatosis. METHOD We conducted a descriptive, retrospective, single-centre study, including all patients undergoing this procedure between December 2007 and January 2010. The following data were recorded: anthropometric data, personal and surgical events, indication, previous treatments, extent of carcinomatosis, intervention duration, hospital stay, and type of complications and/or adverse events following application of the multidisciplinary treatment. RESULTS We performed 46 interventions on 45 patients diagnosed with peritoneal carcinomatosis from different causes, mainly ovarian cancer (83%). Paclitaxel was the most-used drug (35 interventions). There was no associated mortality, the average intervention time was 6.4 hours and the average hospital stay 7 days. We recorded adverse effects for 42 procedures, being grade 3-4 in 28.3% of the patients. The severe adverse events were: 10.9% gastrointestinal, 10.9% infectious, 6.5% haemorrhage or bleeding, 6.5% medullary toxicity, 4.4% respiratory, 2.2% coagulation and 2.2% hepatobiliary disorders. One patient developed grade III neutropaenia, probably associated with cisplatin. CONCLUSION The morbidity and mortality is in line with the average of published studies, and has mainly been attributed to surgical complications. Toxicity data lower than other studies can be due to using more tolerable chemotherapy regimens, not including drug combinations and given that paclitaxel was the main drug.
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Affiliation(s)
- A Mancebo-González
- Servicio de Farmacia, Hospital Universitario Virgen de la Arrixaca, Murcia, España
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Mohr Z, Hirche C, Liebeskind U, Rau B, Hünerbein M. Feasibility of Delayed Hyperthermic Intraperitoneal Chemotherapy in Case of Unforeseen Complications. Eur Surg Res 2011; 47:19-25. [DOI: 10.1159/000327397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 03/08/2011] [Indexed: 11/19/2022]
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Vásquez Jiménez W, González Bayón L, García-Sabrido JL, González Moreno S. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignant disease. Clin Transl Oncol 2010; 12:794-804. [PMID: 21156410 DOI: 10.1007/s12094-010-0601-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Peritoneal Malignant Disease (PMD) is the presence of tumoral tissue on the peritoneal surface from primary tumors or tumors from other locations (e.g. digestive or gynecologic). It is a regional disease with poor prognosis when treated with repeated "debulking" and traditional systemic chemotherapy. Cytoreduction plus hyperthermic intraperitoneal chemotherapy (HIPEC) is a combined multimodal regional procedure aimed at reducing the macroscopic tumoral mass as much as possible and treating with chemotherapy the microscopic disease that is out of the scope of the surgeon. This combined treatment may change the natural history of PMD, it is translated into a higher overall survival and cancer-free survival and it offers the option of cure in selected cases. The high-complexity procedure is also associated with complications and mortality, but in similar rates as other major oncologic procedures.
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Roviello F, Caruso S, Marrelli D, Pedrazzani C, Neri A, De Stefano A, Pinto E. Treatment of peritoneal carcinomatosis with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: state of the art and future developments. Surg Oncol 2010; 20:e38-54. [PMID: 20888755 DOI: 10.1016/j.suronc.2010.09.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 08/06/2010] [Accepted: 09/06/2010] [Indexed: 02/06/2023]
Abstract
Peritoneal carcinomatosis (PC) had long been regarded as a terminal disease, characterized by a very poor survival and worth treating with palliative therapy. A new strategy combining maximal surgery (cytoreductive surgery, CRS), with maximal regional chemotherapy (hyperthermic intraperitoneal chemotherapy, HIPEC), has been proposed to treat PC, resulting in long-term survival rates in selected patients. The emerging trend is to view localised peritoneal carcinomatosis, in the absence of other metastases, as a regional metastatic disease that is amenable to locoregional therapy. In spite of the need for more high quality studies, many international experts now agree that the use of this new strategy is a gold standard for treating selected patients with PC with the intent of curing. The best results are achieved in patients with limited disease who have completed macroscopic tumor removal. To offer a comprehensive review, we summarized the present status and possible future progress of this treatment modality, in particular outlining its rationale, current practice and general outcome.
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Affiliation(s)
- Franco Roviello
- Department of Human Pathology and Oncology, University of Siena, Italy.
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Roviello F, Pinto E, Corso G, Pedrazzani C, Caruso S, Filippeschi M, Petrioli R, Marsili S, Mazzei MA, Marrelli D. Safety and potential benefit of hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal carcinomatosis from primary or recurrent ovarian cancer. J Surg Oncol 2010; 102:663-70. [PMID: 20721959 DOI: 10.1002/jso.21682] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To analyze the outcomes of cytoreductive surgery and HIPEC in patients with peritoneal carcinomatosis from ovarian cancer. METHODS Fifty-three patients with peritoneal carcinomatosis from primary (45 cases) and recurrent (8 cases) ovarian cancer were previously treated by systemic chemotherapy with platinum and taxanes and then submitted to surgical cytoreduction and HIPEC (cisplatin and mitomycin-C) with a closed abdomen technique. The median follow-up period was 27 months (range: 3-107). RESULTS At the end of operation a complete cytoreduction (CCR-0) was obtained in 37 patients (70%). Major morbidity occurred in 12 patients (23%); reoperation was necessary in 2 patients (4%), and no postoperative mortality was observed. Overall 5-year survival probability was 55%; it was 71% in CCR-0, 44% in CCR-1, and none in patients with CCR-2 or CCR-3 residual tumor (log-rank test: P = 0.017). The cumulative risk of recurrence in 37 CCR-0 cases was 54% at 5 years from operation. CONCLUSIONS The results of our study indicate the feasibility and the potential benefit of a protocol including systemic chemotherapy, surgical cytoreduction and HIPEC in patients with peritoneal carcinomatosis from ovarian cancer. A phase III trial to compare this approach with conventional treatment is needed.
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Affiliation(s)
- Franco Roviello
- Department of Human Pathology and Oncology, Section of Advanced Surgical Oncology, University of Siena, Siena, Italy
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Glockzin G, Renner P, Popp FC, Dahlke MH, von Breitenbuch P, Schlitt HJ, Piso P. Hepatobiliary procedures in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol 2010; 18:1052-9. [PMID: 21046262 DOI: 10.1245/s10434-010-1415-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND The long-term prognosis of patients with peritoneal malignancies has greatly improved since the introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Nevertheless, CRS can be associated with high postoperative morbidity. In this retrospective study, we analyzed the influence of hepatobiliary surgery as part of CRS on postoperative short-term patient outcome. METHODS Between 2005 and 2008, a total of 63 (25%) of 252 patients with peritoneal surface malignancies undergoing CRS and HIPEC required hepatobiliary surgery. Liver resection was performed in 22, resection of Glisson capsule in 39, and bile duct resection in 2 patients. The mean age of the study population was 49.3 years. Thirty-four patients (54%) were women. RESULTS Complete macroscopic cytoreduction (CC-0/1) was reached in 59 patients (93.7%). The median hospital stay was 18 days. Twenty-two patients developed minor complications (35%), such as moderate fever, pain, or secondary wound healing. In 21 patients (33%), severe complications occurred, most commonly pancreatitis and abdominal abscess. Three patients (4.8%) developed a biliary leakage. Of these, 2 had to be reoperated. CONCLUSIONS In our experience, hepatobiliary procedures have to be performed in up to one-third of patients and are associated with a low rate of specific complications, such as biliary leakages.
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Affiliation(s)
- Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
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Hyperthermic intraperitoneal chemotherapy with oxaliplatin and without adjuvant chemotherapy in stage IIIC ovarian cancer. Bull Cancer 2010; 97:E23-32. [PMID: 20202920 DOI: 10.1684/bdc.2010.1063] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the feasibility and efficacy of cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) without adjuvant chemotherapy for relapsed or persistent advanced ovarian cancer. METHODS This observational study included stage IIIC ovarian cancer patients due to undergo CRS (interval debulking or recurrent surgery) followed by HIPEC with oxaliplatin (460 mg/m2) for 30 min. RESULTS Twenty-two patients (12 interval debulking procedures and 10 recurrence procedures) were enrolled between September 2003 and September 2007. HIPEC was not performed in four patients because of operative findings. No patient received adjuvant chemotherapy after HIPEC. Patients were followed up routinely until recurrence or death. Median peritoneal cancer index at surgery was 6 (range: 1-18). Before HIPEC, all patients had completeness of cytoreduction scores of 0 or 1. Median length of hospital stay was 21 days (range 13-65). Ten patients (55.6%) had CTCAE grade 3-4 toxicity, including three patients (16.7%) requiring reoperation. No postoperative mortality was observed. With a median follow-up of 38 months (CI 95% 23.8-39.2), median overall survival was not reached. The 3-year overall survival rate was 83% (CI 95% 54-95). Median disease-free survival was, respectively, 16.9 months (CI 95% 10.2-23.2) and 10 months (CI 95% 4.5-11.3) for patients undergoing interval debulking or recurrence surgery. CONCLUSION HIPEC without adjuvant chemotherapy is both feasible and safe, but with a high rate of grade 3-5 toxicity. Survival results are encouraging but should be confirmed in a randomized trial.
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Abstract
As life expectancy increases and advances in cancer treatment more often convert deadly conditions into more chronic diseases, the surgical intensivist can expect to be faced with greater numbers of oncology patients undergoing aggressive surgical treatments for curative intent, prolonging survival, or primarily palliation by alleviating obstruction, infection, bleeding, or pain. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) are a paradigm for the emerging field of multimodal aggressive oncological surgery. This article describes the CRS/HIPEC technique, and discusses the most common postoperative complications and critical care issues in these patients, including anastomotic leaks, intestinal perforation, abscesses, and intra-abdominal bleeding. The leading cause of mortality is sepsis leading to multiple organ failure, and such patients are at particularly higher risk due to the extensive CRS and HIPEC. The intensivist must be vigilant to ensure that source control is not overlooked. This process is a very difficult one, made even more challenging by the blunting of physiologic responses and the frequent absence of the classic acute abdomen.
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Affiliation(s)
- Sanam Ahmed
- Division of Critical Care Medicine, Department of Surgery, The Mount Sinai School of Medicine, 1 Gustave L. Levy Place, New York, NY 10029, USA
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Baratti D, Kusamura S, Laterza B, Balestra MR, Deraco M. Early and long-term postoperative management following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. World J Gastrointest Oncol 2010; 2:36-43. [PMID: 21160815 PMCID: PMC2999156 DOI: 10.4251/wjgo.v2.i1.36] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 08/31/2009] [Accepted: 09/07/2009] [Indexed: 02/05/2023] Open
Abstract
Peritoneal surface malignancies have been traditionally regarded as end-stage conditions amenable to merely palliative options. The combination of aggressive cytoreductive surgery (CRS), involving peritonectomy procedures and multivisceral resections, with intra-operative hyperthermic intra-peritoneal chemotherapy (HIPEC) and/or early postoperative intra-peritoneal chemotherapy (EPIC) to treat the microscopic residual tumor is a new concept. In recent years, promising results have been reported for peritoneal mesothelioma and carcinomatosis of gastrointestinal and gynaecologic origin treated by this combined protocol. However, CRS with HIPEC and/or EPIC is a complex procedure associated with high rates of potentially life-threatening complications. Furthermore, disease progression following comprehensive treatment is not uncommon and represents a relevant cause of treatment failure. The present paper reviews the available information on early postoperative management and long-term follow-up in patients treated with CRS and intraperitoneal chemotherapy. The peculiar clinical and biological alterations that can be expected during an uncomplicated postoperative course, as compared to standard digestive surgery, are discussed. Early recognition and appropriate management of the most common adverse events are addressed, in order to minimize the impact of treatment-related morbidity on survival and quality of life results. Since re-operative surgery with additional HIPEC, has proven to be useful in selected patients with recurrent disease, long-term surveillance aiming at early detection of postoperative disease progression has become a relevant issue. Current results on follow-up investigations are presented.
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Affiliation(s)
- Dario Baratti
- Dario Baratti, Shigeki Kusamura, Barbara Laterza, Maria Rosaria Balestra, Marcello Deraco, Department of Surgery, National Cancer Institute, Via Venezian 1, 20133 Milan, Italy
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Jaehne J. Cytoreductive procedures-strategies to reduce postoperative morbidity and management of surgical complications with special emphasis on anastomotic leaks. J Surg Oncol 2009; 100:302-5. [PMID: 19697435 DOI: 10.1002/jso.21328] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) for the therapy of peritoneal carcinomatosis are associated with substantial morbidity and acceptable mortality. Patient selection, learning curve, patient warming, and reduced blood loss are the main factors to decrease morbidity. Morbidity is mostly associated with bowl fistulas and anastomotic leakages. Depending on the site of leaks they may be managed conservatively or by reoperation. For standardization of study reports on morbidity and mortality the CTCAE classification is recommended.
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Affiliation(s)
- Joachim Jaehne
- Department of General and Visceral Surgery, Diakoniekrankenhaus Henriettenstiftung gGmbH, Hannover, Germany.
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66
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Glockzin G, Ghali N, Lang SA, Schlitt HJ, Piso P. Results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal cancer. J Surg Oncol 2009; 100:306-10. [DOI: 10.1002/jso.21332] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Morbidity and mortality with cytoreductive surgery and intraperitoneal chemotherapy: the importance of a learning curve. Cancer J 2009; 15:196-9. [PMID: 19556904 DOI: 10.1097/ppo.0b013e3181a58d56] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Evidence for the efficacy of cytoreductive surgery, combined with hyperthermic intraperitoneal chemotherapy (HIPEC), in the treatment of peritoneal carcinomatosis is accumulating. Many centers around the world now have considerable experience of the complex techniques required to achieve complete cytoreduction with the administration of HIPEC. Procedure-related morbidity ranges from 12% to 67.6% and mortality from 0% to 9% in recent studies of cytoreductive surgery and HIPEC for pseudomyxoma peritonei. A number of specialized centers have studied the factors that influence perioperative complications and mortality and have demonstrated impressive reductions in morbidity and mortality over time. However, for this treatment to be accepted as standard of care, teams undertaking this treatment strategy must aim to minimize morbidity and mortality by learning from the experience of established centers and using the "global learning curve."
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Piso P, Slowik P, Popp F, Dahlke MH, Glockzin G, Schlitt HJ. Safety of gastric resections during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis. Ann Surg Oncol 2009; 16:2188-94. [PMID: 19408049 DOI: 10.1245/s10434-009-0478-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 03/25/2009] [Accepted: 03/25/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) including gastric resection combined with hyperthermic intraperitoneal chemotherapy (HIPEC) can improve the prognosis of selected patients with peritoneal surface malignancies. Perioperative morbidity of this aggressive treatment strategy is high; however, overall mortality can be low in specialized centers. The aim of this study was to assess the safety of gastric resections with anastomosis during CRS and HIPEC. METHODS Between 2005 and 2008, 204 patients underwent CRS and HIPEC at our tertiary referral centre. Of these, 37 procedures (male/female 24/13, median age 55 years) included gastric resections. The clinical data of all patients were introduced into a database and analyzed with respect to the morbidity associated with the gastric resections. RESULTS Of all patients included, 16 had pseudomyxoma peritonei, 11 gastric carcinoma, 4 ovarian carcinoma, 3 malignant peritoneal mesothelioma, and 3 colon carcinoma. Twenty-seven patients had previous surgery (n = 22) and/or systemic chemotherapy (n = 18). Fifteen total gastrectomies, 3 subtotal gastrectomies, 12 distal gastrectomies, and 7 gastric wedge resections were performed during CRS. The overall postoperative morbidity was 45%; main surgical complications were pancreatitis (n = 6), abdominal abscess (n = 4), bile leakage (n = 2), and digestive fistula (leakage of ileorectostomy and small bowel perforation) (n = 2). However, no complications occurred at the site of the esophageal anastomosis (n = 15), gastric anastomosis (n = 15) or gastric suture (n = 7). No patient died postoperatively during the hospitalization period. CONCLUSIONS CRS in combination with HIPEC is associated with high postoperative morbidity; however, anastomosis following total or subtotal gastrectomy is safe in experienced centers. No leakages related to gastric resections occurred in this high-risk patient group.
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Affiliation(s)
- Pompiliu Piso
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany.
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Fagotti A, Paris I, Grimolizzi F, Fanfani F, Vizzielli G, Naldini A, Scambia G. Secondary cytoreduction plus oxaliplatin-based HIPEC in platinum-sensitive recurrent ovarian cancer patients: a pilot study. Gynecol Oncol 2009; 113:335-40. [PMID: 19345401 DOI: 10.1016/j.ygyno.2009.03.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Revised: 03/02/2009] [Accepted: 03/04/2009] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To assess feasibility, complications and efficacy of secondary surgical cytoreduction (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in a selected group of platinum-sensitive recurrent ovarian cancer patients. METHODS Recurrent ovarian cancer patients with a platinum-free interval of at least 6 months were prospectively enrolled. After complete CRS they were submitted to intraperitoneal perfusion of oxaplatinum (460 mg/m(2)) heated to 41.5 degrees C for 30 min. Then they received systemic chemotherapy with taxotere 75 mg/m(2) and oxaliplatin 100 mg/m(2) for 6 cycles. Patients were followed up routinely until recurrence or death. RESULTS Twenty-five recurrent ovarian cancer patients were valuable for the study. The median Platinum Free Interval (PFI) was 25 months (range 7-67). The majority of the patients (76%) had diffuse carcinosis. Nobody had ascites. An optimal residual disease was obtained in all patients. The median duration of CRS+HIPEC was 312 min (range 138-619). Median intensive care unit (ICU) stay was 2 days (1-6), median hospital stay was 13 days (7-30). Post-operative major complications were observed in 7 patients (28%). Post-operative mortality was 0%. With a median follow-up time of 18 months (range 3-38), 24 patients (96%) are alive, but seven women (28%) have relapsed. CONCLUSIONS Adequate pre-operative selection can improve feasibility of CRS and HIPEC. Morbidity rate is comparable to aggressive cytoreduction without HIPEC. Although associated with some post-operative morbidity, long-term results are encouraging, waiting for larger series and longer follow-up data.
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Affiliation(s)
- A Fagotti
- Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome, Italy.
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Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. World J Surg Oncol 2009; 7:5. [PMID: 19133112 PMCID: PMC2639355 DOI: 10.1186/1477-7819-7-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Accepted: 01/08/2009] [Indexed: 12/12/2022] Open
Abstract
Background Peritoneal tumor dissemination arising from colorectal cancer, appendiceal cancer, gastric cancer, gynecologic malignancies or peritoneal mesothelioma is a common sign of advanced tumor stage or disease recurrence and mostly associated with poor prognosis. Methods and results In the present review article preoperative workup, surgical technique, postoperative morbidity and mortality rates, oncological outcome and quality of life after CRS and HIPEC are reported regarding the different tumor entities. Conclusion Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provide a promising combined treatment strategy for selected patients with peritoneal carcinomatosis that can improve patient survival and quality of life. The extent of intraperitoneal tumor dissemination and the completeness of cytoreduction are the leading predictors of postoperative patient outcome. Thus, consistent preoperative diagnostics and patient selection are crucial to obtain a complete macroscopic cytoreduction (CCR-0/1).
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