Pressurized intraperitoneal aerosol chemotherapy (PIPAC): occupational health and safety aspects

Repetitive electrostatic pressurised intraperitoneal aerosol chemotherapy (ePIPAC) with oxaliplatin as a palliative monotherapy for isolated unresectable colorectal peritoneal metastases: protocol of a Dutch, multicentre, open-label, single-arm, phase II study (CRC-PIPAC)

INTRODUCTION

Repetitive electrostatic pressurised intraperitoneal aerosol chemotherapy with oxaliplatin (ePIPAC-OX) is offered as a palliative treatment option for patients with isolated unresectable colorectal peritoneal metastases (PM) in several centres worldwide. However, little is known about its feasibility, safety, tolerability, efficacy, costs and pharmacokinetics in this setting. This study aims to explore these parameters in patients with isolated unresectable colorectal PM who receive repetitive ePIPAC-OX as a palliative monotherapy.

METHODS AND ANALYSIS

This multicentre, open-label, single-arm, phase II study is performed in two Dutch tertiary referral hospitals for the surgical treatment of colorectal PM. Eligible patients are adults who have histologically or cytologically proven isolated unresectable PM of a colorectal or appendiceal carcinoma, a good performance status, adequate organ functions and no symptoms of gastrointestinal obstruction. Instead of standard palliative treatment, enrolled patients receive laparoscopy-controlled ePIPAC-OX (92 mg/m² body surface area (BSA)) with intravenous leucovorin (20 mg/m² BSA) and bolus 5-fluorouracil (400 mg/m² BSA) every 6 weeks. Four weeks after each procedure, patients undergo clinical, radiological and biochemical evaluation. ePIPAC-OX is repeated until disease progression, after which standard palliative treatment is (re)considered. The primary outcome is the number of patients with major toxicity (grade ≥3 according to the Common Terminology Criteria for Adverse Events v4.0) up to 4 weeks after the last ePIPAC-OX. Secondary outcomes are the environmental safety of ePIPAC-OX, procedure-related characteristics, minor toxicity, postoperative complications, hospital stay, readmissions, quality of life, costs, pharmacokinetics of oxaliplatin, progression-free survival, overall survival, and the radiological, histopathological, cytological, biochemical and macroscopic tumour response.

ETHICS AND DISSEMINATION

This study is approved by an ethics committee, the Dutch competent authority and the institutional review boards of both study centres. Results are intended for publication in peer-reviewed medical journals and for presentation to patients, healthcare professionals and other stakeholders.

TRIAL REGISTRATION NUMBER

NCT03246321, Pre-results; ISRCTN89947480, Pre-results; NTR6603, Pre-results; EudraCT: 2017-000927-29, Pre-results.

Occupational safety of pressurized intraperitoneal aerosol chemotherapy (PIPAC) in an operating room without laminar airflow

AIM OF THE STUDY

The safety of pressurized intraperitoneal aerosol chemotherapy (PIPAC) is often questioned when newly implemented in an operating room (OR); as it may increase the risk of exposure to cytotoxics for healthcare workers. There are no data on the risk of healthcare exposure in OR without laminar airflow. We aimed to ensure the safety of PIPAC for surgeons and their co-workers for newly implemented procedures in an OR without laminar airflow.

PATIENTS AND METHODS

Twenty-six samples with cellulosic wipes from surgeons and co-workers' environmental items and 5 specific polytetrafluoroethylene air-filtered collections were randomly performed for the first 2 cisplatin/doxorubicin-based PIPAC procedures in Strasbourg University Hospital. PIPAC was performed according to previously described safety protocol but without a laminar airflow and with an additional plastic cover and smoke evacuation device. Sampling and analyzes were performed by 2 accredited independent certified organizations.

RESULTS

All air measurements were negative for cisplatin and doxorubicin. Only one wipe sample out of 26 was positive for cisplatin (4%) on the outer surgeon's pair of gloves but dosages on the surgeon's inner pair and hands were negative.

CONCLUSION

When performed in approved security conditions, even without laminar airflow, PIPAC might seem harmless for surgeons and their co-workers with very limited risk of exposure to cytotoxics.

Unresectable peritoneal metastasis treated by pressurized intraperitoneal aerosol chemotherapy (PIPAC) leading to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

PIPAC is a recent method of intraperitoneal chemotherapy. The aim of this study was to describe the clinical characteristics of the patients who became amenable to CRS & HIPEC after PIPAC treatment.

METHODS

All patients diagnosed with unresectable PM who became resectable throughout PIPAC treatment were included. Outcome criteria were adverse events following PIPAC procedure and rate of secondary CRS and HIPEC.

RESULTS

Four hundred thirty-seven PIPAC were done in 146 consecutive patients. Among them, 26 patients (17.8%) who underwent 76 PIPAC were scheduled for CRS and HIPEC after reduction of the peritoneal burden. PM were from gastric, peritoneal mesothelioma, ovarian, colorectal and small bowel in 13, 7, 4, 1 and 1 patients, respectively. At the time of the first PIPAC, median age was 58.6 years (32-76.3). Median PCI was 16 (1-39). All patients had systemic chemotherapy in between PIPAC session. Median consecutive PIPAC procedure was 3 (1-8). Complications occurred in 3 PIPAC session (4%) and there was no major complication (CTCAE III or higher). Complete CRS and HIPEC was achieved in 21 patients of the 26 scheduled (14.4%). The remaining 5 patients were considered unresectable at the exploratory laparotomy. Among patients who underwent CRS and HIPEC, with median follow-up of 7 (1-26) months, 14 patients (66.7%) were alive without recurrence, 2 patients (9.5%) were alive with recurrence and 5 patients (23.8%) died.

CONCLUSIONS

Complete CRS and HIPEC can be achieved in strictly selected patient with unresectable PM at diagnosis after repeated PIPAC session with palliative intent.

Pressurized IntraPeritoneal Aerosol Chemotherapy vs. intravenous chemotherapy for unresectable peritoneal metastases secondary to platinum resistant ovarian cancer - study protocol for a randomized control trial

Background

Despite optimal surgery and appropriate first-line chemotherapy, ∼70–80 % of patients with epithelial ovarian cancer will develop disease relapse. The prognosis is poor especially for women with Platinum resistant ovarian cancer. The standard treatment for these groups of patients is non-platinum-containing chemotherapy like taxanes, anthracyclines, gemcitabine, topotecan, and trabectedin. These drugs in various combinations and sequences provide modest survival or symptomatic benefit but with significant side effects. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a minimally-invasive drug-delivery technique specifically addressing limited tissue penetration and poor drug distribution with promising results. PIPAC is a novel method of delivering normothermic chemotherapy into the abdominal cavity as an aerosol under pressure. This concept seems to enhance the effectiveness of intra peritoneal chemotherapy by taking advantage of the physical properties of gas and pressure by generating an artificial pressure gradient and enhancing tissue uptake and distributing drugs homogeneously within the closed and expanded peritoneal cavity. Thus, due to the high local bioavailability during PIPAC, the chemotherapy dosage can be reduced which in turn largely prevents systemic side effects and organ toxicity.

Methods

The study aims to investigate the therapeutic efficacy measured as objective tumour response according to Response Evaluation Criteria in Solid Tumours (RECIST) criteria, of PIPAC in comparison with conventional Intravenous chemotherapy for women with recurrent platinum resistant ovarian cancer with peritoneal metastasis (PM). Consecutive patients diagnosed with PM secondary to platinum-resistant ovarian cancer will be randomized to PIPAC group or IV chemotherapy group. The primary objective of this study is to determine the efficacy after three cycles of PIPAC with cisplatin and doxorubicin in comparison with six cycles of systemic chemotherapy. The secondary outcome measures include morbidity and mortality, overall survival and disease specific survival. Analysis is by intention to treat.

Aim

Assess the objective tumour response of PIPAC in comparison with systemic intravenous chemotherapy for women with platinum-resistant ovarian cancer.

Study type

Prospective randomized control intervention trial.

Intervention model

IV Chemotherapy group (Control group) PIPAC group (Experimental group)

Masking

Open label.

Primary purpose

Treatment.

Sample size

Calculated sample size is 97 and rounded to 100. For each treatment group sample size of 50 will be considered.

Primary outcome criteria

Objective tumour response according to Response Evaluation Criteria in Solid Tumours (RECIST) criteria version 1.1.

Discussion

PIPAC in women with platinum resistant ovarian PM has good response owing to superior tissue penetration and better drug distribution. The procedure is safe and well tolerated owing it to its minimal invasiveness. Typical side-effects of systemic chemotherapy, such as alopecia, peripheral neurotoxicity, nausea and myelosuppression are absent. We expect reduction of ascites with symptomatic relief and CA 125 levels. PIPAC is a novel technique for selected patients with platinum resistant ovarian PM and further investigation in comparative clinical trials with conventional chemotherapy will establish its role as a good palliative treatment option.

Ethics committee approval

Obtained.

Status

Recruiting.

Trial registration number

REF/2018/08/021223 Registered on Clinical Trials Registry – India (CTRI); www.ctri.nic.in

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC): Initial Experience from Indian Centers and a Review of Literature

Cytoreductive surgery and HIPEC is a therapeutic option that benefits only selected patients with peritoneal metastases (PM). New treatments like pressurized intraperitoneal aerosol chemotherapy (PIPAC) have been developed to overcome some limitations of intraperitoneal chemotherapy and treat patients who are not eligible for a curative approach. The safety and feasibility of the procedure in the first few Indian patients treated with PIPAC, and the technique and the set-up required for PIPAC are described here. From May 2017 to August 2017, data was collected prospectively for all patients undergoing PIPAC at three Indian centers. The patients' characteristic, operative findings, and perioperative outcomes were recorded. Seventeen procedures were performed in 16 patients with peritoneal metastases from various primary sites using standard drug regimens developed for the procedure. The median hospital stay was 1 day, minor and major complications were seen in two patients each (11.7%), and there was one post-operative death. Of the six patients who completed at least 6 weeks of follow-up, there was disease progression in two, unrelated problems in two patients, and a second procedure was performed in one patient. One patient underwent subsequent CRS and HIPEC. Our results show the feasibility and safety of PIPAC in Indian patients with a low morbidity and mortality and short hospital stay. While clinical trials will determine its role in addition to systemic chemotherapy, it can be used in patients who have progressed on one or more lines of systemic chemotherapy and those who have chemotherapy-resistant ascites.

Pressurized intraperitoneal aerosol chemotherapy and its effect on gastric-cancer-derived peritoneal metastases: an overview

This manuscript aspires to portray a review of the current literature focusing on manifest peritoneal metastasis (PM) derived from gastric cancer and its treatment options. Despite the development of chemotherapy and multimodal treatment options during the last decades, mortality remains high worldwide. After refreshing important epidemiological considerations, the molecular mechanisms currently accepted through which PM occurs are revised. Palliative chemotherapy is the only recommended treatment option for patients with PM of gastric cancer according to the National Comprehensive Cancer Network guidelines, although cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy demonstrated promising results in selected patients with regional PM and localized intraabdominal tumor spread. A novel treatment named pressurized intraperitoneal aerosol chemotherapy may have a promising future in improving overall survival with an acceptable postoperative complication rate and stabilizing quality of life during treatment. Additionally, the procedure has been proved to be safe for the patient and medical personnel and a feasible, repeatable method to deter metastatic proliferation. This overview comprehensively addresses this novel and promising treatment in the context of a scientifically and clinically challenging disease.

Pressurized intraperitoneal aerosol chemotherapy procedure for nonresectable peritoneal carcinomatosis: First Indian study

BACKGROUND

Peritoneal carcinomatosis (PC) is a common evolution of abdominal cancers and is associated with poor prognosis. A few selected patients have option of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, but majority who are not eligible for curative approach can undergo pressurized intraperitoneal aerosol chemotherapy (PIPAC). It is an emerging field of research with major therapeutic potential. It is a safe and innovative approach, which enhances the effect of chemotherapy without major toxicity.

METHODS

Between June 2017 and December 2017, 21 PIPAC applications in seven patients with standard chemotherapy regimen every 6 weeks at 37°C and 12 mmHg for 30 min was performed. The patients' demographics, perioperative findings, adverse events, and outcomes were prospectively recorded.

RESULTS

Twenty-one PIPAC administrations were performed in 7 patients with PC from various pathologies. The median hospital stay was 1 day. All the patients had symptomatic relief with complete resolution of ascites. There was no major perioperative complications. CTCAE Grades 1 and 2 were observed in three patients, for abdominal pain and nausea. Renal and hepatic functions were not impaired. Of the seven patients, one patient had complete histological remission; three patients had partial response, one had stable disease and one patient had no response with clinical progression.

CONCLUSION

Our results show the feasibility and safety of PIPAC in Indian patients. The procedure has low morbidity with no mortality with the short learning curve. It can be easily adapted for Indian patients with diffuse PC as a palliative option apart from systemic chemotherapy.

Severe hypersensitivity reactions to platinum compounds post-pressurized intraperitoneal aerosol chemotherapy (PIPAC): first literature report

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) shows encouraging results for patients with unresectable peritoneal metastasis. Several reports demonstrated the safety of the procedure combined with systemic chemotherapy, with a low rate of complication. The aim of this study is to report severe hypersensitivity reactions to platinum compounds (SHRPC) during PIPAC procedures.

METHODS

All patients who underwent PIPAC for non-resectable PC in Lyon Sud University hospital were included in a prospective institutional database. All patients who presented a SHRPC after PIPAC were included in our analysis.

RESULTS

One hundred and thirty-two patients underwent 383 PIPAC procedures between December 2015 and December 2017. oxaliplatin's and cisplatin-doxorubicin's protocols were used in 71 and 312 PIPAC, respectively. Four patients (3%) developed SHRPC; two patients (2.8%) after oxaliplatin and two patients (0.6%) after cisplatin-doxorubicin protocols. SHRPC occurred during the 6th PIPAC with cisplatin-doxorubicin protocol and during 2nd and 3rd PIPAC of the oxaliplatin protocol. Three events appeared within 15 min and one event occurred 50 min following nebulization. All the SHRPC have been managed successfully without any complication.

CONCLUSIONS

This is the first report of SHRPC after PIPAC. The physician must constantly keep this rare but life-threatening complication in mind, especially after repeated PIPAC administration or previous platinum-based systemic chemotherapy.

How to Perform Safe and Technically Optimized Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC): Experience After a Consecutive Series of 1200 Procedures

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new approach to deliver intraperitoneal chemotherapy as a pressurized aerosol in patients with advanced peritoneal metastases (PM). Although this treatment has rapidly been adopted into clinical practice, most surgeons are not familiar with the basics and principles of this technology. The purpose of this article is to review patient selection criteria, as well as highlighting important operative and technical details regarding PIPAC technology with a focus on "how to do it." To this end, safety and feasibility data from a series of 1200 consecutive PIPAC procedures performed by two pioneers of PIPAC treatment are presented.

Pharmacokinetics and Tissue Transport of Intraperitoneal Chemotherapy

The presence of a peritoneal barrier results in a pharmacokinetic advantage associated with intraperitoneal (IP) delivery of anticancer drugs. The anticancer efficacy of IP chemotherapy depends, however, on its ability to penetrate the tumor stroma. Tumor tissue transport is governed by diffusion and convection and is affected by numerous physical, biological, and pharmaceutical variables. From preclinical and clinical studies, it appears that tissue penetration after IP chemotherapy delivery is very limited. Several approaches are studied in order to improve tissue penetration of small molecular and macromolecular anticancer drugs after IP instillation.

Feasibility, Safety, and Efficacy of Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) for Peritoneal Metastasis: A Registry Study

INTRODUCTION

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel drug delivery system with superior pharmacological properties for treating peritoneal metastasis (PM). Safety and efficacy results of PIPAC with cisplatin/doxorubicin or oxaliplatin from a registry cohort are presented.

METHODS

IRB-approved registry study. Retrospective analysis. No predefined inclusion criteria, individual therapeutic recommendation by the interdisciplinary tumor board. Safety assessment with CTCAE 4.0. Histological assessment of tumor response by an independent pathologist using the 4-tied peritoneal regression grading system (PRGS). Mean PRGS and ascites volume were assessed at each PIPAC.

RESULTS

A total of 142 PIPAC procedures were scheduled in 71 consecutive patients with PM from gastric (n = 26), colorectal (n = 17), hepatobiliary/pancreatic (n = 9), ovarian (n = 6), appendiceal (n = 5) origin, pseudomyxoma peritonei (n = 4), and other tumors (n = 3). Mean age was 58 ± 13 years. Patients were heavily pretreated. Mean PCI was 19 ± 13. Laparoscopic nonaccess rate was 11/142 procedures (7.7%). Mean number of PIPAC/patient was 2. All patients were eligible for safety analysis. There was no procedure-related mortality. There were 2.8% intraoperative and 4.9% postoperative complications. 39 patients underwent more than one PIPAC and were eligible for efficacy analysis, and PRGS could be assessed in 36 of them. In 24 patients (67%), PRGS improved or remained unchanged at PIPAC#2, reflecting tumor regression or stable disease. Ascites was present in 24 patients and diminished significantly under therapy. Median survival was 11.8 months (95% CI: 7.45-16.2 months) from PIPAC#1.

CONCLUSION

PIPAC is feasible, safe, and well-tolerated and can induce histological regression in a significant proportion of pretreated PM patients. This trial is registered with NCT03210298.

Randomized control trial comparing quality of life of patients with end-stage peritoneal metastasis treated with pressurized intraperitoneal aerosol chemotherapy (PIPAC) and intravenous chemotherapy

Background

Peritoneal metastasis (PM) is a common occurrence in gynaecological and gastrointestinal cancers and is associated with poor survival. Patients typically present with ascites, abdominal pain, malnutrition, nausea, emesis, and bowel obstruction which significantly compromise the quality of life (QoL). The treatment remains a particular challenge, with palliative systemic chemotherapy being the standard of care. However, the efficacy of systemic chemotherapy is poor but with high potential for side effects and complications. QoL plays an important role in patients with PM and is deteriorating continuously until death. Thus, there is an obvious medical need for better therapeutic options in PM for prolonging survival and preserving QoL by reducing both disease-related symptoms and therapy side effects. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel technique for delivering pressurized normothermic chemotherapy into the abdominal cavity as an aerosol. This concept seems to enhance the effectiveness of intraperitoneal chemotherapy by taking advantage of the physical properties of gas and pressure by generating an artificial pressure gradient and enhancing tissue uptake and distributing drugs homogeneously within the closed and expanded peritoneal cavity.

Methods

The primary objective of this study is to assess QoL and symptoms in a consecutive cohort of patients with PM treated with PIPAC procedure in comparison with conventional systemic intravenous chemotherapy. QoL is assessed prospectively using European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30(Version 3.0) questionnaire. QLQ-C30 is a 30-question self-administered questionnaire inquiring about global health status, 9 individual symptoms, and 5 functional scales. Baseline QoL is measured using the global physical health functional score, and symptom scores derived from EORTC QLQ30 questionnaire before starting therapy, followed by at 60, 120, and 180 days after the first intervention. Calculated sample size is 119 and rounded to 120. For each treatment group, sample size of 60 will be enrolled; Intervention model: IV chemotherapy group (control group) and PIPAC group (experimental group); Study type: prospective randomized control intervention trial

Discussion

All consecutive patients diagnosed with advanced end-stage PM are randomized to be treated with PIPAC or IV chemotherapy. The primary objective of this study is to determine the QoL after three cycles of PIPAC in comparison with six cycles of systemic chemotherapy. The secondary outcome measures include morbidity and mortality. Analysis is by intention to treat.

Results

The effect of systemic chemotherapy remains limited on the peritoneum due to poor vascularization and low penetration. Side effects after systemic chemotherapy for PM are relatively frequent. QoL plays an important role in these patients and is deteriorating continuously due to the disease or therapy related. Thus, there is need for better therapeutic options for prolonging survival and preserving QoL by reducing both disease-related symptoms and therapy side effects. PIPAC is a novel minimally invasive repeatable treatment modality which demonstrated potentially encouraging tumour response and only minimal toxicity in patients with PM of various origins. It can optimize local drug delivery and improve clinical outcome due to superior pharmacological properties as compared to systemic chemotherapy.

Trial registration

REF/2018/08/021225 Registered on Clinical Trials Registry-India (CTRI); www.ctri.nic.in

The scientific report from the first pressurized intraperitoneal aerosol chemotherapy (PIPAC) procedures performed in the eastern part of Central Europe

Objective To perform a single-centre, detailed analysis of the preparations for the introduction of the first pressurized intraperitoneal aerosol chemotherapy (PIPAC) programme in the eastern part of Central Europe. Methods The study analysed the 14-month preparation period prior to the performance of the first PIPAC procedure with respect to: (i) general preparations; (ii) patient referral and qualification; (iii) the first PIPAC procedure; (iv) the 2 weeks following PIPAC programme establishment; and (v) general problematic issues that arose. Results The length of time needed to prepare our institution for the first PIPAC procedure was extremely long compared with other European Union PIPAC centres: 14 months versus a standard 3-6 months of preparation. The longest amount of time (12 months) was required to prepare the required paperwork. Conclusions A new PIPAC programme was successfully established in the eastern part of Central Europe. The length of time to implement this method was significantly longer because of lengthy bureaucratic processes. These current findings should help new centres, especially in this part of Europe, to establish a PIPAC programme more quickly.

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) for peritoneal metastases of pancreas and biliary tract cancer

Data on the effectivness of PIPAC in patients with peritoneal metastases of pancreaticobiliary origin is scarce. We here present further proof of treatment efficacy in this subset of patients. Repetitive PIPAC treatment with low-dose cisplatin 7.5 mg/m² and doxorubicin 1.5 mg/m² body surface area every 6 weeks and prospective data collection. Documentation included microscopic histological regression, median overall survival and treatment-related adverse events. Twelve patients with a median age of 57 years (range 43-78 years) were included. Six patients suffered from pertioneal metastases of pancreatic adenocarcinoma (PDAC) and six patients from cholangiocarcinoma (CC). In total 23 cycles of PIPAC were adminstered with the median number of PIPAC cycles being two (range 1-4). Complete tumor regression was found in four patients and major regression in one patient. Median overall survival after the first PIPAC cycle was 12.7 months for PDAC patients and 15.1 months for CC patients. 11 of the 12 patients are still alive after a median follow-up of 438 days. There were no CTCAE Grade 3 or 4 complications. PIPAC is an innovative and attractive treatment option in the salvage situation for patients with peritoneal metastases of pancreaticobiliary tumors after failure of systemic chemotherapy. In 40% of the patients histological regression can be induced. Further studies are warranted to further elucidate treatment efficacy.

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) for peritoneal carcinomatosis: systematic review of clinical and experimental evidence with special emphasis on ovarian cancer

BACKGROUND

Systemic chemotherapy is not effective in patients with peritoneal carcinomatosis (PC) and only a minority of affected patients is eligible for cytoreductive surgery. Intraperitoneal chemotherapy may provide a therapy alternative for these patients.

METHODS

We performed a systematic review of clinical and experimental evidence on the safety and efficacy of pressurized intraperitoneal aerosol chemotherapy (PIPAC) in patients with PC and provide clinical recommendations based on the available evidence.

RESULTS

Fifty-eight reports were identified, categorized as experimental (18 reports), clinical (28 reports), and other articles (14 reports). Experimental studies demonstrated improved tissue penetration and peritoneal coverage. The 28 clinical studies reported on 3515 procedures in 1547 patients with PC of various primary tumors with 16 of these studies reporting on patients with ovarian cancer. Toxicity was manageable. Based on 1197 patients in 22 studies, adverse events CTCAE grades 1, 2, 3, 4, and 5 were observed in 537 (45%), 167 (14%), 83 (7%), 10 (0.8%), and 19 (1.6%) cases, respectively. In a pooled analysis, the objective tumor response rate was 69% and the mean overall survival duration was 13.7 months. No significant hepatic, renal, or hematologic toxicity was described. PIPAC maintained and/or improved quality of life, as reported in 10 studies with 396 patients.

CONCLUSIONS

Available evidence from controlled trials (phase I and phase II) and retrospective cohort studies in > 1500 patients unequivocally demonstrates that PIPAC is feasible, safe, and effective. PIPAC maintains quality of life in patients with recurrent cancer and PC. PIPAC is as evidence-based as any other treatment in women with ovarian cancer and PC beyond the third line of systemic chemotherapy and can be recommended in this indication.

Adjuvant Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) in resected high-risk colon cancer patients - study protocol for the PIPAC-OPC3 Trial. A prospective, controlled phase 2 Study

BACKGROUND

Peritoneal metastasis (PM) is the second most common site of recurrence in colon cancer (CC) patients and accounts for approximately one-third of all recurrences. Patients with T4 or intraperitoneal perforated colon cancers have an increased risk of developing PM, and since manifest PM is difficult to treat, high-risk patients should be offered prophylactic treatment. Here, we propose a study of adjuvant oxaliplatin administered as pressurized intraperitoneal aerosol chemotherapy (PIPAC OX) in patients with high-risk colon cancer (T4, perforated tumors, ovarian metastasis).

METHODS

PIPAC-OPC3 CC is a non-randomized, non-blinded phase 2 cohort study designed to treat high-risk colon cancer patients with adjuvant PIPAC-directed therapy. Based on an expected 90 % peritoneal recurrence-free survival with adjuvant PIPAC against the estimated 75 % without, 60 patients are needed (α: 0.05, power: 0.8). Eligible patients will receive two PIPAC treatments with oxaliplatin (92 mg/m2) at 4-6 week intervals. During laparoscopy, the peritoneum is biopsied at two locations, and peritoneal lavage with 500 mL of saline and laparoscopic ultrasound is performed. The patients are screened for adverse medical events and surgery-related complications after each PIPAC procedure. After the second PIPAC procedure, the patients will be examined in the outpatient clinic and followed with CT scans 12, 24 and 36 months after resection. The primary outcome of the PIPAC-OPC3 CC trial is to evaluate if PIPAC-directed adjuvant therapy can reduce the risk of PM. Secondary outcomes include the number of conversions from positive to negative peritoneal lavage cytology after one PIPAC procedure, completion rate of two adjuvant PIPAC treatments, toxicity and complication rate and recurrence-free and overall survival rates after 1, 3 and 5 years.

RESULTS

It is expected that PIPAC-directed adjuvant therapy can provide an absolute risk reduction of 15 % regarding the development of PM in high-risk colon cancer patients, and that this may result in increased survival rates. We expect that free intraperitoneal tumor cells (FITC) may be detected by peritoneal lavage performed just prior to the administration of PIPAC-directed therapy, and that this treatment may convert FITC-positive patients to a FITC-negative status.

CONCLUSIONS

This study may provide important knowledge to be used in designing additional studies on PIPAC in the adjuvant setting of other primary cancers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03280511 (2017-09-12). European Clinical Trials Database (EudraCT) 2017-002637-37.

Treatment of peritoneal carcinomatosis with Pressurized IntraPeritoneal Aerosol Chemotherapy - PIPAC-OPC2

BACKGROUND

Peritoneal carcinomatosis (PC) is a common endpoint in both gastrointestinal and non-gastrointestinal cancers, and PC is treated as other systemic metastases - unfortunately with disappointing results and considerable side-effects. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a new method of applying traditional chemotherapy, and preliminary data indicate that PIPAC is safe, able to stabilize or improve quality of life, and can induce an objectively measurable reduction in disease burden in PC.

METHODS

PIPAC-OPC2 is a prospectively controlled Phase II, single center, one-arm, open-label clinical trial investigating the treatment effect of PIPAC in patients with histological or cytological proven PC from gastrointestinal, ovarian or primary peritoneal cancer. Eligible patients will receive PIPAC in series of three using a combination of doxorubicin (1.5 mg/m2) and cisplatin (7.5 mg/m2) for non-colorectal cancer patients (PIPAC C/D), and oxaliplatin (92 mg/m2) in patients with PC of colorectal origin (PIPAC OX). Patients are monitored by: (1) repeated measurements of the Peritoneal Regression Grading Score (PRGS) in biopsies obtained from metal clips marked areas, (2) Quality-of-Life (QoL) questionnaires, (3) Magnetic Resonance Imaging (MRI) and (4) Prognostic Nutritional Index (PNI). Adverse events and surgical complications will be recorded according to the 30 days definition.

RESULTS

The primary outcome of PIPAC-OPC2 is to evaluate if PIPAC can induce major or complete response (PRGS 1 or 2) within a series of three PIPAC procedures. Secondarily this study investigates changes in QoL and MRI as a staging and response evaluation tool. The secondary outcomes will be used to create a model that may predict which of the patients will benefit from PIPAC treatment.

CONCLUSIONS

It is expected that PIPAC directed therapy can induce major or complete response in 50 % of patients with PC of colorectal origin and in 30 % of patients with PC of non-colorectal origin - and at the same time stabilize or even improve quality of life. This trial may provide data regarding the utility of MRI as a staging and response evaluation tool in patients with PC.

TRIAL REGISTRATION

The study is registered with ClinicalTrials.gov Identifier NCT03287375 and the European Clinical Trials Database (EudraCT) number 2016-003394-18.

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) in combination with standard of care chemotherapy in primarily untreated chemo naïve upper gi-adenocarcinomas with peritoneal seeding - a phase II/III trial of the AIO/CAOGI/ACO

BACKGROUND

Peritoneal metastasis is a common and dismal evolution of several gastrointestinal (GI) tumors, including gastric, colorectal, hepatobiliary, pancreatic, and other cancers. The therapy of peritoneal metastasis is largely palliative; with the aim of prolonging life and preserving its quality. In the meantime, a significant pharmacological advantage of intraperitoneal chemotherapy was documented in the preclinical model, and numerous clinical studies have delivered promising clinical results.

METHODS

This is a prospective, open, randomized multicenter phase III clinical study with two arms that aims to evaluate the effects of pressurized intraperitoneal aerosol chemotherapy (PIPAC) combined with systemic chemotherapy vs. intravenous systemic chemotherapy alone on patients with metastatic upper GI tumors with a peritoneal seeding. Upper GI-adenocarcinomas originated from biliary tract, pancreas and stomach, or esophago- gastric junction are eligible. Patients in the study are treated with standard of care systemic palliative chemotherapy (mFOLFOX6) vs. PIPAC with intravenous (i.v.) chemotherapy (mFOLFOX6). Patients in first line with first diagnosed peritoneal seeding are eligible. Primary outcome is progression free survival (PFS).

CONCLUSIONS

PIPAC-procedure is explicit a palliative method but it delivers cytotoxic therapy like in hyperthermic intraperitoneal chemotherapy (HIPEC)-procedure directly to the tumor in a minimally invasive technique, without the need for consideration of the peritoneal-plasma barrier. The technique of PIPAC is minimally invasive and very gentle and the complete procedure takes only round about 45 min and, therefore, optimal in a clearly palliative situation where cure is not the goal. It is also ideal for using this approach in a first line situation, where deepest response should be achieved. The symbiosis of systemic therapy and potentially effective surgery has to be well-planned without deterioration of the patient due to aggressive way of surgery like in cytoreductive surgery (CRS)+HIPEC.

TRIAL REGISTRATION

EudraCT: 2018-001035-40.

Prospective, single-center implementation and response evaluation of pressurized intraperitoneal aerosol chemotherapy (PIPAC) for peritoneal metastasis

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a laparoscopy-guided administration of aerosolized chemotherapy. PIPAC seems to improve objective tumor response, survival and quality of life in patients with peritoneal metastasis. We assessed feasibility and efficacy of PIPAC in patients with peritoneal metastasis (PM).

METHODS

Patients were included in a prospective PIPAC protocol. Patients with colorectal PM were treated with oxaliplatin, patients with other primary tumors were treated with cisplatin and doxorubicin. Any chemotherapy exposure for healthcare workers was monitored by environmental and biological sampling. Feasibility was quantified by completion and complication rates. Response evaluation was documented by the peritoneal regression grading score (PRGS) and by peritoneal lavage cytology. Biopsy sites were marked by clips. Quality of life questionnaires were collected at baseline and after 60, 120 and 180 days.

RESULTS

A total of 35 patients with PM were treated with a median of three PIPAC procedures (range 1-9). Intraperitoneal access and completion of PIPAC was achieved in all patients. Few complications and adverse events were noted. There was no risk of chemotherapy exposure for healthcare workers. The mean PRGS was reduced significantly and a reduction of the PRGS was seen in 67% of the patients. Conversion from positive to negative cytology was achieved in 23% of the patients. Quality of life was stabilized from baseline to day 60.

CONCLUSIONS

PIPAC is feasible and well tolerated, may stabilize the quality of life in patients with end-stage PM and may induce histological and cytological regression.This study is registered at www.clinicaltrials.gov [ClinicalTrials.gov identifier: NCT02320448].

PIPAC EstoK 01: Pressurized IntraPeritoneal Aerosol Chemotherapy with cisplatin and doxorubicin (PIPAC C/D) in gastric peritoneal metastasis: a randomized and multicenter phase II study

BACKGROUND

Peritoneal metastasis (PM) from gastric cancer often remains undiagnosed until it reaches an advanced stage. Despite curative management combining perioperative systemic chemotherapy, cytoreductive surgery (CRS), and hyperthermic intraperitoneal chemotherapy (HIPEC), treated patients' 5 year survival rate remains under 20 % when patients are carefully selected. Palliative intravenous chemotherapy in patients with non-resectable cancer is frequently associated with poor long-term benefit and an estimated survival time below 1 year. Recently, two retrospectives studies reported that Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) improves patients' overall survival without impairing their quality of life (QoL). This promising result needs however to be studied on large randomized clinical trial to validate the effect of PIPAC on survival and QoL of patients with gastric PM.

METHODS

PIPAC EstoK 01 is a prospective, open, randomized multicenter phase II clinical study with two arms that aims at evaluating the effects of PIPAC with doxorubicin and cisplatin on patients with PM of gastric cancer with peritoneal cancer index (PCI)>8, treated with systemic chemotherapy between two PIPAC procedures. Patients were randomized at the end of explorative laparoscopy and after signing a written consent. Patients received in the first experimental arm a treatment associating PIPAC and systemic chemotherapy (1 PIPAC then 2 IV Chemo) and systemic chemotherapy only in the control arm. Primary endpoint was progression-free survival from the date of surgery to the date of death, or to the end of the 5 year follow-up. Secondary endpoint was 2 year overall survival, morbidity, QoL and secondary resectability rate. The number of patients randomized was calculated to be 94.

TRIAL REGISTRATION

Retrospectively registered.

Occupational exposure to platinum drugs during intraperitoneal chemotherapy. Biomonitoring and surface contamination

BACKGROUND

Hyperthermic intraperitoneal chemotherapy (HIPEC) has been introduced over the last decade for the treatment of peritoneal carcinomatosis. In this procedure, heated cytotoxic drugs are administered directly into the abdominal cavity, ensuring cancer cells to be exposed while reducing systemic toxicity. More recently, pressurized intraperitoneal aerosol chemotherapy (PIPAC), where the chemotherapeutic drug is injected into the peritoneal cavity as an aerosol under pressure, has been proposed to patients in palliative situation, as a new approach. The amount of drug used is up to 10 fold lower than in HIPEC. The use of cytotoxic drugs poses an occupational risk for the operating room personnel. This study investigated the potential exposure of the medical staff by biomonitoring and surface contamination measurements, during a HIPEC procedure and a PIPAC procedure.

METHOD

Wipe samples were collected from various locations in operating rooms including gloves, hands, devices and floor. Urines samples were collected from 10 volunteers of the medical staff and from a control group. The platinum analysis was performed by inductively coupled plasma mass spectrometry.

RESULTS

Significant contaminations were observed on the floor, gloves, shoes and devices. However, urinary platinum was below the limit of quantification (<10 ng/L) for more than 50% of samples from the healthcare workers performing HIPEC and PIPAC. Concentrations did not differ significantly from those reported for the control group.

CONCLUSION

There appears to be little risk of exposure to platinum drugs during HIPEC and PIPAC providing the adequate safety measures are implemented.

Occupational exposure to cisplatin/oxaliplatin during Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC)?

INTRODUCTION

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a new promising treatment for patients with peritoneal carcinomatosis. It is supposed to provide a higher local drug concentration and deeper penetrate into the tumor tissue compared to systemic chemotherapy or hyperthermic intraperitoneal chemotherapy perfusion (HIPEC). Due to the application of cytotoxic drug aerosols within the operating room (OR), concern has been raised regarding the occupational exposure risk of the involved OR staff.

MATERIALS AND METHODS

In this study, an OR workplace monitoring was performed during 14 PIPAC procedures in two hospitals by collecting air samples (n = 14) during PIPAC and wipe samples (n = 223) before and after PIPAC: 56 samples from the OR floor, 84 from the injector, 28 from trocars and 55 from gloves. All samples were analyzed for platinum (Pt).

RESULTS

While air Pt concentrations were below 3.1 pg/m³, surface contaminations widely varied between 0.01 pg/cm² and 1733 pg/cm² (median 1.04 pg/cm²), with substantial Pt concentrations on injector parts (i.e. syringe holder) and trocars. Floors and particularly injectors were often higher contaminated before compared to after PIPAC, probably due to inefficient cleaning or cross-contamination. Glove samples taken after different tasks ranged between 0.04 and 423 pg/cm² (median 0.58 pg/cm²).

CONCLUSION

Contamination on various OR surfaces widely ranged and can lead to a distribution of cytotoxic drug residues. However, the air contamination was very low. The results indicate that PIPAC performance seems to be possible with low occupational exposure risk, but adequate safety and cleaning standards for PIPAC must be developed and monitored.

A phase I, single-arm, open-label, dose escalation study of intraperitoneal cisplatin and doxorubicin in patients with recurrent ovarian cancer and peritoneal carcinomatosis

OBJECTIVE

We performed a phase I, single-arm, non-randomized, open-label, dose-escalation trial to determine the dose-limiting toxicity of intraperitoneal cisplatin and doxorubicin applied as pressurized intraperitoneal aerosol chemotherapy (PIPAC) in women with recurrent ovarian cancer.

METHODS

We used a standard 3 + 3 dose-escalation design with doxorubicin 1.5 mg/m², cisplatin 7.5 mg/m² q 4 to 6 weeks for 3 cycles and subsequent dose escalation steps (20% increment per step) in patients with recurrent ovarian cancer and peritoneal carcinomatosis. Toxicity and clinical efficacy were monitored. The primary endpoint was the maximum-tolerable dose. Secondary endpoints included histologic tumor regression and serum parameters.

RESULTS

15 evaluable patients (3, 7, and 5 in cohorts 1, 2, and 3, respectively) on average received 2.3 PIPAC cycles. No dose limiting toxicities were found. Adverse side effects were 1 grade 3 event (colon perforation) and 85 grade 1/2 events including fatigue (n = 19), abdominal pain (n = 18), nausea/vomiting (n = 14), sleep disorder (n = 8), diarrhea (n = 5), and fever (n = 2). Liver and renal toxicity was not observed in any of the 3 cohorts (AST 19.1 ± 3.2, 25.8 ± 6.5, and 22.1 ± 4.5 IU/L, respectively; ALT 14.7 ± 3.5, 18.5 ± 5.6, and 23.3 ± 13.0 IU/L, respectively; GGT 45.7 ± 35.1, 25.2 ± 10.3, and 43.9 ± 26.4 IU/L, respectively; serum creatinine 1.06 ± 0.23, 0.80 ± 0.17, and 0.89 ± 0.35 mg/dL, respectively). No systemic hematologic toxicity, alopecia, or neurotoxicity was noted. The maximum tolerable dose was not reached. Histologic tumor regression was observed in 7/11 (64%) patients who underwent ≥2 PIPAC cycles.

CONCLUSIONS

PIPAC with cisplatin and doxorubicin may be safely used at an intraperitoneal dose of 10.5 mg/m² and 2.1 mg/m², respectively. Systemic toxicity of this therapy is low.

Tumour tissue transport after intraperitoneal anticancer drug delivery

Intraperitoneal (IP) drug delivery, either as an intraoperative chemoperfusion or as an adjuvant, repeated instillation, is an established treatment modality in patients with peritoneal carcinomatosis. The efficacy of IP drugs depends on its ability to penetrate the tumour stroma in order to reach their (sub)cellular target. It is known, that drug penetration after IP delivery is limited to a few millimetres. Here, we review the basic tissue transport mechanisms after IP delivery and discuss the biophysical barriers and obstacles that limit penetration distance. In addition, we review the physical and pharmaceutical interventions that have been studied in order to improve delivery of small molecular and macromolecular drugs after IP instillation. These interventions could inform the design of future clinical trials aiming at an improved efficacy of IP-based drug delivery in carcinomatosis patients.

Perioperative concerns and management of pressurised intraperitoneal aerosolised chemotherapy: Report of two cases

Pressurised intraperitoneal aerosolised chemotherapy (PIPAC) is a new, mostly supportive approach to help patients with advanced peritoneal metastasis to increase the lifespan. It carries occupational hazards to health-care workers and especially anaesthesiologist during the procedure. The aerosolised chemotherapy can also cause chemical peritonitis and organ dysfunction in the perioperative period. In this case report, we present the report of two cases and discuss the perioperative concerns and management related to PIPAC.

Multicenter comprehensive methodological and technical analysis of 832 pressurized intraperitoneal aerosol chemotherapy (PIPAC) interventions performed in 349 patients for peritoneal carcinomatosis treatment: An international survey study

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new drug delivery method offered in selected patients suffering from non-resectable peritoneal carcinomatosis (PC). As reported experience is still limited, we conducted a survey among active PIPAC centers aiming to report their technical approach and clinical findings.

METHODS

An online survey was sent to active PIPAC centers worldwide. The questionnaire consisted of 34 closed questions and was conducted over a period of 3 months beginning in March 2017.

RESULTS

Nine out of 15 contacted centers completed the questionnaire totaling 832 PIPAC procedures in 349 patients. Most common indications for PIPAC were PC from gastric, ovarian and colorectal origin. The mean time between each PIPAC procedure was 6-8 weeks. Seven of nine (77.8%) centers evaluate the PCI at every PIPAC procedure. At least four tissue samples for histopathology analysis were retrieved in 5 (55.6%). All centers (100%) use the same chemotherapy protocol: oxaliplatin at a dosage of 92mg/m² for PC of colorectal origin and a combination of cisplatin and doxorubicin at a dosage of 7.5mg/m² and 1.5mg/m², respectively, for other types of PC. Eight centers (88.9%) perform routine radiological evaluation before first PIPAC and after third PIPAC.

CONCLUSION

These data confirm that PIPAC procedures are homogeneously performed in established centers. Standardization of the procedure will facilitate future international multicenter prospective clinical trials.

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) Procedure for Non-resectable Peritoneal Carcinomatosis (with Video)

BACKGROUND

Peritoneal carcinomatosis (PC) is a common evolution of abdominal cancers and is associated with poor prognosis in the absence of aggressive multimodal therapy.1 Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a safe and innovative approach, which enhances the effect of chemotherapy 2 without reported renal/hepatic toxicity.3,4 It requires mastery of technical aspects to reduce postoperative morbidity, increase effectiveness, and prevent caregiver chemotherapy exposure. We, therefore, report herein the surgical protocol after 2 years of implementation in our university center specialized in PC management, accompanied by a short video, to share our experience.

METHODS

The procedure was performed under general anesthesia and capnoperitoneum (12 mmHg, 37 °C) using two balloon trocars placed in the midline, in accordance with the open laparoscopic technique. Explorative laparoscopy allowed Sugarbaker peritoneal cancer index to be determined. Parietal biopsies were taken, and ascites was removed for peritoneal cytology. The nebulizer was inserted and connected to a high-pressure injector. A pressurized aerosol containing chemotherapy agents was then administered; cisplatin (7.5 mg/m² in 150 ml 0.9%NaCl) immediately followed by doxorubicin (1.5 mg/m² in 50 ml 0.9%NaCl), or oxaliplatin alone (92 mg/m² in 150 ml 0.9%NaCl), based on PC origin and chemotherapy history. The aerosol was kept in a steady-state for 30 min then exhausted through a closed filter system, and trocars were retracted. Each step is illustrated in the video.

CONCLUSION

This video protocol provides a better understanding of the PIPAC procedure and the safety measures essential for this method of chemotherapy administration. It should help all teams wishing to implement a PIPAC therapy program.

The use of PIPAC (pressurized intraperitoneal aerosol chemotherapy) in gynecological oncology: a statement by the "Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR)", the Swiss and Austrian AGO, and the North-Eastern German Society of Gynaecologic Oncology

BACKGROUND

Ovarian, tubal, and peritoneal carcinomas primarily affect the peritoneal cavity, and they are typically diagnosed at an advanced tumor stage (Foley, Rauh-Hain, del Carmen in Oncology (Williston Park) 27:288-294, 2013). In the course of primary surgery, postoperative tumor residuals are, apart from the tumor stage, the strongest independent factors of prognosis (du Bois, Reuss, Pujade-Lauraine, Harter, Ray-Coquard, Pfisterer in Cancer 115:1234-1244, 2009). Due to improved surgical techniques, including the use of multi-visceral procedures, macroscopic tumor clearance can be achieved in oncological centers, in most cases (Harter, Muallem, Buhrmann et al in Gynecol Oncol 121:615-619, 2011). However, to date, it has not been shown that peritoneal carcinomatosis is, per se, an independent factor of prognosis or that it excludes the achievement of tumor clearance. Several studies have shown that a preceding drug therapy in peritoneal carcinomatosis could positively influence the overall prognosis (Trimbos, Trimbos, Vergote et al in J Natl Cancer Inst 95:105-112, 2003). In relapses of ovarian carcinoma, studies have shown that peritoneal carcinomatosis is a negative predictor of complete tumor resection; however, when it is possible to resect the tumor completely, peritoneal carcinomatosis does not play a role in the prognosis (Harter, Hahmann, Lueck et al in Ann Surg Oncol 16:1324-1330, 2009).

RESULTS

PIPAC is a highly experimental method for treating patients with ovarian, tubal, and peritoneal cancer. To date, only three studies have investigated a total of 184 patients with peritoneal carcinomatosis (Grass, Vuagniaux, Teixeira-Farinha, Lehmann, Demartines, Hubner in Br J Surg 104:669-678, 2017). Only some of those studies were phase I/II studies that included PIPAC for patients with different indications and different cancer entities. It is important to keep in mind that the PIPAC approach is associated with relatively high toxicity. To date, no systematic dose-finding studies have been reported. Moreover, no studies have reported improvements in progression-free or overall survival associated with PIPAC therapy.

CONCLUSIONS

Randomized phase III studies are required to evaluate the effect of this therapy compared to other standard treatments (sequential or simultaneous applications with systemic chemotherapy). In cases of ovarian, tubal, and peritoneal cancer, PIPAC should not be performed outside the framework of prospective, controlled studies.

Inflammatory Response and Toxicity After Pressurized IntraPeritoneal Aerosol Chemotherapy

Background: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel mode of intraperitoneal (IP) drug delivery claiming high IP tissue concentrations with low systemic uptake. The aim was to study inflammatory response and systemic toxicity after PIPAC.

Methods: Retrospective monocentric analysis of a consecutive cohort of PIPAC patients between January 2015 and April 2016. Detailed hematological and biochemical analysis was performed the day before surgery and once daily until discharge. Comparative statistics were performed using Mann-Whitney U test and Wilcoxon signed ranked test.

Results: Fourty-two consecutive patients underwent a total of 91 PIPAC procedures. Twenty patients received oxaliplatin and 22 cisplatin+doxorubicin (37 vs. 54 procedures). Creatinine, AST and ALT were not significantly altered after PIPAC (p=0.095, p= p=0.153 and p=0.351) and not different between oxaliplatin and cisplatin+doxorubicin regimens (p=0.371, p=0.251 and p=0.288). C-reactive protein (CRP) and procalcitonin (PCT) increased on post-operative day (POD) 2: ∆max 29±5 mg/L (p<0.001) and ∆max 0.05±0.01 μg/L (p=0.005), respectively. Leucocytes increased at POD 1: ∆max 2.2±0.3 G/L (p<0.001). Albumin decreased at POD 2: ∆max -6.0±0.5 g/L (p<0.001). CRP increase correlated positively with Peritoneal Cancer Index (tumor load) (ρ =0.521, p<0.001).

Conclusion: PIPAC was followed by a modest and transitory inflammatory response that was commensurate to the disease extent. No hematological, renal or hepatic toxicity was observed even after repetitive administration.

Pseudomyxoma Peritonei: A Case Report Diagnosed in a 47-Year-Old Woman with Chronic Pelvic Abdominal Pain and Appendicular Origin: Review of the Literature and Management

The authors report a case of pseudomyxoma peritonei with gelatinous peritoneum in a 47-year-old-woman. The main symptom for discovery was a chronic pelvic abdominal pain. This disease is particularly rare. The gelatinous substance is often associated with a malignant ovarian tumor or appendicitis perforated. Currently, on the whole, an exploratory laparoscopy allows diagnosis, biopsies, and appendectomy. The treatment is essentially surgical. The prognosis depends on grade (1/3) and response to chemotherapy. This case was presented to the tumor board.

Pressurized Intra Peritoneal Aerosol Chemotherapy in patients suffering from peritoneal carcinomatosis of pancreatic adenocarcinoma

BACKGROUND

Patients suffering from peritoneal carcinomatosis of pancreatic adenocarcinoma were treated with Pressurized Intra Peritoneal Aerosol Chemotherapy (PIPAC), initial clinical findings are presented.

METHODS

Single institution, tertiary referral center certified for therapy of peritoneal disease. Prospective data collection of PIPAC therapy with doxorubicin 1.5 mg/m2 and cisplatin 7.5 mg/m2 of body surface delivered at intervals of six weeks. The outcome criteria were microscopic pathological response, survival and adverse events (v4.0 CTCAE).

RESULTS

A total of 20 patients (m/f = 3:1) with a mean age of 64.9 (range: 45.0 to 87.0) years underwent 41 PIPAC procedures without intraoperative complications. The mean number of PIPAC cycles was 2.1 (range: one to four). Ten patients with ≥ 2 PIPAC applications were eligible for histological analysis to assess carcinoma regression. Complete or high grade tumor regression was found in two (10%) and five (25%) patients, respectively. An overall median survival of 36.6 weeks after the first PIPAC application was observed. One patient died postoperatively due to small bowel obstruction. No CTCAE level 3 and 4 complications occurred.

CONCLUSION

In about one third of patients, repeated PIPAC therapy did induce histological regression of systemic chemo-resistant PC of pancreatic adenocarcinoma. Prospective randomized trials are needed to further clarify any clinical impact of such observations.

Multicentric initial experience with the use of the pressurized intraperitoneal aerosol chemotherapy (PIPAC) in the management of unresectable peritoneal carcinomatosis

BACKGROUND

PIPAC is a recent approach for intraperitoneal chemotherapy with promising results for patients with peritoneal carcinomatosis (PC). We aimed to evaluate the postoperative outcome of PIPAC in patients with non-resectable PC during our initial experience of the technique.

METHODS

All patients who underwent PIPAC for non-resectable PC in three centers were analyzed regarding postoperative outcomes.

RESULTS

Seventy-three patients underwent 164 PIPAC. PC was from colorectal, gastric, ovarian, malignant mesothelioma, pseudomyxoma peritonei or other origins in 20, 26, 13, 8, 1 and 5 patients respectively. Forty-five (62%), 31 (42%), 8 (11%), 6 (8%), 1 (1%) patients underwent a second, third, fourth, fifth, and sixth PIPAC respectively. At the time of the first PIPAC, the median PCI was 17 (1-39), 57 patients presented with symptomatic PC (pain: 33; ascites: 35; transit disorder like diarrhea and constipation: 11). PCI improved in 64.5% of patients, 63.5% of patients presented with complete disappearance of symptoms. Major complications occurred as the outcome of 16 PIPAC (9.7%) and 5 (6.8%) patients died within 30 days of the PIPAC procedure. Rate of mortality and major complications 40% and 62% respectively occurred in first 20 treated patients. For 64 (88%) patients, systemic chemotherapy was associated with PIPAC and could be administered after PIPAC with a median delay of 14 days (2-28).

CONCLUSIONS

Implementing a PIPAC program in association with systemic chemotherapy is feasible and is associated with a risk of postoperative morbidity, even in teams highly experienced in PC management and requires a learning curve in patient selection.

Occupational safety of pressurized intraperitoneal aerosol chemotherapy (PIPAC)

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has emerged as a novel method to treat extensive, small volume peritoneal metastases. The clinical use of chemotherapy containing aerosols represents a potential occupational health hazard. We report the results of toxicological analysis during the first two clinical PIPAC procedures performed at Ghent University Hospital.

METHODS

After extensive preparation and in vitro testing, two patients were treated with PIPAC: the first using doxorubicin (2.86 mg in 51.43 mL) and cisplatin (14.28 mg in 164.3 mL), the second using oxaliplatin (182.10 mg in 186.42 mL). A standardized safety checklist was developed and used. Aerosol delivery was combined with electrostatic precipitation (ePIPAC). The following samples were obtained at several time points and locations: environmental air, floor surface wipes, surgeon's gloves, surgeon's hand wipes, circuit filters, and fluid from the water seal collection chamber container placed along the closed aerosol waste evacuating line. Platinum concentration was measured in these samples using voltammetry. Sample collection and analysis were performed by an independent external laboratory.

RESULTS

Platinum was not detected on the four floor locations after both procedures (detection limit 0.02 ng/cm2). Similarly, no platinum was detected in environmental air during both PIPACs at the surgeon's or anesthesiologist's position (detection limit 4.0-27 ng/m3). No platinum contamination was detected on the hands, outer pair of gloves, or inner pair of gloves of the surgeon (detection limit 70 and 50 ng respectively). Platinum was not detected on the filters and in the air-seal container liquid.

CONCLUSIONS

With adequate preparation and precautions, a clinical PIPAC program can be established without measurable chemotherapy exposure to the operating room environment or healthcare workers.

High-Pressure Nebulization as Application Route for the Peritoneal Administration of siRNA Complexes

Peritoneal carcinomatosis is a severe form of cancer in the abdomen, currently treated with cytoreductive surgery and intravenous chemotherapy. Recently, nebulization has been proposed as a less invasive strategy for the local delivery of chemotherapeutic drugs. Also, RNA interference has been considered as a potential therapeutic approach for treatment of cancer. In this study, Lipofectamine RNAiMAX/siRNA complexes and cyclodextrin/siRNA complexes are evaluated before and after nebulization. Nebulization of the siRNA complexes does not significantly lower transfection efficiency when compared to non-nebulized complexes. After incubation in ascites fluid, however, the cyclodextrin/siRNA complexes show a drastic decrease in transfection efficiency. For the Lipofectamine RNAiMAX/siRNA complexes, this decrease is less pronounced. It is concluded that nebulization is an interesting technique to distribute siRNA complexes into the peritoneal cavity, providing the complexes are stable in ascites fluid which might be present in the peritoneal cavity.

Peritoneal metastasis from pancreatic cancer treated with pressurized intraperitoneal aerosol chemotherapy (PIPAC)

Patients with peritoneal metastasis (PM) from pancreatic cancer have a short life expectancy. Systemic combination chemotherapy leads to a median overall survival of 7-8 months. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a treatment alternative, where studies in patients with PM from ovarian, gastric and colorectal cancer show a high safety profile and interesting results. This case study report data on the PIPAC treatment in patients with PM from pancreatic cancer. In a standard laparoscopy, chemotherapeutics (cisplatin and doxorubicin) are nebulized within the peritoneal cavity. After 30 min, the chemotherapeutics are evacuated through a closed system. The PIPAC procedure is repeated every 4-6 weeks. Five patients with PM from pancreatic cancer were treated with a total of 16 PIPAC procedures. All patients received >1 PIPAC and were eligible for evaluation of histological regression. Four patients demonstrated histological regression, and one patient had stable disease. Three patients are still alive, and the median overall survival is 14 months (range 10-20) since the diagnosis of PM. The histological regression and survival figures in this pilot study suggest activity of PIPAC with low-dose cisplatin and doxorubicin in pretreated peritoneal metastasis of pancreatic origin. This should now be evaluated in prospective studies.

Systematic review of pressurized intraperitoneal aerosol chemotherapy for the treatment of advanced peritoneal carcinomatosis

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a minimally invasive approach under investigation as a novel treatment for patients with peritoneal carcinomatosis of various origins. The aim was to review the available evidence on mechanisms, clinical effects and risks.

METHODS

This was a systematic review of the literature on pressurized intraperitoneal chemotherapy published between January 2000 and October 2016. All types of scientific report were included.

RESULTS

Twenty-nine relevant papers were identified; 16 were preclinical studies and 13 were clinical reports. The overall quality of the clinical studies was modest; five studies were prospective and there was no randomized trial. Preclinical data suggested better distribution and higher tissue concentrations of chemotherapy agents in PIPAC compared with conventional intraperitoneal chemotherapy by lavage. Regarding technical feasibility, laparoscopic access and repeatability rates were 83-100 and 38-82 per cent. Surgery-related complications occurred in up to 12 per cent. Postoperative morbidity was low (Common Terminology Criteria for Adverse Events grade 3-5 events reported in 0-37 per cent), and hospital stay was about 3 days. No negative impact on quality of life was reported. Histological response rates for therapy-resistant carcinomatosis of ovarian, colorectal and gastric origin were 62-88, 71-86 and 70-100 per cent respectively.

CONCLUSION

PIPAC is feasible, safe and well tolerated. Preliminary good response rates call for prospective analysis of oncological efficacy.

Pressurized IntraPeritoneal Aerosol Chemotherapy - Practical aspects

INTRODUCTION

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) has been introduced as novel treatment for peritoneal carcinomatosis. Only proper patient selection, stringent safety protocol and careful surgery allow for a secure procedure. We hereby report the essentials for safe implementation.

METHODS

All consecutive procedures within 20 months after PIPAC implementation were analyzed with regards to practical and surgical aspects. Special emphasis was laid on modifications of technique and safety measures during the implementation process with systematic use of a dedicated checklist. Further, surgical difficulty was documented by use of a visual analogue scale (VAS).

RESULTS

127 PIPAC procedures were performed in 58 patients from January 2015 until October 2016. 81% of patients had at least one previous laparotomy. Median operation time was 91 min (87-103) for the first 20 cases, 93 min (IQR 88-107) for PIPAC21-50, and 103 min (IQR 91-121) for the following 77 procedures. Primary and secondary non-access occurred in 3 patients (2%), all of them having prior hyperthermic intraperitoneal chemotherapy (HIPEC). Using open Hasson technique, one single bowel lesion occurred, which was the only intraoperative complication. One 5 mm and another 10/12 mm trocar were used in 88% of procedures while additional trocars were needed in 12%. No leak of cytostatics was observed and no procedure needed to be stopped. VAS for overall difficulty of the procedure was 3 ± 2.4, and 3 ± 2.9 and 3 ± 2.5, respectively, for abdominal access and intraoperative staging.

CONCLUSIONS

With standardized surgical approach and dedicated safety checklist, PIPAC can be safely introduced in clinical routine with minimal learning curve.

Feasibility and Safety of Pressurized Intraperitoneal Aerosol Chemotherapy for Peritoneal Carcinomatosis: A Retrospective Cohort Study

Background. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has been introduced as a novel repeatable treatment for peritoneal carcinomatosis. The available evidence from the pioneer center suggests good tolerance and high response rates, but independent confirmation is needed. A single-center cohort was analyzed one year after implementation for feasibility and safety. Methods. PIPAC was started in January 2015, and every patient was entered into a prospective database. This retrospective analysis included all consecutive patients operated until April 2016 with emphasis on surgical feasibility and early postoperative outcomes. Results. Forty-two patients (M : F = 8 : 34, median age 66 (59–73) years) with 91 PIPAC procedures in total (4×: 1,  3×: 17,  2×: 12, and  1×: 12) were analyzed. Abdominal accessibility rate was 95% (42/44); laparoscopic access was not feasible in 2 patients with previous HIPEC. Median initial peritoneal carcinomatosis index (PCI) was 10 (IQR 5–17). Median operation time was 94 min (89–108) with no learning curve observed. One PIPAC application was postponed due to intraoperative intestinal lesion. Overall morbidity was 9% with 7 minor complications (Clavien I-II) and one PIPAC-unrelated postoperative mortality. Median postoperative hospital stay was 3 days (2-3). Conclusion. Repetitive PIPAC is feasible in most patients with refractory carcinomatosis of various origins. Intraoperative complications and postoperative morbidity rates were low. This encourages prospective studies assessing oncological efficacy.

Impact of Pressurized Intraperitoneal Aerosol Chemotherapy on Quality of Life and Symptoms in Patients with Peritoneal Carcinomatosis: A Retrospective Cohort Study

Background. Peritoneal cancer treatment aims to prolong survival, but preserving Quality of Life (QoL) under treatment is also a priority. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel minimally invasive repeatable treatment modality. The aim of the present study was to assess QoL in our cohort of PIPAC patients. Methods. Analysis of all consecutive patients included from the start of PIPAC program (January 2015). QoL (0-100: optimal) and symptoms (no symptom: 0-100) were measured prospectively before and after every PIPAC procedure using EORTC QLQ-C30. Results. Forty-two patients (M : F = 8 : 34, median age 66 (59-73) years) had 91 PIPAC procedures in total (1 : 4x, 17 : 3x, 12 : 2x, and 12 : 1x). Before first PIPAC, baseline QoL was measured as median of 66 ± 2.64. Prominent complaints were fatigue (32 ± 4.3) and digestive symptoms as diarrhea (17 ± 3.75), constipation (17 ± 4.13), and nausea (7 ± 2.54). Overall Quality of Life was 64 ± 3.75 after PIPAC#1 (p = 0.57), 61 ± 4.76 after PIPAC#2 (p = 0.89), and 70 ± 6.67 after PIPAC#3 (p = 0.58). Fatigue symptom score was 44 ± 4.86 after PIPAC#1 and 47 ± 6.69 and 34 ± 7.85 after second and third applications, respectively (p = 0.40). Diarrhea (p = 0.31), constipation (p = 0.76), and nausea (p = 0.66) did not change significantly under PIPAC treatment. Conclusion. PIPAC treatment of peritoneal carcinomatosis had no negative impact on patients' overall QoL and its components or on main symptoms. This study was registered online on Research Registry (UIN: 1608).

Cytotoxic effect of different treatment parameters in pressurized intraperitoneal aerosol chemotherapy (PIPAC) on the in vitro proliferation of human colonic cancer cells

Background

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has been recently reported as a new approach for intraperitoneal chemotherapy (IPC). By means of a patented micropump, the liquid chemotherapy is delivered into the peritoneal cavity as an aerosol which is supposed to achieve “gas-like” distribution. However, recent data report that the fraction of the submicron aerosol (gas-like) is less than 3 vol% of the total amount of aerosolized chemotherapy. Until today, possible modifications of treatment parameters during PIPAC with the aim of improving therapeutic outcomes have not been studied yet.

This study aims to establish an in vitro PIPAC model to explore the cytotoxic effect of the submicron aerosol fraction and to investigate the impact of different application parameters on the cytotoxic effect of PIPAC on human colonic cancer cells.

Methods

An in vitro model using HCT8 colon adenocarcinoma wild-type cells (HCT8^WT) and multi-chemotherapy refractory subline (HCT8^RT) was established. Different experimental parameters such as pressure, drug dosage, time exposure, and system temperature were monitored in order to search for the conditions with a higher impact on cell toxicity. Cell proliferation was determined by means of colorimetric MTT assay 48 h following PIPAC exposures.

Results

Standard operational parameters applied for PIPAC therapy depicted a cytotoxic effect of the submicron aerosol fraction generated by the PIPAC micropump. We also observed that increasing pressure significantly enhanced tumor cell toxicity in both wild-type and chemotherapy-resistant cells. A maximum of cytotoxicity was observed at 15 mmHg. Pressure >15 mmHg did not show additional cytotoxic effect on cells. Increased oxaliplatin dosage resulted in progressively higher cell toxicity as expected. However, in resistant cells, a significant effect was only found at higher drug concentrations. Neither an extension of exposure time nor an increase in temperature of the aerosolized chemotherapy solution added an improvement in cytotoxicity.

Conclusions

In this in vitro PIPAC model, the gas-like PIPAC aerosol fraction showed a cytotoxic effect which was enhanced by higher intra-abdominal pressure with a maximum at 15 mmHg. Similar findings were observed for drug dose escalation. A phase I dose escalation study is currently performed at our institution. However, increasing the intra-abdominal pressure might be a first and simple way to enhance the cytotoxic effect of PIPAC therapy which needs further clinical investigations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-017-1109-4) contains supplementary material, which is available to authorized users.

Single-port access for Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC): technique, feasibility and safety

BACKGROUND

Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a drug delivery system for treatment of peritoneal metastasis (PM). A limitation of this technique is the non-access rate (10-15 %) due to peritoneal adhesions. The aim of the study was to assess feasibility and safety of the single-port access technique for PIPAC.

METHODS

Single-center, pilot study. Case series, retrospective analysis on 17 patients with PM of various origin treated with intraperitoneal cisplatin, doxorubicin and/or oxaliplatin administered as PIPAC. Single-port access was attempted in all patients by minilaparotomy.

RESULTS

Twenty-nine PIPAC procedures were performed. Nine patients were subjected to 1 PIPAC, four patients to 2 PIPAC and four patients to 3 PIPAC. Access to peritoneal cavity was possible in all cases. There was no bowel access lesion. Tightness of the abdomen (CO2-flow = 0) was achieved in all cases. No postoperative complications according to CTCAE (Common Terminology Criteria for Adverse Events)>2 were observed, no re-laparotomies required and no postoperative mortality recorded.

CONCLUSIONS

Single port-access is feasible and safe for PIPAC. Potential advantages over multiple trocars technique are a lower non-access rate, a lower risk of bowel lesions and a better tightness of the abdomen. This has now to be confirmed in a comparative study.

Environmental safety during the administration of Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC)

Background

Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is an innovative technique for intraperitoneal drug delivery. This study investigates the efficacy of the occupational health safety measures taken to prevent exposition of healthcare workers to the toxic chemotherapy aerosol.

Methods

Air samples were taken at the working place of the surgeon and of the anesthetist during 2 PIPAC procedures and analyzed for content of platinum by inductively coupled plasma mass spectrometry (ICP-MS). Airborne particles were quantified in real time. Biological monitoring was performed in two surgeons after 50 PIPAC by examining blood samples for possible traces of platinum. Analysis was performed by an independent company.

Results

Safety measures included tightly closed abdomen, operating room (OR), ventilation meeting requirements of ISO norm 14644-1 class 5, closed aerosol waste system and remote control of PIPAC administration. No traces of platinum were found in the air of the OR (detection limit of 0.0001 mg/filter). No specific rise in particle concentration was detected in the air during the PIPAC procedure, patient closure and removal of the sterile drapes. Blood samples of the surgeons showed no traces of platinum.

Conclusions

After implementation of adequate safety measures, no signs of environmental contamination or biological exposure of the surgeons were detected during PIPAC.

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) as a neoadjuvant therapy before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel drug delivery system able to induce regression of peritoneal metastasis (PM) in the salvage situation. The aim of this study was to determine the clinical characteristics, tumor histology, and extent of disease of the patients having undergone cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) after "neoadjuvant" PIPAC.

METHODS

This study was performed at a single institution, tertiary center. In a prospective registry, retrospective analysis was done. PIPAC indication was restricted to patients in the salvage situation who were not eligible for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

RESULTS

Nine-hundred sixty-one PIPAC sessions were successfully performed in 406 patients: 21 patients (5.2 %) were scheduled for CRS and HIPEC. Twelve of these patients had a low PCI (mean 5.8 ± 5.6). The remaining nine patients showed an advanced peritoneal disease (mean PCI 14.3 ± 5.3) at initial laparoscopy. After repeated PIPAC (mean number of cycles 3.5 ± 0.9), radiological tumor regression was observed in 7/9 patients and major histological regression was observed in 8/9 patients, so that secondary CRS and HIPEC became possible.

CONCLUSIONS

PIPAC might be used as a neoadjuvant therapy before CRS and HIPEC in order to improve the outcome of CRS and HIPEC, to select patients with chemosensitive, biologically favorable tumors, to extent the indications of CRS and HIPEC in the presence of diffuse small bowel involvement, and to reduce the extent of cytoreductive surgery.

Therapeutic options for peritoneal metastasis arising from colorectal cancer

Peritoneal metastasis is a common sign of advanced tumor stage, tumor progression or tumor recurrence in patients with colorectal cancer. Due to the improvement of systemic chemotherapy, the development of targeted therapy and the introduction of additive treatment options such as cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), the therapeutic approach to peritoneal metastatic colorectal cancer (pmCRC) has changed over recent decades, and patient survival has improved. Moreover, in contrast to palliative systemic chemotherapy or best supportive care, the inclusion of CRS and HIPEC as inherent components of a multidisciplinary treatment regimen provides a therapeutic approach with curative intent. Although CRS and HIPEC are increasingly accepted as the standard of care for selected patients and have become part of numerous national and international guidelines, the individual role, optimal timing and ideal sequence of the different systemic, local and surgical treatment options remains a matter of debate. Ongoing and future randomized controlled clinical trials may help clarify the impact of the different components, allow for further improvement of patient selection and support the standardization of oncologic treatment regimens for pmCRC. The addition of further therapeutic options such as neoadjuvant intraperitoneal chemotherapy or pressurized intraperitoneal aerosol chemotherapy, should be investigated to optimize therapeutic regimens and further improve the oncological outcome.