Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy: experience with 501 procedures

Cure for peritoneal metastases? An evidence-based review

There is now a considerable body of published evidence supporting the use of a multimodal approach consisting of cytoreductive surgery (CS) and heated intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal metastases (PM) arising from selected gastrointestinal tract malignancies. In the absence of systemic metastases, it is thought that disease confined to the peritoneum may be eradicated through optimum cytoreduction. This review critically evaluates the current body of published evidence for the use of CS/HIPEC in the treatment of advanced colorectal, appendiceal and gastric cancer. Although its role remains less defined in patients with gastric PM, current evidence provides a compelling argument for its use in PM of colorectal and appendiceal origin. With a low mortality and acceptable morbidity rate, CS/HIPEC may offer hope of long-term survival and cure in a defined group of patients with this disease.

Obesity and peritoneal surface disease: outcomes after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for appendiceal and colon primary tumors

BACKGROUND

It is estimated that 37% of the U.S. population is obese. It is unknown how obesity influences the operative and survival outcomes of cytoreductive surgery (CRS)/hyperthermic intraperitoneal chemotherapy (HIPEC) procedures.

METHODS

A retrospective analysis of a prospective database of 1,000 procedures was performed. Type of malignancy, performance status, resection status, hospital and intensive care unit stay, comorbidities, morbidity, mortality, and survival were reviewed.

RESULTS

A total of 246 patients with body mass index (BMI) of >30 kg/m(2) underwent 272 CRS/HIPEC procedures. Ninety-five (38.6%) were severely obese (BMI > 35 kg/m(2)). A total of 135 (49.6%) procedures were performed for appendiceal and 60 (22.1%) for colon cancer. Median follow-up was 52 months. Both major and minor morbidity were similar for obese and non-obese patients. The 30-day mortality rates for obese and non-obese patients were 1.5 and 2.5%, respectively. Median intensive care unit and hospital stay were 1 and 9 days, regardless of BMI. The 30-day readmission rate was similar between obese and non-obese patients (24.8 vs. 19.4%, p = 0.11). Median survival for low-grade appendiceal cancer (LGA) was 76 months for obese patients and 107 months for non-obese patients (p = 0.32). Survival was worse for severely obese patients (median survival 54 months) versus non-obese patients with LGA (p = 0.04). Survival was similar for obese and non-obese patients with peritoneal surface disease (PSD) from colon cancer or high-grade appendiceal cancer.

CONCLUSIONS

Obesity does not influence postoperative morbidity or mortality of patients with PSD, regardless of primary tumor. Severe obesity is associated with decreased long-term survival only in patients with LGA primary disease; however, application of CRS/HIPEC still offers meaningful prolongation of life. Obesity should not be considered a contraindication for CRS/HIPEC procedures.

Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality

BACKGROUND

Cytoreductive surgery (CRS)/Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is associated with prolonged survival in selected patients with peritoneal surface disease. Yet, for elderly patients (older than 70 years of age) CRS/HIPEC is controversial, due to associated morbidity.

METHODS

A retrospective analysis of a prospective database of 950 procedures was performed. Type of malignancy, demographics, performance and resection status, hospitalization, morbidity, mortality, and survival were reviewed.

RESULTS

A total of 81 patients (median age 73, range 70-87) underwent CRS/HIPEC between 1991 and 2011. Median follow-up was 48.1 months. Complete cytoreduction was achieved in 44 %. Median survival was 31.8 months for appendiceal cancer, 41.5 for mesothelioma, 54.0 for ovarian cancer, 13.2 for colon cancer, and 7.6 for gastric cancer. The 30-day mortality was 13.6 %. The combined grade III and IV morbidity was 38 %. Median ICU and hospital stay for uncomplicated patients was 1 and 8 days, respectively. The 3-month mortality was 27.4 %. There were no deaths in the octogenarian group. In stepwise multivariate analysis, type of primary (p = 0.03), albumin (p = 0.02), and R status (p = 0.007) were predictive of survival only in the absence of complications. Splitting the data at the midpoint of surgical experience, there was a drop in 1- and 3-month mortality over time to 9.5 and 19.3 %, respectively, while the median survival increased from 11.2 (N = 39) to 46.9 months (N = 42).

CONCLUSIONS

HIPEC in the elderly is associated with a steep learning curve and considerable morbidity and mortality. However, age alone is not a contraindication for the procedure. Institutional experience and stringent patient selection are key factors for prolonged survival.

Antibiotic treatment decreases microbial burden associated with pseudomyxoma peritonei and affects β-catenin distribution

PURPOSE

Pseudomyxoma peritonei is an understudied cancer in which an appendiceal neoplasm invades the peritoneum and forms tumor foci on abdominal organs. Previous studies have shown that bacteria reside within pseudomyxoma peritonei tumors and mucin. Thus, we sought to analyze the effect of antibiotics on bacterial density and β-catenin expression within pseudomyxoma peritonei samples.

EXPERIMENTAL DESIGN

The study included 48 patients: 19 with disseminated peritoneal adenomucinosis (DPAM) and 29 with peritoneal mucinous carcinomatosis (PMCA). Fourteen patients were given antibiotics (30 mg lansoprazole, 1 g amoxicillin, and 500 mg clarithromycin) twice a day for 14 days. One week after completion of therapy, surgery was conducted and specimens were harvested for pathology, bacterial culture, ISH, and immunohistochemistry.

RESULTS

ISH showed the presence of bacteria in 83% of the patient samples, with a higher Helicobacter pylori density observed in PMCA versus DPAM. PMCA patients treated with antibiotics had a significantly lower bacterial density and decreased β-catenin levels in the cytoplasm, the cell nuclei, and mucin-associated cells. Although not significant, similar trends were observed in DPAM patients. Cell membrane β-catenin was significantly increased in both DPAM and PMCA patients receiving antibiotics.

CONCLUSIONS

Bacteria play an important role in pseudomyxoma peritonei. Antibiotic treatment improved the histopathology of tissue, particularly in PMCA patients. In PMCA, antibiotics decreased bacterial density and were associated with a significant β-catenin decrease in the cytoplasm, cell nuclei, and mucin along with a small membrane increase. These results suggest that antibiotics offer potential protection against cell detachment, cellular invasion, and metastasis.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis from Small Bowel Adenocarcinoma

Peritoneal carcinomatosis arising from small bowel adenocarcinoma (PCSBA) carries a dismal prognosis. Presently, limited data have been published on the outcome of PCSBA treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). This series represents the largest series published to date examining our experience with 17 patients. From 1995 to 2011, 17 patients underwent HIPEC with mitomycin for PCSBA. Patients in this study were identified from a prospectively maintained database. Twenty HIPEC procedures were performed on 17 patients with a mean age of 52.2 years. Patients have achieved a mean overall postoperative survival of 18.4 months after progression on chemotherapy with an overall postoperative one- and three-year survival of 52 and 23 per cent, respectively. The mean total length of hospital stay was 10 days. There was no treatment-related mortality. Six patients were readmitted to the hospital within 30 days of discharge (35%). Eight patients (47%) experienced postoperative complications, in which two patients had major postoperative complications in the form of intra-abdominal abscess requiring interventions (12%). HIPEC has encouraging survival results for patients with PCSBA compared with similar patients treated with conventional treatments. However, even with such advancement in management, treatment for small bowel adenocarcinoma still remains a challenge.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in Asian patients: 100 consecutive patients in a single institution

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to improve survival in selected patients with peritoneal carcinomatosis. We review our institutional experience with the procedure and evaluate the overall survival (OS) and disease-free survival (DFS) rates in 100 consecutive patients.

METHODS

Data were prospectively collected from 100 consecutive patients with peritoneal carcinomatosis treated by CRS and HIPEC at the National Cancer Centre Singapore between April 2001 and May 2012. Our primary end points were OS and DFS.

RESULTS

Of the 100 patients, 84 were of Chinese ethnicity, 3 were Malay, 6 were Indian, and 7 were of other ethnicities. Primary tumors were ovarian cancer (n=39), colorectal cancer (n=28), primary peritoneal (n=6), appendiceal cancer (n=20), and mesothelioma (n=7). Median follow-up duration was 21 months. At 5 years, the DFS was 26.3% and OS was 50.9%. Factors influencing OS and DFS were cytoreductive score, primary cancer, and disease-free interval of more than 12 months on univariate analysis. The only factors that remained significant for prognosis after multivariate analysis were primary cancer and cytoreductive score. Thirty-day morbidity was 56%, and there were no 30-day mortalities.

CONCLUSIONS

CRS and HIPEC can be safely carried out in Asian patients with peritoneal carcinomatosis from ovarian, colorectal, appendiceal, mesothelioma, and primary peritoneal origins. Overall, the ovarian, appendiceal, mesothelioma, and primary peritoneal cancer patients tended to do better than the colorectal patients, but careful patient selection ensuring that optimal cytoreduction can be achieved is essential for the success of this procedure.

Complications and toxicities after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

INTRODUCTION

The purpose of our study was to evaluate the perioperative complications, toxicity, mortality rates after cytoreductive surgery (CRS), and effects of hyperthermic intraperitoneal chemotherapy (HIPEC) used in the treatment of peritoneal surface malignancies.

METHODS

Between September 2007 and March 2012, we performed 118 CRS and HIPEC with the closed abdominal technique on 115 patients with peritoneal carcinomatosis (PC). Systemic toxicities were graded according to the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 3.0 criteria and were analyzed from a prospectively collected database.

RESULTS

The mean age of patients was 53.4 (range, 20-82) years; 76.3 % were female. PC was synchronous to primary cancer in 53.4 % of patients, metachronous in 41.5 %, and recurrent in 5.1 % of the patients. PCI was ≥15 in 53.4 % of the patients, and CC-0 cytoreduction was achieved in 68.5 % of the patients. Perioperative mortality was observed in 9 (7.6 %) patients. A total of 98 complications were observed in 46 (39.0 %) patients, and 4 patients underwent 6 reoperations for perioperative surgical complications. We observed toxicity in 25.4 % of the patients, nephrotoxicity in 18.6 %, and hematological toxicity in 13.6 % of patients. No significant difference was observed among age, gender, PCI and CC scores, origin of the primary tumor, and occurrence of toxicity and surgical complications. Prolonged operation times resulted in higher complication and/or toxicity rates (P < 0.01).

CONCLUSIONS

Cytoreductive surgery and HIPEC is a combined treatment strategy for peritoneal surface malignancies with acceptable complication and toxicity rates.

Right hemicolectomy for mucinous adenocarcinoma of the appendix: just right or too much?

BACKGROUND

The surgical management of mucinous adenocarcinoma of the appendix (MA) is controversial, given its infrequent nodal metastases and its propensity for peritoneal dissemination compared to nonmucinous adenocarcinoma. We sought to identify the appropriateness of a right hemicolectomy (RH) for MA in staging and treatment of these tumors.

METHODS

We queried all patients with MA captured in the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2007. Demographics, and tumor and therapy characteristics were extracted. Overall and disease-specific survival was compared by Cox regression analyses.

RESULTS

Of 2,101 patients with MA, the median age was 59 (range 49-72) years; 55 % were women (n = 1,151). Tumor, node, metastasis staging revealed that tumors were frequently T3 (33 %) or T4 (46 %), N0 (80 %), and M1 (46 %). Fifty-one percent (n = 666) of patients underwent an appendectomy. In patients with complete staging information who underwent RH, nodal metastases were less frequent than the nonmucinous adenocarcinoma group (odds ratio 0.63, p = 0.003). Well-differentiated tumors had a low likelihood of nodal metastases (6 % T1, 0 % T2, 7 % T3, 22 % T4). Adjusted survival for patients undergoing appendectomy was similar to those undergoing a RH (hazard ratio 0.93, p = 0.52). Median survival for both groups was similar with positive nodes (28 [appendectomy] vs. 26 months [RH], p = 0.26) or metastatic disease (52 [appendectomy] vs. 43 months [RH], p = 0.28).

CONCLUSIONS

There does not appear to be a therapeutic benefit to a RH in the setting of known node-positive or metastatic disease. Benefits of a staging operation can be individualized on the basis of the probability of nodal metastases, which is lower than nonmucinous tumors.

Multivariate comparison of B-ultrasound guided and laparoscopic continuous circulatory hyperthermic intraperitoneal perfusion chemotherapy for malignant ascites

OBJECTIVE

Clinical efficacy of B-ultrasound-guided and laparoscopy-assisted continuous hyperthermic intraperitoneal perfusion chemotherapy (CHIPC) for treatment of malignant ascites was investigated.

METHODS

Sixty-two patients with malignant ascites induced by ovarian or gastrointestinal cancers were randomly treated with B-ultrasound-guided CHIPC (therapeutic group) or laparoscopy-assisted CHIPC (control group) performed at the same center. Hospitalization costs and surgical duration were evaluated. Follow-up was conducted for 21 months with B-ultrasound or computed tomography at least once per month for assessment of ascites amount and tumor progression. Clinical efficacy was assessed by modified World Health Organization criteria. Survival time, Karnofsky performance score (KPS) of quality of life (QOL), and complications were recorded for all patients.

RESULTS

Overall condition, primary disease type, and ascites amounts were comparable between groups. Significantly shorter mean duration of perfusion catheter placement (35 vs. 85 min) and mean hospitalization cost (36,000 vs. 55,000 ¥/patient) were observed in the therapeutic group than the control group (P < 0.01). Significantly different KPS scores were not observed before or after CHIPC (23.13 vs. 22.64 %) in both groups (P > 0.05). No significant differences in objective remission rates of malignant ascites (93.75 vs. 93.34 %), median survival times (9 vs. 8 months), or stamp hole metastasis rates (18.75 vs. 18.15 %) were observed between groups (P > 0.05).

CONCLUSIONS

B-ultrasound-guided and laparoscopy-assisted CHIPC have similar clinical efficacy for improving QOL and prolonging patient survival. B-ultrasound-guided CHIPC may, however, shorten operation times and reduce hospitalization costs, making the treatment available to a broader patient population, although port hole metastasis remains an issue.

Identification of a subgroup of patients at highest risk for complications after surgical cytoreduction and hyperthermic intraperitoneal chemotherapy

OBJECTIVE

To assess the influence of parietal and visceral peritonectomy procedures on moderate/severe morbidity in patients undergoing surgical cytoreducion and hyperthermic intraperitoneal chemotherapy (HIPEC) and to identify subgroups of patients at highest operative risk.

BACKGROUND

Cytoreducion with HIPEC is an effective but potentially morbid treatment option for peritoneal surface malignancies. Although complication rates have recently decreased with increasing experience, risk-factors for adverse operative outcome are still poorly understood.

METHODS

A prospective database of 426 combined procedures was reviewed. Multivariate analysis tested the correlation between major morbidity and 6 peritonectomies (greater and lesser omentectomy, pelvic, parietal anterior, left and right diaphragmatic peritonectomy), 14 visceral resections, 5 other operative factors, and 12 clinical variables. The extent of peritoneal involvement was quantified by peritoneal cancer index (PCI).

RESULTS

Mortality and major morbidity were 2.6% and 28.2%. PCI, number of visceral resections, poor performance status, and cisplatin dose more than 240 mg independently correlated to morbidity. The type and number of parietal peritonectomies and the type of visceral resections did not correlated to complications. Major morbidity rate was 65.7% in 35 (8.2%) patients with at least 2 of the following factors: PCI greater than 30, more than 5 visceral resections, poor performance status. Morbidity was 100% in 9 patients presenting all the risk factors.

CONCLUSIONS

Acceptable morbidity and low mortality may be achieved in high-volume centers. Operative outcome is mainly affected by a complex interplay of tumor, patient, and treatment-related factors. Preoperative and early intraoperative assessment of operative risk may identify a subset of patients unlikely to tolerate aggressive management.

Current status and future directions in gastric cancer with peritoneal dissemination

Peritoneal carcinomatosis arising from gastric cancer is mostly associated with poor prognosis. Despite the improvement of survival with modern polychemotherapy, the results are still unsatisfactory. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy might provide an additional therapeutic option for highly selected patients with gastric cancer and peritoneal metastasis leading to improved prognosis. Considering the increased rate of perioperative morbidity and the crucial prognostic role of complete macroscopic cytoreduction, adequate preoperative diagnostics and patient selection are strongly recommended. Further prospective randomized trials are needed to determine the roles of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy as part of an interdisciplinary treatment concept.

Predictors of survival in patients with high-grade peritoneal metastases undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Peritoneal metastases in patients with high-grade adenocarcinoma have been typically associated with a poor outcome. Recent literature has suggested that cytoreduction surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may improve survival. We examined this subset of patients in an effort to better delineate those factors which contribute to improved survival.

METHODS

A retrospective review was performed looking at patients who had undergone CRS/HIPEC. Patients were identified as high-grade histology on the basis of pathology reports indicating their lesion as high grade, moderately, or poorly differentiated and/or associated with signet ring or goblet cell carcinoid features. Peritoneal cancer index and completeness of cytoreduction (CC) were used to define disease burden. Survival analysis was performed by the method of Kaplan-Meier with the log-rank test used to determine significance.

RESULTS

Of the 250 patients who underwent CRS/HIPEC between 1999 and 2011, 36 (14%) were identified as having peritoneal metastases from a high-grade gastrointestinal primary. Actual overall survival from the time of diagnosis was 11.1% at 5 years. Median survival from time of surgery was 21.6 months. Survival advantage was conferred to those patients who underwent a CC0/CC1 resection, had a peritoneal cancer index score at time of surgery ≤20, appendiceal primary, or moderately differentiated histopathology. Receipt of neoadjuvant chemotherapy and nodal status was not significantly predictive of improved survival. Patients with signet ring cell histology had a particularly poor prognosis.

CONCLUSION

For those patients with high-grade peritoneal metastases and historically a poor prognosis, prolonged survival may be achieved through CRS/HIPEC, optimally with a CC0/CC1 resection.

Splenectomy ameliorates hematologic toxicity of hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is a promising modality for peritoneal carcinomatosis. Splenectomy is frequently required, however effect upon hematotoxicity is unknown.

METHODS

195 patients undergoing the procedure were evaluated and granulocyte colony stimulating factor administered for white blood cell counts <4.0.

RESULTS

52% of 195 underwent splenectomy; average white blood cell and platelet nadirs were 6.1,172. Non-splenectomy patients averaged white blood cell nadir 4.6, platelet nadir 164.1. Granulocyte colony stimulating factor administered in 29% of splenectomy, 43% of non-splenectomy (P=0.043).

CONCLUSION

Splenectomy ameliorates hematotoxicity of hyperthermic intraperitoneal chemotherapy and significantly reduces post-operative granulocyte colony stimulating factor requirements.

B ultrasound-guided hyperthermic intraperitoneal perfusion chemotherapy for the treatment of malignant ascites

To minimize invasive surgery, we employed B ultrasound to guide the placement of the catheters used in continuous circulatory hyperthermic intraperitoneal perfusion chemotherapy (CHIPC) in malignant ascites treatment. Thirty-two patients with malignant ascites were treated with CHIPC guided by B-mode ultrasound. Ascites were originally from ovarian cancer (11 cases), gastric cancer (10 cases), colorectal cancer (9 cases) and pancreatic cancer (2 cases). The CHIPC was carried out at 43˚C for 90 min with 0.9% saline solution as a carrier containing cisplatin and doxorubicin or mitomycin-C as therapeutic reagents depending on the type of the primary tumor. The therapeutic efficacy, postoperative complications and survival period of these patients were assessed with follow-up examinations. Among all participates to be assessed with ascites, 26 and 4 patients showed complete remission (CR) and partial remission (PR) respectively, with an objective remission rate (ORR) of 93.75%. The KPS scores were elevated by 23.1±9.0 after 3 sessions of ultrasound guided CHIPC and the quality of life (QOF) of patients was significantly improved (p<0.01). The median survival time was 9 months and 18 patients survived between 3 and 30 months after CHIPC treatment. Additionally, patients with different types of cancers significantly differed in the survival time (p<0.01). A novel approach of using B ultrasound guided CHIPC for the treatment of malignant ascites demonstrated satisfactory outcomes. The approach shows benefit in minimizing invasive surgery, improving the patient QOF and prolonging survival time.

Delay of Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy in Patients with Appendiceal Neoplasm

Cytoreductive surgery/heated intraperitoneal chemotherapy (CRS/HIPEC) has been shown to be effective for selected patients with advanced appendiceal cancer. We propose that delaying CRS/HIPEC leads to disease progression and affects outcome. A retrospective analysis of a prospective database was carried out. Patients were divided into two groups based on time from diagnosis to CRS/HIPEC (less than 6 months = early, greater than 6 months = delayed). Comparison was made of Peritoneal Cancer Index (PCI), Prior Surgery Score (PSS), complete cytoreduction (CC), and lymph node status. Overall survival (OS) was calculated using Kaplan-Meier estimates. Of 127 patients, 50 had disseminated peritoneal adenomucinosis and 77 had peritoneal mucinous carcinomatosis (PMCA). Of patients with PMCA, 41 had early CRS/HIPEC and 36 delayed. PCI was less than 20 in 46 and 17 per cent ( P = 0.007) of the early and delayed groups, respectively. CC was achieved in 88 and 61 per cent ( P = 0.009) of the early and delayed groups, respectively. PSS was (2 of 3) in 51 and 91 per cent ( P = 0.001) of the early and delayed groups, respectively. Five-year OS was 54 per cent for the early group and 45 per cent for the delayed group ( P = 0.2). Delaying CRS/HIPEC was associated with higher tumor load and lower chance for complete cytroreduction. Longer follow-up and larger numbers are needed to determine if OS difference will reach statistical significance.

Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion: The University of Arizona early experience

AIM: To evaluate the safety and effectiveness of our new cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) program.

METHODS: Retrospective review of patients with gastrointestinal malignancies who were suitable candidates for CRS and HIPEC between 12/1/2009 and 10/1/2010. All clinicopathologic data were reviewed with a special focus on the surgical outcome and the postoperative morbidity and mortality.

RESULTS: Fourteen patients were identified. Median age was 64 years; seven were female. The primary tumors were: colonic (29%), appendiceal (36%), peritoneal mesothelioma (14%), gastric (7%), adenocarcinoma of unknown primary (7%), and gastrointestinal stromal tumor (7%). Eleven patients (79%) received CRS/HIPEC, three for palliation. Three patients that did not undergo CRS/HIPEC had an average peritoneal cancer index (PCI) of 25. The eight patients that underwent curative CRS/HIPEC had an average PCI of 10 and a completeness of cytoreduction score of 0 (87.5%) or 1 (12.5%). Postoperative morbidity was 36%; the worst adverse event was Grade 3 ileus. Mortality rate was 0%.

CONCLUSION: CRS with HIPEC is safe and feasible at tertiary institutions with fledgling programs. PCI is an accurate predictor of surgical outcomes.

Patient rated outcomes and survivorship following cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CS + HIPEC)

BACKGROUND

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CS + HIPEC) is a treatment combining cytoreductive surgery with hyperthermic chemotherapy directly into the peritoneal cavity. Recipients may gain extended life when compared with best supportive care; yet results often are achieved with substantial morbidity and health-related quality of life (HRQOL) deficits. The purpose of this study was to record patient rated outcomes and the HRQOL of long-term survivors.

METHODS

One hundred and two patients living 12+ months post-treatment completed a survey including the Medical Outcomes Study 36-item Short Form Health Survey (SF-36), Functional Assessment of Cancer Therapy-Colon (FACT-C), and Pittsburgh Sleep Quality Index.

RESULTS

SF-36 Physical Component scores were significantly lower than general population norms (46.7, z= -2.943, P=0.003), while Mental Component scores were significantly higher (53.6, z=4.208, P ≤ 0.001). FACT scores were higher than general FACT normative scores. The majority (56%) of these survivors reported significant sleep quality impairment.

CONCLUSION

Although most HRQOL scores were comparable to or higher than those of the general population, long-term physical and functional deficits remain. These deficits, along with the poor sleep quality of recipients, may be improved by survivorship programs or targeted psychosocial interventions.

Gene expression profiling of peritoneal metastases from appendiceal and colon cancer demonstrates unique biologic signatures and predicts patient outcomes

BACKGROUND

Treatment of peritoneal metastases from appendiceal and colon cancer with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) shows great promise. Although long-term disease-free survival is achieved in some cases with this procedure, many patients have recurrence. Oncologists have treated such recurrences of appendiceal cancer similarly to colorectal carcinoma, which has been largely ineffective. This study uses gene expression analysis of peritoneal metastases to better understand these neoplasms.

STUDY DESIGN

From a prospectively maintained database and tissue bank, 41 snap frozen samples of peritoneal metastases (26 appendiceal, 15 colorectal) from patients undergoing HIPEC with complete cytoreduction and more than 3 years of follow-up underwent global gene expression analysis. Distinct phenotypes were identified using unsupervised hierarchical clustering based on differential gene expression. Survival curves restratified by genotype were generated.

RESULTS

Three distinct phenotypes were found, 2 consisting of predominantly low grade appendiceal samples (10 of 13 in Cluster 1 and 15 of 20 in Cluster 2) and 1 consisting of predominantly colorectal samples (7 of 8 in Cluster 3). Cluster 1 consisted of patients with good prognosis and Clusters 2 and 3 consisted of patients with poor prognosis (p = 0.006). Signatures predicted survival of low- (Cluster 1) vs high-risk (Cluster 2) appendiceal (p = 0.04) and low-risk appendiceal (Cluster 1) vs colon primary (Cluster 3) (p = 0.0002).

CONCLUSIONS

This study represents the first use of gene expression profiling for appendiceal cancer, and demonstrates genomic signatures quite distinct from colorectal cancer, confirming their unique biology. Consequently, therapy for appendiceal lesions extrapolated from colonic cancer regimens may be unfounded. These phenotypes may predict outcomes guiding patient management.

Right Hemicolectomy is not Routinely Indicated in Pseudomyxoma Peritonei

Pseudomyxoma peritonei (PMP) is primarily the result of a ruptured mucinous appendix neoplasm (MAN). Often MAN is lumped with but biologically distinct from intestinal appendiceal adenocarcinoma. Nodal and systemic dissemination are rare with the peritoneal cavity being the primary site of recurrence. Routine performance of right hemicolectomy (RHC) for PMP/MAN has been extensively debated without consensus. Our objective was to ascertain whether RHC has a survival advantage over appendectomy. We hypothesize if RHC is mandatory, then increased tumor recurrence and mortality should be observed in appendectomy only. Retrospective chart review was carried out in patients with tumors that met the Ronnett classification for PMP/MAN. Demographics, tumor grade, extent, recurrence, and progression were recorded. We report the rate of nodal involvement/recurrence in patients treated with RHC versus appendectomy as well as the rate of systemic and peritoneal recurrence and survival. Multivariate logistic regression was done to identify factors that impact survival. Of 120 patients, 48 had appendectomy and 72 had RHC. Seven per cent of patients undergoing RHC had positive lymph nodes and no nodal failures (0%) in patients undergoing appendectomy. Appendectomy versus RHC recurrence rates (21 vs. 28%, P = 0.12) and death resulting from disease (8 vs. 22%, P = 0.27) were similar. Logistic regression revealed that the type of surgery had no impact on recurrence and mortality, only optimal resection score and performance status. There was no difference in tumor recurrence or survival based on treatment by appendectomy or RHC. Performance status and complete cytoreduction are the only factors associated with survival. Lymph node involvement is rare and selective RHC is safe in PMP/MAN.

Survival and quality of life following cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis of colonic origin

BACKGROUND

Peritoneal carcinomatosis of colonic origin (PCC) is a life-threatening diagnosis. Cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) offers patients the prospect of long-term survival with alleviation of symptoms.

METHODS

Patients underwent HIPEC for PCC and completed questionnaires preoperatively (T1) and after surgery at 3 (T2), 6 (T3), and 12 (T4) months. Questionnaires included the Functional Assessment of Cancer Therapy-Colon (FACT-C), Brief Pain Inventory (BPI), SF-36 Medical Outcomes Study Survey (SF-36), Center for Epidemiologic Studies-Depression Scale (CES-D), and the ECOG Performance Status Rating.

RESULTS

A total of 62 patients were assessed before surgery. Median overall survival was 18 months, with 71.3 ± 6.3% survival at 1 year. Emotional well-being (P = .0007) improved after HIPEC. Social/family well-being (P = .065) and the colon subscale (P = .061) of the FACT worsened at T2, but recovered by T3. One-third to one-half of patients reported depressive symptoms over the course of the study. Pain scores increased above BL at T2, but decreased below BL at T3 and T4.

CONCLUSIONS

Emotional well being is improved after CS + HIPEC despite complications that may affect short-term recovery. Most patients remaining in the study recover to preoperative levels of functioning between 3 and 6 months after surgery. For some, survival can be attained without major decrement in QOL at 1 year. QOL concerns must be a key component in the evaluation for patients with PCC for CS and HIPEC.

Low surface contamination by cis/oxaliplatin during hyperthermic intraperitoneal chemotherapy (HIPEC)

AIM

The aim of this study was to evaluate contamination by platinum drugs in the operating room during hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

Environmental sampling of 151 wipe samples from surfaces on the HIPEC devices and operating room floors was performed for platinum in six German hospitals during 19 HIPEC procedures. Additionally, 45 wipe samples from surgeons' and perfusionists' protective gloves were analyzed.

RESULTS

Platinum concentrations from the HIPEC devices and operating room floors ranged from 0.07 to 110,000 pg/cm(2) (Median: 1.5 pg/cm(2)) with high contamination on the regulation knob and reservoir after HIPEC procedure, particularly when injecting the cytostatic drug into the reservoir via syringe. Samples from perfusionists' and surgeons' protective gloves ranged between 0.01 and 729 ng/pair.

CONCLUSIONS

Although sporadically high platinum concentrations on surfaces on the HIPEC device and operating room floor were detected, our study revealed that low surface loads are definitely possible and can be documented by wipe samples. Important factors for achieving low surface contamination are the use of infusion bags instead of syringes for injection of the cytostatic solution, careful cleaning of the device after HIPEC and wearing of two pairs of gloves.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for patients with peritoneal carcinomatosis secondary to urachal adenocarcinoma

BACKGROUND AND OBJECTIVES

Urachal adenocarcinoma with peritoneal dissemination is an unusual presentation of a rare disease. It is associated with patients experiencing significant pain, poor outcomes, and historical median survival times between 12 and 24 months. We describe our 18-year experience in managing these patients with cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

Five patients who underwent six CRS with HIPEC for disseminated urachal cancer were identified. Demographics, perioperative data, and oncologic results were reviewed.

RESULTS

All patients successfully completed CRS followed by HIPEC with Mitomycin C. Three patients had prior urachal mass excision and one had previous cystoprostatectomy with ileal conduit. At time of surgery, complete resection of all visible disease was only achieved in two patients. All patients developed local or distant disease recurrence at a median of 13 months postoperatively (range 7-31). The majority of patients (3/5) underwent postoperative intravenous chemotherapy for recurrence (2) or residual disease (1). All patients died of their disease, with median survival following date of surgery of 27 months (range 21-87). Symptomatic control of peritoneal disease was achieved in 2/5 (40%) of the cases.

CONCLUSIONS

Urachal adenocarcinoma with peritoneal dissemination is an aggressive, rare disease, which is uniformly fatal. In our experience, CRS followed by HIPEC with Mitomycin C may increase patient survival and palliation, although further treatment improvements are clearly required.

Management of peritoneal carcinomatosis from colorectal cancer

The management of peritoneal carcinomatosis from colorectal cancer is evolving. The introduction of new chemotherapeutic and biologic agents has certainly improved the outlook for many patients with metastatic colorectal cancer. Traditionally, patients with limited hepatic or pulmonary metastases were the only candidates for metastasectomy. However, patients with metastasis localized to the peritoneum have been shown to be candidates for metastasectomy with improved clinical outcomes. Cytoreductive surgery with the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) in this cohort of patients offers the only chance for long-term survival. Complete cytoreduction in combination with HIPEC for peritoneal surface disease has been demonstrated to produce survival outcomes similar to liver resection for hepatic metastases. This review will examine recent evidence pertaining to the evolving surgical oncology paradigm for management of colorectal peritoneal carcinomatosis.

Prognostic significance of lymph node metastases in patients with high-grade appendiceal cancer

BACKGROUND

In treating high-grade appendiceal cancer, appropriate patient selection for cytoreductive surgery and heated intraperitoneal chemotherapy (CRS/HIPEC) is essential. The effect of lymph node (LN) status on survival is not clear. We hypothesize that LN metastases negatively affect long-term survival.

METHODS

Retrospective analysis of peritoneal mucinous carcinomatosis (PMCA) patients from a prospective database was conducted. Using Kaplan-Meier survival curves and Cox proportional hazards ratio analysis, the effect of LN status, completeness of cytoreduction (CC), and peritoneal cancer index (PCI) was studied.

RESULTS

Of 134 patients with appendiceal cancer who underwent CRS/HIPEC, 77 (57%) had PMCA. Mean follow-up was 22 (range, 3-90) months. Overall survival (OS) was 88, 56, and 40% for 1, 3, and 5-year, respectively. Thirty-four patients (44%) had LN metastases, 23 of whom (68%) had CC, whereas in LN negative patients 35 of 43 (81%) had CC (p = 0.191). PCI ≥ 20 was seen in 23 of 34 patients (68%) with LN metastases and 29 of 43 (67%) without metastases (p = 0.191). Five-year OS for patients with LN metastases was 11% compared with 76% for LN negative (p < 0.001). Among patients with complete cytoreduction, 5-year OS for LN positive vs. negative was 21 and 73%, respectively (p = 0.002). On multivariate regression analysis of LN status, CC score and PCI, the following hazard ratios were obtained: 3.4 (95% confidence interval (CI), 1.3-9.0), 2.6 (95% CI, 1.03-6.7), and 2.8 (95% CI, 0.8-10.4), respectively.

CONCLUSIONS

Patient selection for CRS/HIPEC should take into consideration LN status, but it should not be a contraindication if preoperative evaluation revealed a high likelihood of complete cytoreduction.

The role of cytoreductive surgery and heated intraperitoneal chemotherapy (CRS/HIPEC) in patients with high-grade appendiceal carcinoma and extensive peritoneal carcinomatosis

BACKGROUND

Patients with peritoneal mucinous carcinomatosis (PMCA) of appendiceal origin and extensive disease are commonly advised against CRS/HIPEC. We hypothesize that CRS/HIPEC is a beneficial treatment for this group.

METHODS

Retrospective analysis of 134 patients with appendiceal cancer treated with CRS/HIPEC was performed from a prospective database. Extent of disease, measured by peritoneal cancer index (PCI), was related to completeness of cytoreduction (CC), lymph node (LN) status, and prior surgery score (PSS). Overall survival (OS) was estimated by Kaplan-Meier curves. Test differences were calculated using log-rank test.

RESULTS

A total of 77 patients (57%) had PMCA. Mean follow-up was 22 months with a median of 18 months. OS was 88%, 56%, and 40% for 1, 3, and 5 years, respectively. 68% had PCI ≥ 20. LN metastasis was found in 44% of patients in PCI ≥ 20 and PCI < 20 groups. 73% and 60% of patients had PSS of 2 or 3 in PCI ≥ 20 and PCI < 20 groups, respectively (P = .196). Complete cytoreduction was achieved in 65% of PCI ≥ 20 group and 96% of PCI < 20 group (P = .004). With complete cytoreduction, the 5-year OS was 45% in PCI ≥ 20 group and 66% in PCI < 20 group (P = .139). 18 of 19 patients with incomplete cytoreduction had PCI ≥ 20, with 3- and 5-year OS of 27% and 0%. Hazard ratios (by Cox regression) were 2.8 (95% confidence interval [95% CI] 0.8-10.2) and 3.6 (95% CI 1.5-8.8) for PCI < 20 and complete cytoreduction, respectively.

CONCLUSIONS

Meaningful long-term survival could be achieved in patients with PMCA even with extensive peritoneal disease. PCI ≥ 20 should not be used as an exclusion criterion when selecting these patients for CRS/HIPEC, and every effort should be made to achieve complete cytoreduction.

[Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy associated toxicity in treatment of peritoneal carcinomatosis]

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.

Phagocytosis of dying tumor cells by human peritoneal mesothelial cells

Peritoneal carcinomatosis is an advanced form of metastatic disease characterized by cancer cell dissemination onto the peritoneum. It is commonly observed in ovarian and colorectal cancers and is associated with poor patient survival. Novel therapies consist of cytoreductive surgery in combination with intraperitoneal chemotherapy, aiming at tumor cell death induction. The resulting dying tumor cells are considered to be eliminated by professional as well as semi-professional phagocytes. In the present study, we have identified a hitherto unknown type of 'amateur' phagocyte in this environment: human peritoneal mesothelial cells (HMCs). We demonstrate that HMCs engulf corpses of dying ovarian and colorectal cancer cells, as well as other types of apoptotic cells. Flow cytometric, confocal and electron microscopical analyses revealed that HMCs ingest dying cell fragments in a dose- and time-dependent manner and the internalized material subsequently traffics into late phagolysosomes. Regarding the mechanisms of prey cell recognition, our results show that HMCs engulf apoptotic corpses in a serum-dependent and -independent fashion and quantitative real-time PCR (qRT-PCR) analyses revealed that diverse opsonin receptor systems orchestrating dying cell clearance are expressed in HMCs at high levels. Our data strongly suggest that HMCs contribute to dying cell removal in the peritoneum, and future studies will elucidate in what manner this influences tumor cell dissemination and the antitumor immune response.

Selection Criteria for Complete Cytoreduction after Cytoreductive Surgery for Peritoneal Surface Malignancy: Lessons Learned from Our First Series of Patients

The appropriate selection criteria for complete cytoreduction in patients with peritoneal surface malignancies have not been determined. We performed a retrospective analysis of all patients receiving cytoreductive surgery (CRS) during the study period of 2004 to 2008 to determine appropriate selection criteria for successful complete cytoreduction. During the study period, 38 patients underwent attempted CRS. Cytoreduction was scored complete, incomplete, or not reported in 53 per cent (n = 20), 37 per cent (n = 14), and 11 per cent (n = 4), respectively. Median overall survival for compete and incomplete cytoreduction was 56 months versus 5 months ( P = 0.011), respectively. Compared with incomplete cytoreduction, patients receiving complete cytoreduction were more likely to have a lower Peritoneal Cancer Index (PCI) and not have received preoperative systemic chemotherapy (CT). Univariate analysis verified PCI greater than 20 (hazard ratio [HR], 0.048; CI, 0.004 to 0.515; P = 0.01) and CT (HR, 0.17; 0.004 to 0.77; P = 0.021) as predictors of incomplete cytoreduction. Small bowel (100%), periportal region (33%), and mesentery (27%) were the most common sites of residual disease. In conclusion, PCI less than 20 and the need for preoperative chemotherapy should be strongly considered when selecting patients with peritoneal surface malignancy for attempted cytoreduction. Early evaluation of the small bowel, mesentery, and periportal region for resectability prevents unnecessary surgery.

Treatment of peritoneal carcinomatosis with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: state of the art and future developments

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.

Hepatobiliary procedures in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

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.

Effects of intraperitoneal chemotherapy with mitomycin C on the prevention of peritoneal recurrence in colorectal cancer patients with positive peritoneal lavage cytology findings

BACKGROUND

The detection of intraperitoneal free cancer cells in colorectal cancer (CRC) patients is associated with a poorer prognosis. The aim of this study was to investigate the effects of intraperitoneal chemotherapy (IPC) with mitomycin C (MMC) on preventing peritoneal recurrence in CRC patients with positive peritoneal lavage cytology findings.

METHODS

A total of 52 CRC patients who had no clinically confirmed peritoneal dissemination and whose status of peritoneal lavage cytology was positive were investigated. Conventional peritoneal lavage cytology was performed. Overall, 31 of the 52 patients (59.6%) were administered IPC with MMC. Before closure of the abdomen, 4 silicon catheters were inserted into peritoneal cavity. After closure, the perfusate (diluting 20 mg MMC with 500 ml saline) was instilled from the catheter, and all catheters were clumped. All catheters were opened 1 h later.

RESULTS

The mean follow-up period was 83.1 months. According to univariate analyses of all 52 patients and the subgroup of 36 patients with stage II or III tumors, patients with IPC had a significantly better peritoneal recurrence-free survival and cancer-specific survival than patients who did not receive IPC (P < 0.005). In multivariate analysis, IPC remained an independent prognostic factor for peritoneal recurrence-free survival in all patients.

CONCLUSIONS

It appears that IPC with MMC is an effective treatment to prevent peritoneal recurrence and prolong the cancer-specific survival in CRC patients without peritoneal dissemination, but who have positive peritoneal lavage cytology. It is necessary to verify the effectiveness of IPC with MMC in a prospective trial.

Toward curative treatment of peritoneal carcinomatosis from nonovarian origin by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy: a multi-institutional study of 1,290 patients

BACKGROUND

Peritoneal carcinomatosis (PC) from nonovarian malignancies long has been regarded as a terminal disease. Over the past decade, new locoregional therapeutic approaches combining cytoreductive surgery with perioperative intraperitoneal chemotherapy (PIC) have evolved that have demonstrated improved survival.

METHODS

A retrospective, multicenter cohort study was performed in French-speaking institutions to evaluate toxicity and principal prognostic factors after cytoreductive surgery and PIC (hyperthermic intraperitoneal chemotherapy [HIPEC] and/or early postoperative intraperitoneal chemotherapy [EPIC]) for PC from nongynecologic malignancies.

RESULTS

The study included 1290 patients from 25 institutions who underwent 1344 procedures between February 1989 and December 2007. HIPEC was performed in 1154 procedures. The principal origins of PC were colorectal adenocarcinoma (N = 523), pseudomyxoma peritonei (N = 301), gastric adenocarcinoma (N = 159), peritoneal mesothelioma (N = 88), and appendiceal adenocarcinoma (N = 50). The overall morbidity and mortality rates were 33.6% and 4.1%, respectively. In multivariate analysis, patient age, the extent of PC, and institutional experience had a significant influence on toxicity. The overall median survival was 34 months; and the median survival was 30 months for patients with colorectal PC, not reached for patients with pseudomyxoma peritonei, 9 months for patients with gastric PC, 41 months for patients with peritoneal mesothelioma, and 77 months for patients with PC from appendiceal adenocarcinoma. Independent prognostic indicators in multivariate analysis were institution, origin of PC, completeness of cytoreductive surgery, extent of carcinomatosis, and lymph node involvement.

CONCLUSIONS

A therapeutic approach that combined cytoreductive surgery with PIC was able to achieve long-term survival in a selected group of patients who had PC of nonovarian origin and had acceptable morbidity and mortality. The current results indicated that this treatment should be centralized to institutions with expertise in the management of PC.

Successful treatment of recurrent small bowel adenocarcinoma by cytoreductive surgery and chemotherapy: a case report and review of the literature

Introduction

Small bowel adenocarcinoma is a rare malignancy associated with a poor prognosis and there is little evidence of effective treatment. Recurrent small bowel adenocarcinoma is an intractable disease for which there is little information available regarding its treatment by palliative therapy. We present a case of recurrent small bowel adenocarcinoma successfully treated by cytoreductive surgery and palliative chemotherapy.

Case presentation

We report the case of a 72-year-old Japanese female who developed a peritoneal metastasis from recurrent small bowel adenocarcinoma after curative resection and adjuvant chemotherapy with S-1 and polysaccharide K. She underwent cytoreductive surgery followed by chemotherapy with folinic acid/fluorouracil/oxaliplatin and folinic acid/fluorouracil/irinotecan with polysaccharide K. Subsequently, no sign of a recurrence was observed 42 months after the second operation.

Conclusion

To the best of our knowledge, this is the first case report of the successful treatment of peritoneal metastasis from small bowel adenocarcinoma by cytoreductive surgery and combination chemotherapy (folinic acid/fluorouracil/oxaliplatin and folinic acid/fluorouracil/irinotecan with polysaccharide K).

Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for malignant peritoneal mesothelioma: mitomycin versus cisplatin

BACKGROUND

Malignant peritoneal mesothelioma (MPM) is a rare, rapidly fatal disease. Because traditional treatments offer little benefit, there has been increasing interest in cytoreductive surgery (CS) with intraperitoneal hyperthermic chemotherapy (IPHC). The most efficacious chemotherapy regimen is not established. Herein we report clinical outcomes of MPM patients treated with CS and IPHC and contrast results using two chemoperfusates: mitomycin and cisplatin.

METHODS

Thirty-four patients were treated for MPM. Following CS, 19 patients underwent IPHC with mitomycin and 15 received cisplatin. Overall survival, disease-free survival, and progression-free survival were compared between the two groups.

RESULTS

Overall survival was 56 and 17% at 3 and 5 years, with median survival of 40.8 months. Those perfused with cisplatin were more likely to be alive at 1, 2, and 3 years (P < 0.05, 0.05, and 0.04, respectively). Median survival for mitomycin and cisplatin was 10.8 and 40.8 months, respectively (P = 0.22). Median disease-free survival and progression-free survival were 10.3 and 9.1 months, respectively. There was a trend toward improved disease-free and progression-free survival using cisplatin.

CONCLUSIONS

CS with IPHC is a promising modality for patients with MPM, and clinical outcomes appear to be improved using cisplatin. We recommend using high-dose intraperitoneal cisplatin following cytoreductive surgery when treating malignant peritoneal mesothelioma.

Chemotherapy with laparoscope-assisted continuous circulatory hyperthermic intraperitoneal perfusion for malignant ascites

AIM: To investigate the procedure, feasibility and effects of laparoscope-assisted continuous circulatory hyperthermic intraperitoneal perfusion chemotherapy (CHIPC) in treatment of malignant ascites induced by peritoneal carcinomatosis from gastric cancers.

METHODS: From August 2006 to March 2008, the laparoscopic approach was used to perform CHIPC on 16 patients with malignant ascites induced by gastric cancer or postoperative intraperitoneal seeding. Each patient underwent CHIPC three times after laparoscope-assisted perfusion catheters placing. The first session was completed in operative room under general anesthesia, 5% glucose solution was selected as perfusion liquid, and 1500 mg 5-fluorouracil (5-FU) and 200 mg oxaliplatin were added in the perfusion solution. The second and third sessions were performed in intensive care unit, 0.9% sodium chloride solution was selected as perfusion liquid, and 1500 mg 5-FU was added in the perfusion solution alone. CHIPC was performed for 90 min at a velocity of 450-600 mL/min and an inflow temperature of 43 ± 0.2°C.

RESULTS: The intraoperative course was uneventful in all cases, and the mean operative period for laparoscope-assisted perfusion catheters placing was 80 min for each case. No postoperative deaths or complications related to laparoscope-assisted CHIPC occurred in this study. Clinically complete remission of ascites and related symptoms were achieved in 14 patients, and partial remission was achieved in 2 patients. During the follow-up, 13 patients died 2-9 mo after CHIPC, with a median survival time of 5 mo. Two patients with partial remission suffered from port site seeding and tumor metastasis,and died 2 and 3 mo after treatment. Three patients who are still alive today survived 4, 6 and 7 mo, respectively. The Karnofsky marks of patients (50-90) increased significantly (P < 0.01) and the general status improved after CHIPC. Thus satisfactory clinical efficacy has been achieved in these patients treated by laparoscopic CHIPC.

CONCLUSION: Laparoscope-assisted CHIPC is a safe, feasible and effective procedure in the treatment of debilitating malignant ascites induced by unresectable gastric cancers.

Peritoneal carcinomatosis of gastrointestinal origin: natural history and treatment options

BACKGROUND

Peritoneal carcinomatosis (PC) is a challenging consequence of certain malignancies, associated with a poor prognosis and limited treatment options. Generally, PC has been treated similarly to metastatic cancers of the primary tumor, but associated with worse outcomes when compared to other sites of metastatic disease from the same primary tumor site. With supportive care alone, the median survival with PC is 3-6 months. More recently, a limited number of centers have reported success with cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in a subset of patients with PC, resulting in improved survival compared with historical controls.

OBJECTIVES

This paper outlines the natural history of PC, and surgical, chemotherapeutic, and combined modality treatment options, with a focus on PC of colorectal (CRC) and appendiceal origin.

RESULTS

At this time, the 'standard' treatment for PC remains incompletely defined. As such, the optimal management strategies for both 'localized' and unresectable disease is unclear. CS + HIPEC is a promising treatment with a significant survival benefit of 10 months over systemic therapy alone demonstrated in a clinical trial of patients with CRC.

CONCLUSION

Well-designed clinical trials need to continue to be offered to improve care and determine the optimal treatment strategies for PC.

Peritoneal-based Malignancies and Their Treatment

Introduction: Patients with peritoneal carcinomatosis (PC) usually have dismal prognoses, even with traditional systemic therapy. Peritonectomy or cytoreductive surgery (CRS) has been used to treat selected patients. It is also commonly used in the management of pseudomyxoma peritonei (PMP), often in combination with hyperthermic intraperitoneal chemotherapy (HIPEC). Methods and Results: In the present review article, the indications for CRS and HIPEC are examined, along with its technical aspects, resulting morbidity and mortality. Patients with documented peritoneal carcinomatosis from colorectal and ovarian cancer or PMP, absence of extra-abdominal metastases and liver parenchymal metastases and with an ECOG performance status of <2 should be considered for CRS and HIPEC. Conclusion: It is important to recognise the role of and indications for CRS and HIPEC. Biologic factors of the disease and completeness of resection are important prognostic factors. Cytoreductive surgery, combined with intraperitoneal chemotherapy, can improve survival in selected patients with peritoneal-based malignancies. Key words: Cytoreductive surgery, Intraperitoneal chemotherapy, Peritonectomy, Peritoneal carcinomatosis, Pseudomyxoma peritone

Early and long-term postoperative management following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

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.

Peritoneal colorectal carcinomatosis treated with surgery and perioperative intraperitoneal chemotherapy: retrospective analysis of 523 patients from a multicentric French study

PURPOSE Peritoneal carcinomatosis (PC) from colorectal cancer traditionally is considered a terminal condition. Approaches that combine cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) have been developed recently. The purpose of this study was to assess early and long-term survival in patients treated with that strategy. PATIENTS AND METHODS A retrospective-cohort, multicentric study from French-speaking countries was performed. All consecutive patients with PC from colorectal cancer who were treated with CRS and PIC (with or without hyperthermia) were included. Patients with PC of appendiceal origin were excluded. Results The study included 523 patients from 23 centers in four French-speaking countries who underwent operation between 1990 and 2007. The median follow-up was 45 months. Mortality and grades 3 to 4 morbidity at 30 days were 3% and 31%, respectively. Overall median survival was 30.1 months. Five-year overall survival was 27%, and five-year disease-free survival was 10%. Complete CRS was performed in 84% of the patients, and median survival was 33 months. Positive independent prognostic factors identified in the multivariate analysis were complete CRS, PC that was limited in extent, no invaded lymph nodes, and the use of adjuvant chemotherapy. Neither the grade of disease nor the presence of liver metastases had a significant prognostic impact. CONCLUSION This combined treatment approach against PC achieved low postoperative morbidity and mortality, and it provided good long-term survival in patients with peritoneal scores lower than 20. These results should improve in the future, because the different teams involved will gain experience. This approach, when feasible, is now considered the gold standard in the French guidelines.

Intraperitoneal hyperthermic chemotherapy: an evolving paradigm for the treatment of peritoneal surface malignancies

Unfortunately, advanced colorectal cancer is often present at the time the disease is diagnosed. Many intra-abdominal malignancies spread throughout the peritoneal cavity, which is known as carcinomatosis. Peritoneal carcinomatosis is uniformly a terminal disease with a median survival of 6 months. Systemic chemotherapy is palliative and generally provides limited improvement in survival. Conventional surgery has typically been limited to ileostomy, colostomy or intestinal bypass procedures. Cytoreductive surgery alone has long been used to treat macroscopic disease, with limited success. However, cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy (IPHC) has evolved into a novel approach for peritoneal surface malignancy. IPHC was initially described in a canine model by Spratt. Although the first clinical series of peritoneal perfusion were small, Japanese trials, which utilized IPHC for prophylaxis in patients with gastric adenocarcinoma, Fujimoto was the first to report an improvement in survival for established gastric cracinomatosis. This early work provided the proof-of-principle for what has evolved into current management with aggressive cytoreduction and IPHC. The present review will outline the rationale, current practice and future directions of IPHC in the management of peritoneal surface malignancies.

Rapid photothermal intracellular drug delivery using multiwalled carbon nanotubes

Carbon nanotubes are unique materials that absorb infrared (IR) radiation, especially between 700 and 1100 nm, where body tissues are most transparent. Absorbed IR promotes molecular oscillation leading to efficient heating of the surrounding environment. A method to enhance drug localization for peritoneal malignancies is perfusion of warm (40-42 degrees C) chemotherapeutic agents in the abdomen. However, all tissues in the peritoneal cavity are subjected to enhanced drug delivery due to increased cell membrane permeability at hyperthermic temperatures. Here we show that rapid heating (within ten seconds) of colorectal cancer cells to 42 degrees C, using infrared stimulation of nanotubes as a heat source, in the presence of the drugs oxaliplatin or mitomycin C, is as effective as two hours of radiative heating at 42 degrees C for the treatment of peritoneal dissemination of colorectal cancer. We demonstrate increased cell membrane permeability due to hyperthermia from multiwalled carbon nanotubes in close proximity to cell membranes and that the amount of drug internalized by colorectal cancer cells heated quickly using carbon nanotubes equals levels achieved during routine application of hyperthermia at 42 degrees C. This approach has the potential to be used as a rapid bench to bedside clinical therapeutic agent with significant impact for localizing chemotherapy agents during the surgical management of peritoneal dissemination of colorectal cancer.

Should the treatment of peritoneal carcinomatosis by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still be regarded as a highly morbid procedure?: a systematic review of morbidity and mortality

BACKGROUND

: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been offered in many institutions worldwide since the 1990s. Despite its existence of more than 10 years, this treatment has received heavy criticism for its morbidity and mortality rates. This consequentially resulted in a lack of randomized trials being conducted and translates into a lack of the most reliable form of scientific evidence in clinical research, hence limiting its general acceptance.

OBJECTIVE

: To report the morbidity and mortality outcomes of CRS and HIPEC from all institutions performing this treatment as a prelude toward establishing the safety of this treatment for peritoneal carcinomatosis.

METHODS

: A systematic review of relevant studies before August 2008 was performed. Each study was appraised using a predetermined protocol. The quality of studies was assessed. The morbidity and mortality of the treatment were synthesized through a narrative review with full tabulation of results of all included studies.

CONCLUSIONS

: The morbidity and mortality outcomes of CRS and HIPEC are similar to a major gastrointestinal surgery, such as a Whipple's procedure. To derive the maximal benefit of this treatment, careful patient selection with an optimal level of postoperative care must be advocated to avoid undesirable complications of this treatment.

Incidence, risk factors, and impact of severe neutropenia after hyperthermic intraperitoneal mitomycin C

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered the standard of care for patients with peritoneal dissemination of appendiceal cancer and are increasingly being evaluated for use in patients with carcinomatosis from colon cancer. Mitomycin C (MMC) is one of the most frequently used HIPEC agents in the management of peritoneal-based gastrointestinal malignancies. This study analyzes the incidence and risk factors for developing neutropenia following MMC-HIPEC combined with CRS.

METHODS

All patients undergoing CRS and MMC-HIPEC for appendiceal cancer between January 1993 and October 2006 were retrospectively reviewed. Logistic regression was used to identify risk factors for the development of neutropenia, defined as an absolute neutrophil count (ANC) <1,000/mm(3).

RESULTS

One hundred and twenty MMC-HIPEC were performed in 117 patients with appendiceal cancer. The incidence of neutropenia was 39%. Neutropenia occurred in 57.6% of female and 21.3% of male patients (p < 0.0001). Female gender and MMC dose per body surface area (BSA) were independent risk factors for neutropenia on multivariable logistic regression [odds ratio (OR) of neutropenia in females = 3.58 (95% confidence interval, CI: 1.52, 8.43); OR for 5 unit (mg/m(2)) increase in MMC dose per BSA = 3.37 (95% CI: 1.72, 6.63)]. Neutropenia did not increase the risk of mortality, postoperative infection or length of hospital stay.

CONCLUSION

Neutropenia is a frequent complication associated with MMC-HIPEC. Female sex and MMC dose per BSA are independent risk factors for neutropenia. These differences must be considered in the management of patients undergoing MMC-HIPEC to minimize the toxicity of the procedure.