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Aoyagi T, Terracina KP, Raza A, Takabe K. Current treatment options for colon cancer peritoneal carcinomatosis. World J Gastroenterol 2014; 20:12493-12500. [PMID: 25253949 PMCID: PMC4168082 DOI: 10.3748/wjg.v20.i35.12493] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/10/2014] [Accepted: 06/05/2014] [Indexed: 02/06/2023] Open
Abstract
Peritoneal carcinomatosis (PC), the dissemination of cancer cells throughout the lining of the abdominal cavity, is the second most common presentation of colon cancer distant metastasis. Despite remarkable advances in cytotoxic chemotherapy and targeted therapy for colon cancer over the last 15 years, it has been repeatedly shown that these therapies remain ineffective for colon cancer PC. Recently, there has been a rapid accumulation of reports that cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) prolongs the life of colon cancer PC patients. Here, we will review the clinical presentation, the mechanisms of disease progression, and current treatment options for colon cancer PC, with a focus on the benefits and limitations of CRS-HIPEC.
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202
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Long-term results after proactive management for locoregional control in patients with colonic cancer at high risk of peritoneal metastases. Int J Colorectal Dis 2014; 29:1081-9. [PMID: 24980687 DOI: 10.1007/s00384-014-1929-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE A major problem in treating patients with peritoneal spread from colorectal cancer is that at diagnosis wide peritoneal involvement often precludes all curative attempts. A possible solution is to identify those patients at risk for peritoneal metastases and intervene early to prevent locoregional disease spread before it develops and, thus, to improve outcome. METHODS We analyzed long-term results from a previous study and compared outcomes in 25 patients with advanced colon cancer considered at high risk for peritoneal spread (pT3/pT4 and mucinous or signet ring cell histology) prospectively included and managed with a proactive surgical approach including target organ resection for peritoneal spread plus hyperthermic intraperitoneal chemotherapy (HIPEC) and in 50 retrospectively well-matched controls who underwent standard surgical resection during the same period and in the same hospital by different surgical teams. RESULTS At 48 months after the study closed, peritoneal metastases and local recurrence developed significantly less often in proactively managed patients than in controls (4 vs 28%) (p < 0.03). Patients in the proactive group also survived longer than control patients (median overall survival 59.5 vs 52 months). Despite similar morbidity, Kaplan-Meier survival curves disclosed significantly longer disease-free and overall survival in the proactive than in the control group (p < 0.05 and <0.04). CONCLUSIONS In patients with advanced colon cancer at risk for peritoneal recurrence, the proactive surgical approach plus HIPEC seems to achieve good locoregional control preventing peritoneal spread thus improving outcome without increasing morbidity. These advantages merit investigation in a multicentric randomized trial.
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203
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Oxaliplatin and molecular-targeted drug therapies improved the overall survival in colorectal cancer patients with synchronous peritoneal carcinomatosis undergoing incomplete cytoreductive surgery. Surg Today 2014; 45:986-92. [PMID: 25156007 DOI: 10.1007/s00595-014-1017-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 08/06/2014] [Indexed: 12/18/2022]
Abstract
PURPOSE To estimate the feasibility and limitations of incomplete cytoreductive surgery and modern systemic chemotherapy in patients with synchronous peritoneal carcinomatosis from colorectal cancer and to identify risk factors for death and factors associated with the patient prognosis. METHODS Sixty-five consecutive patients underwent surgery for synchronous peritoneal carcinomatosis from colorectal cancer at Hiroshima University, Japan between 1992 and 2012. The clinical, histological, and survival data were analyzed for independent risk factors and prognostic factors. The patients were retrospectively stratified into two groups according to the extent of surgery: complete cytoreductive surgery or incomplete cytoreductive surgery. RESULTS The median survival times in the complete and incomplete cytoreductive surgery groups were 29.8 and 10.0 months, respectively. Receiving systemic chemotherapy alone was an independent risk factor for death in the incomplete cytoreductive surgery group (P < 0.001). Oxaliplatin and molecular-targeted drug (cetuximab or bevacizumab) therapies were also independent prognostic factors (P < 0.001), whereas irinotecan therapy was not a prognostic factor (P = 0.494). CONCLUSION Oxaliplatin and molecular-targeted drug therapies improved the overall survival in patients undergoing incomplete cytoreductive surgery. Future trials for patients with synchronous peritoneal carcinomatosis from colorectal cancer should be undertaken, with patients stratified according to treatment with complete cytoreductive surgery or incomplete cytoreductive surgery with modern chemotherapy.
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204
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Intraperitoneal chemotherapy as adjuvant treatment to prevent peritoneal carcinomatosis of colorectal cancer origin: a systematic review. Br J Cancer 2014; 111:1112-21. [PMID: 25025964 PMCID: PMC4453838 DOI: 10.1038/bjc.2014.369] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/20/2014] [Accepted: 06/09/2014] [Indexed: 01/05/2023] Open
Abstract
Background: Peritoneal carcinomatosis (PC) of colorectal cancer (CRC) origin is associated with poor outcome. This systematic review evaluates the available evidence about adjuvant (hyperthermic) intraperitoneal chemotherapy ((H)IPEC) to prevent the development of PC. Methods: A systematic search of literature was conducted in August 2013 in PubMed, Embase, and the Cochrane database for studies on (H)IPEC to prevent PC in patients who underwent curative surgery for primary CRC. Results: Seven comparative studies and five cohort studies were selected. Treatment schedules varied between repeated fluoropyrimidine-based IPEC administration in the ambulatory setting to intra-operative (H)IPEC procedures using mitomycin-C or oxaliplatin. The reported rates of major complications related to adjuvant (H)IPEC was low. Four out of five evaluable comparative studies reported a significant difference in the incidence of PC in favour of (H)IPEC. All three comparative studies reporting on survival after intra-operative (H)IPEC showed a significant survival benefit in favour of the experimental arm. Substantial heterogeneity in patient selection, treatment protocols, and treatment effect evaluation among studies was observed. Conclusions: The currently available evidence about adjuvant (H)IPEC in high-risk CRC is limited and subject to bias, but points towards improved oncological outcome and supports further randomised studies.
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205
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Baratti D, Kusamura S, Iusco D, Bonomi S, Grassi A, Virzì S, Leo E, Deraco M. Postoperative complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy affect long-term outcome of patients with peritoneal metastases from colorectal cancer: a two-center study of 101 patients. Dis Colon Rectum 2014; 57:858-68. [PMID: 24901687 DOI: 10.1097/dcr.0000000000000149] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is an effective but potentially morbid treatment for colorectal cancer peritoneal metastases. The impact of treatment-related morbidity on long-term survival has been reported in various malignancies, but it has never been assessed in this clinical setting. OBJECTIVE The aim of this study was to assess the impact of major postoperative complications on oncological outcomes after cytoreduction and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases. DESIGN Two prospective databases were reviewed. Major complications were defined as grade 3 to 5 according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. The extent of peritoneal involvement was scored by the use of the Peritoneal Cancer Index. SETTINGS This study was conducted in 2 high-volume peritoneal malignancy management centers. PATIENTS One hundred one consecutive patients with peritoneal metastases potentially amenable to macroscopically complete cytoreduction were selected. INTERVENTIONS Peritonectomy procedures and multivisceral resections were used to remove all macroscopic tumor, and mitomycin-C plus cisplatin-based hyperthermic intraperitoneal chemotherapy was used to control microscopic residual disease. MAIN OUTCOME MEASURES The primary outcomes measured were overall and disease-specific survival. RESULTS Mortality and major morbidity were 3.0%, and 23.8%. Median follow-up was 44.9 months (95% CI, 24.1-65.7). Five-year disease-specific survival was 14.3% for patients who experienced major complications and 52.3% for those who did not (p = 0.001). Five-year overall survival was 11.7% for patients who experienced major complications, and 58.8% for those who did not (p = 0.003). At multivariate analysis, major morbidity correlated to both worse overall and disease-specific survival, along with a Peritoneal Cancer Index >19, and suboptimal cytoreduction. Poor performance status correlated only to worse disease-specific survival, and liver metastases correlated to worse overall survival. Longer operative time (OR, 4.1; 95% CI, 1.3-12.6; p = 0.01) and Peritoneal Cancer Index >19 (OR, 2.6; 95% CI, 1.1-6.0; p = 0.02) were independent risk factors for major morbidity. LIMITATIONS This study is limited by its observational design. CONCLUSIONS The prevention of major complications, by refining surgical technique and patient selection, is crucial because it affects oncologic outcome.
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Affiliation(s)
- D Baratti
- 1Peritoneal Surface Malignancy Program,Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy 2General Surgery Unit, Bentivoglio Hospital, Bentivoglio (BO), Italy 3Colorectal Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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Hugen N, Verhoeven RH, Lemmens VE, van Aart CJ, Elferink MA, Radema SA, Nagtegaal ID, de Wilt JH. Colorectal signet-ring cell carcinoma: benefit from adjuvant chemotherapy but a poor prognostic factor. Int J Cancer 2014; 136:333-9. [PMID: 24841868 DOI: 10.1002/ijc.28981] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/17/2014] [Indexed: 01/05/2023]
Abstract
Colorectal signet-ring cell carcinoma (SRCC) has been associated with poor survival compared with mucinous adenocarcinoma (MC) and the more common adenocarcinoma (AC). Efficacy of adjuvant chemotherapy in SRCC has never been assessed. This study analyzes the prognostic impact of SRCC and determines whether colonic SRCC patients benefit from adjuvant chemotherapy equally compared with MC and AC patients. Data on 196,757 colorectal cancer (CRC) patients in the period 1989-2010 was included in this Dutch nationwide population-based study. Five-year relative survival estimates were calculated and multivariate relative survival analyses using a multiple regression model of relative excess risk (RER) were performed. SRCC was found in 1,972 (1.0%) patients. SRCC patients presented more frequently with stage III or IV disease than AC patients (75.2% vs. 43.6%, p < 0.0001) and SRCC was more frequently found in the proximal colon (57.7 vs. 32.0%, p < 0.0001). SRCC patients had a poor 5-year relative survival of 30.8% (95% CI 28.1-33.6%) in the colon and 19.5% (95% CI 14.7-24.8%) in the rectum compared with 56.8% (95% CI 56.4-57.1%) and 58.5% (95% CI 57.9-59.1%) for AC. This survival difference was found in stage II, but was most prominent in stage III. Compared with AC, there was no significant interaction between SRCC and adjuvant chemotherapy (RER 1.10, 95% CI 0.81-1.51), suggesting a comparable benefit from adjuvant chemotherapy in AC and SRCC. In conclusion, the prognostic impact of SRCC is dismal in both colon and rectal cancer patients, but adjuvant chemotherapy is associated with improved survival in AC, MC, and SRCC patients.
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Affiliation(s)
- Niek Hugen
- Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
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207
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van Gestel YRBM, de Hingh IHJT, van Herk-Sukel MPP, van Erning FN, Beerepoot LV, Wijsman JH, Slooter GD, Rutten HJT, Creemers GJM, Lemmens VEPP. Patterns of metachronous metastases after curative treatment of colorectal cancer. Cancer Epidemiol 2014; 38:448-54. [PMID: 24841870 DOI: 10.1016/j.canep.2014.04.004] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 04/17/2014] [Accepted: 04/21/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study aimed to provide information on timing, anatomical location, and predictors for metachronous metastases of colorectal cancer based on a large consecutive series of non-selected patients. METHODS All patients operated on with curative intent for colorectal cancer (TanyNanyM0) between 2003 and 2008 in the Dutch Eindhoven Cancer Registry were included (N=5671). By means of active follow-up by the Cancer Registry staff within ten hospitals, data on development of metastatic disease were collected. Median follow-up was 5.0 years. RESULTS Of the 5671 colorectal cancer patients, 1042 (18%) were diagnosed with metachronous metastases. Most common affected sites were the liver (60%), lungs (39%), extra-regional lymph nodes (22%), and peritoneum (19%). 86% of all metastases was diagnosed within three years and the median time to diagnosis was 17 months (interquartile range 10-29 months). Male gender (HR=1.2, 95%CI 1.03-1.32), an advanced primary T-stage (T4 vs. T3 HR=1.6, 95%CI 1.32-1.90) and N-stage (N1 vs. N0 HR=2.8, 95%CI 2.42-3.30 and N2 vs. N0 HR=4.5, 95%CI 3.72-5.42), high-grade tumour differentiation (HR=1.4, 95%CI 1.17-1.62), and a positive (HR=2.1, 95%CI 1.68-2.71) and unknown (HR=1.7, 95%CI 1.34-2.22) resection margin were predictors for metachronous metastases. CONCLUSIONS Different patterns of metastatic spread were observed for colon and rectal cancer patients and differences in time to diagnosis were found. Knowledge on these patterns and predictors for metachronous metastases may enhance tailor-made follow-up schemes leading to earlier detection of metastasized disease and increased curative treatment options.
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Affiliation(s)
- Yvette R B M van Gestel
- Eindhoven Cancer Registry/Comprehensive Cancer Centre the Netherlands, P.O. Box 231, 5600 AE, Eindhoven, The Netherlands.
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA, Eindhoven, The Netherlands
| | | | - Felice N van Erning
- Eindhoven Cancer Registry/Comprehensive Cancer Centre the Netherlands, P.O. Box 231, 5600 AE, Eindhoven, The Netherlands
| | - Laurens V Beerepoot
- Department of Internal Medicine, St. Elisabeth Hospital, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, P.O. Box 90158, 4800 RK, Breda, The Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Maxima Medical Centre, P.O. Box 90052, 5600 PD, Eindhoven, The Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA, Eindhoven, The Netherlands; Research Institute Growth & Development, Maastricht Univeristy Medical Centre, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Geert-Jan M Creemers
- Department of Internal Medicine, Catharina Hospital, P.O. Box 1350, 5602 ZA, Eindhoven, The Netherlands
| | - Valery E P P Lemmens
- Eindhoven Cancer Registry/Comprehensive Cancer Centre the Netherlands, P.O. Box 231, 5600 AE, Eindhoven, The Netherlands; Department of Public Health, Erasmus MC University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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208
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Tanaka K, Okugawa Y, Toiyama Y, Inoue Y, Saigusa S, Kawamura M, Araki T, Uchida K, Mohri Y, Kusunoki M. Brain-derived neurotrophic factor (BDNF)-induced tropomyosin-related kinase B (Trk B) signaling is a potential therapeutic target for peritoneal carcinomatosis arising from colorectal cancer. PLoS One 2014; 9:e96410. [PMID: 24801982 PMCID: PMC4011754 DOI: 10.1371/journal.pone.0096410] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 04/07/2014] [Indexed: 01/05/2023] Open
Abstract
Tropomyosin-related receptor kinase B (TrkB) signaling, stimulated by brain-derived neurotrophic factor (BDNF) ligand, promotes tumor progression, and is related to the poor prognosis of various malignancies. We sought to examine the clinical relevance of BDNF/TrkB expression in colorectal cancer (CRC) tissues, its prognostic value for CRC patients, and its therapeutic potential in vitro and in vivo. Two hundred and twenty-three CRC patient specimens were used to determine both BDNF and TrkB mRNA levels. The expression of these proteins in their primary and metastatic tumors was investigated by immunohistochemistry. CRC cell lines and recombinant BDNF and K252a (a selective pharmacological pan-Trk inhibitor) were used for in vitro cell viability, migration, invasion, anoikis resistance and in vivo peritoneal metastasis assays. Tissue BDNF mRNA was associated with liver and peritoneal metastasis. Tissue TrkB mRNA was also associated with lymph node metastasis. The co-expression of BDNF and TrkB was associated with liver and peritoneal metastasis. Patients with higher BDNF, TrkB, and co-expression of BDNF and TrkB had a significantly poor prognosis. BDNF increased tumor cell viability, migration, invasion and inhibited anoikis in the TrkB-expressing CRC cell lines. These effects were suppressed by K252a. In mice injected with DLD1 co-expressing BDNF and TrkB, and subsequently treated with K252a, peritoneal metastatic nodules was found to be reduced, as compared with control mice. BDNF/TrkB signaling may thus be a potential target for treating peritoneal carcinomatosis arising from colorectal cancer.
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Affiliation(s)
- Koji Tanaka
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
- * E-mail:
| | - Yoshinaga Okugawa
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yuji Toiyama
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yasuhiro Inoue
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Susumu Saigusa
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Mikio Kawamura
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Toshimitsu Araki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yasuhiko Mohri
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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209
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Thomassen I, van Gestel Y, Aalbers A, van Oudheusden T, Wegdam J, Lemmens V, de Hingh I. Peritoneal carcinomatosis is less frequently diagnosed during laparoscopic surgery compared to open surgery in patients with colorectal cancer. Eur J Surg Oncol 2014; 40:511-514. [DOI: 10.1016/j.ejso.2014.01.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/23/2013] [Accepted: 01/21/2014] [Indexed: 01/14/2023] Open
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210
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Segelman J, Akre O, Gustafsson UO, Bottai M, Martling A. Individualized prediction of risk of metachronous peritoneal carcinomatosis from colorectal cancer. Colorectal Dis 2014; 16:359-67. [PMID: 24410859 DOI: 10.1111/codi.12552] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 12/02/2013] [Indexed: 12/19/2022]
Abstract
AIM The purpose of the study was to develop a tool for predicting the individual risk of metachronous peritoneal carcinomatosis after surgery for non-metastatic colorectal cancer. METHOD Independent predictors for metachronous colorectal carcinomatosis have previously been identified using a population-based database. Predictive models for colon and rectal cancer were developed from these data. The predictive models were based on multivariable Cox proportional hazard regression and were internally validated with bootstrapping. Performance was assessed by the concordance index and calibration plots. RESULTS In all, 8044 patients who underwent abdominal resection of colorectal cancer Stage I-III were included. The colon and rectal cancer risk score models predicted metachronous peritoneal carcinomatosis with a concordance index of 80% and 78%, respectively. Factors in the models included age, pathological pT stage, pN stage, number of examined lymph nodes (0-11, 12+), type of surgery (emergency/elective), completeness of cancer resection (R0/R1/R2), adjuvant chemotherapy (yes/no), preoperative radiotherapy and tumour location. CONCLUSION The proposed predictive models showed high internal validity and enabled individualized prediction of peritoneal recurrence of colorectal cancer. The models may help in the planning of treatment and follow-up of patients. However, external validation is warranted to assess generalizability of the predicted absolute risks.
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Affiliation(s)
- J Segelman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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211
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Ceelen W, Van Nieuwenhove Y, Putte DV, Pattyn P. Neoadjuvant chemotherapy with bevacizumab may improve outcome after cytoreduction and hyperthermic intraperitoneal chemoperfusion (HIPEC) for colorectal carcinomatosis. Ann Surg Oncol 2014; 21:3023-8. [PMID: 24756812 DOI: 10.1245/s10434-014-3713-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND In selected patients with colorectal peritoneal carcinomatosis (PC), cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) may improve survival. We aimed to assess whether neoadjuvant chemotherapy with or without bevacizumab is indicated in this patient population. METHODS Colorectal PC patients were treated with CRS and HIPEC using oxaliplatin (200-460 mg/m(2)) or mitomycin C (35 mg/m(2)). Postoperative outcome and long-term survival were prospectively recorded. The impact of clinical variables on overall survival (OS) was assessed using univariate and Cox multivariate analysis. RESULTS Between October 2002 and May 2012, 166 patients were treated with CRS and HIPEC. Neoadjuvant chemotherapy alone was administered to 21 % and neoadjuvant chemotherapy with bevacizumab to 16 % of patients. Postoperative mortality and major morbidity were 2.4 and 35 %, respectively. Half of the patients received adjuvant chemotherapy. After a median follow-up of 18 months, OS was 27 months (95 % confidence interval 20.8-33.2). On univariate analysis, OS was associated with extent of disease (P < 0.001), neoadjuvant chemotherapy with bevacizumab (P = 0.021), completeness of cytoreduction (CC) (P < 0.001), and adjuvant chemotherapy (P = 0.04), but not with primary disease site, synchronous presentation, or chemoperfusion drug. In multivariate Cox regression, independent predictors of OS were CC (hazard ratio 0.29, P < 0.001) and neoadjuvant therapy containing bevacizumab (hazard ratio 0.31, P = 0.019). CONCLUSIONS Long-term OS after CRS and HIPEC for colorectal cancer is associated with CC and neoadjuvant therapy containing bevacizumab. This regimen merits prospective study in patients with resectable PC of colorectal origin.
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Affiliation(s)
- Wim Ceelen
- Department of Surgery, Ghent University Hospital, Ghent, Belgium,
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212
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Kuijpers AM, Mehta AM, Boot H, van Leerdam ME, Hauptmann M, Aalbers AG, Verwaal VJ. Perioperative systemic chemotherapy in peritoneal carcinomatosis of lymph node positive colorectal cancer treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Oncol 2014; 25:864-869. [PMID: 24667719 DOI: 10.1093/annonc/mdu031] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the preferred treatment of peritoneal carcinomatosis (PC) of colorectal carcinoma. Patients with positive lymph node status have worse survival after CRS-HIPEC, which is probably due to higher rates of systemic failure. In this study, we analysed the effect of administration and timing of systemic chemotherapy on the outcome of lymph node positive colorectal carcinoma patients treated with CRS-HIPEC. PATIENTS AND METHODS A prospective database was reviewed to identify lymph node positive patients with PC treated with CRS-HIPEC within 1 year after primary tumour diagnosis between 2004 and 2012. Medical history of the patients was studied for the administration of perioperative systemic chemotherapy and follow-up. Outcome parameters were progression-free survival (PFS), overall survival (OS) and pattern of recurrence. RESULTS Seventy-three patients treated with CRS-HIPEC for PC from lymph node positive colorectal carcinoma were identified. Fourteen patients received pre-CRS-HIPEC chemotherapy only, 32 patients underwent post-CRS-HIPEC chemotherapy only, 9 patients received chemotherapy both pre- and post-CRS-HIPEC and 16 patients did not receive any systemic chemotherapy. Of the 47 patients who did not receive pre-CRS-HIPEC chemotherapy, 11 (23%) did not receive any chemotherapy due to major postoperative complications. PFS and OS were significantly higher in patients who received systemic chemotherapy (PFS: median 15 versus 4 months, P = 0.024; OS: median 30 versus 14 months, P = 0.015), although this difference was attenuated after adjustment for major complications. Different chemotherapy timings did not differ significantly in either survival or recurrence patterns. CONCLUSIONS In patients with PC from lymph node positive colorectal carcinoma, perioperative systemic chemotherapy is associated with increased OS and PFS, although this difference may be partly explained by the occurrence of major postoperative complication; with no evidence of difference in PFS, OS and systemic recurrence rate by timing of systemic chemotherapy.
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Affiliation(s)
| | | | | | | | - M Hauptmann
- Epidemiology and Biostatistics, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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213
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van Oudheusden TR, Braam HJ, Nienhuijs SW, Wiezer MJ, van Ramshorst B, Luyer MD, Lemmens VE, de Hingh IH. Cytoreduction and hyperthermic intraperitoneal chemotherapy: a feasible and effective option for colorectal cancer patients after emergency surgery in the presence of peritoneal carcinomatosis. Ann Surg Oncol 2014; 21:2621-6. [PMID: 24671638 DOI: 10.1245/s10434-014-3655-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND When peritoneal carcinomatosis (PC) is diagnosed during emergency surgery for colorectal cancer (CRC), further treatment with curative intent may seem futile given the known poor prognosis of both PC and emergency surgery. The aim of the current study was to investigate the feasibility and effectiveness of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for CRC patients who previously underwent emergency surgery in the presence of PC. METHODS All patients with synchronous PC of CRC referred to two tertiary centers between April 2005 and November 2013 were included in this study. Operative, postoperative and survival details were compared between patients presenting in an emergency or elective setting. RESULTS In total, 149 patients with synchronous PC underwent CRS and HIPEC. Amongst these patients, 36 (24.2 %) initially presented with acute symptoms requiring emergency surgery. Acute presentation did not result in a longer interval between the initial operation and HIPEC (2.2 vs. 2.1 months; P = 0.09). When comparing operative outcomes, no significant differences were found in blood loss (P = 0.47), operation time (P = 0.39), or completeness of cytoreduction (P = 0.97). In addition, complication rates, degree and types of complication did not differ between the groups. Median survival was 36.1 months for emergency presentation compared with 32.1 in the elective group (P = 0.73). CONCLUSION CRS + HIPEC may be performed safely in patients with PC of colorectal origin presenting with acute symptoms requiring emergency surgery. More importantly, the 5-year survival rate in these patients was equal to elective cases. This should be regarded as promising and therefore considered for these patients.
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215
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Hugen N, van de Velde CJH, de Wilt JHW, Nagtegaal ID. Metastatic pattern in colorectal cancer is strongly influenced by histological subtype. Ann Oncol 2014; 25:651-657. [PMID: 24504447 PMCID: PMC4433523 DOI: 10.1093/annonc/mdt591] [Citation(s) in RCA: 319] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 12/11/2013] [Accepted: 12/12/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinical studies regarding colorectal cancer (CRC) have suggested differences in metastatic patterns between mucinous adenocarcinoma (MC), signet-ring cell carcinoma (SRCC) and the more common adenocarcinoma (AC). The current study systematically evaluates metastatic patterns of different histological subtypes in CRC patients and analyzes metastatic disease upon primary tumor localization. PATIENTS AND METHODS A nationwide retrospective review of pathological records of 5817 patients diagnosed with CRC who underwent an autopsy between 1991 and 2010 was performed. Patients were selected from the Dutch pathology registry (PALGA). To substantiate clinical relevance, metastatic patterns were compared with the prospective randomized multicenter Total Mesorectal Excision (TME) trial, which investigated efficacy of preoperative radiotherapy in rectal cancer patients. RESULTS In the autopsy study, 1675 patients had metastatic disease. MC and SRCC patients more frequently had metastatic disease (33.9% and 61.2% versus 27.6%; P < 0.0001) and had metastases at multiple sites more often compared with AC patients (58.6% and 70.7% versus 49.9%; P = 0.001). AC predominantly metastasized to the liver, and MC and SRCC more frequently had peritoneal metastases. Metastatic patterns were also related to the primary tumor site, with a high rate of abdominal metastases in colon cancer patients, whereas rectal cancer patients more often had metastases at extra-abdominal sites. Results from the TME trial confirmed findings in rectal cancer patients from the autopsy study. CONCLUSION There are profound differences in metastatic patterns between histological subtypes and the localization of the primary tumor in CRC. Findings from this study should encourage to take these factors into account for follow-up strategies and future studies.
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Affiliation(s)
- N Hugen
- Department of Surgery, Radboud university medical center, Nijmegen.
| | | | - J H W de Wilt
- Department of Surgery, Radboud university medical center, Nijmegen
| | - I D Nagtegaal
- Department of Pathology, Radboud university medical center, Nijmegen, The Netherlands
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216
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Baratti D, Kusamura S, Deraco M. Prevention and early treatment of peritoneal metastases from colorectal cancer: Second-look laparotomy or prophylactic HIPEC? J Surg Oncol 2014; 109:225-6. [DOI: 10.1002/jso.23492] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 10/19/2013] [Indexed: 01/09/2023]
Affiliation(s)
- Dario Baratti
- PeritonealSurfaceMalignancy Program; Colorectal Cancer Service; Department of Surgery; National Cancer Institute; Milan Italy
| | - Shigeki Kusamura
- PeritonealSurfaceMalignancy Program; Colorectal Cancer Service; Department of Surgery; National Cancer Institute; Milan Italy
| | - Marcello Deraco
- PeritonealSurfaceMalignancy Program; Colorectal Cancer Service; Department of Surgery; National Cancer Institute; Milan Italy
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217
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Value of cardiophrenic angle lymph node for the diagnosis of colorectal peritoneal carcinomatosis. Eur J Cancer 2013; 49:3798-805. [DOI: 10.1016/j.ejca.2013.06.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 06/25/2013] [Accepted: 06/26/2013] [Indexed: 11/21/2022]
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218
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Incidence, prognosis, and treatment options for patients with synchronous peritoneal carcinomatosis and liver metastases from colorectal origin. Dis Colon Rectum 2013; 56:1373-80. [PMID: 24201391 DOI: 10.1097/dcr.0b013e3182a62d9d] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Peritoneal carcinomatosis and liver metastases are common metastatic sites in patients who have colorectal cancer. Quite frequently, patients present with both synchronous liver and peritoneal metastases, which may result in a dilemma regarding the optimal treatment. OBJECTIVE In the absence of reliable data, the aim of the current study was to provide population-based data on such patients and to review the literature for possible treatment options. DESIGN This study is a retrospective analysis of a prospective database and a review. PATIENTS All patients diagnosed between 1995 and 2010 with synchronous peritoneal carcinomatosis and liver metastases were identified from the Eindhoven Cancer Registry. OUTCOME MEASURES Incidence and survival were analyzed. Next, the literature was reviewed for articles reporting on the results of treatment with curative intent. RESULTS In total, 27,632 patients were diagnosed with colorectal cancer, of whom 5638 patients (20%) presented with metastasized disease. Synchronous liver metastasis and peritoneal carcinomatosis were present in 440 patients, being 11% of patients with liver metastases, 34% of patients with peritoneal carcinomatosis, 8% of patients with metastasized disease, and 2% of all patients diagnosed with colorectal cancer. Median survival for patients with liver metastasis and peritoneal carcinomatosis was 5 months, in comparison with 95 months for patients with nonmetastasized disease. No improvement in survival was noted over time. None of the patients underwent treatment with curative intent during this period. LIMITATIONS No data on the extent of peritoneal carcinomatosis and liver metastases were available in the population-based study. This complicates comparison with treated patients from the literature review, which probably reflects a highly selected patient population. CONCLUSIONS Both liver metastasis and peritoneal carcinomatosis were present in 8% of patients presenting with metastasized colorectal cancer. Population-based survival was only 5 months, with none of the patients undergoing treatment with curative intent. Median survival rates of up to 36 months after treatment with curative intent as published in the literature may be regarded as promising for selected patients.
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219
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van Gestel YRBM, Thomassen I, Lemmens VEPP, Pruijt JFM, van Herk-Sukel MPP, Rutten HJT, Creemers GJ, de Hingh IHJT. Metachronous peritoneal carcinomatosis after curative treatment of colorectal cancer. Eur J Surg Oncol 2013; 40:963-9. [PMID: 24183168 DOI: 10.1016/j.ejso.2013.10.001] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 09/25/2013] [Accepted: 10/02/2013] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Population-based data on metachronous peritoneal carcinomatosis (PC) after curative resection of colorectal origin are scarce. The aim of this study was to investigate the incidence of and risk factors for developing metachronous PC from colorectal cancer as well as survival since diagnosis of PC. METHODS Data on metachronous metastases were collected between 2010 and 2011 for all patients diagnosed with M0 colorectal cancer between 2003 and 2008 in the Dutch Eindhoven Cancer Registry. Median follow-up was 5.0 years. Survival was defined as time from metastases diagnosis to death. RESULTS Of the 5671 colorectal cancer patients, 1042 (18%) were diagnosed with metachronous metastases of whom 197 (19%) developed metachronous PC. The peritoneal surface was the only site of metastasis in 81 (41%) patients while 116 (59%) patients were diagnosed with both PC and metastases elsewhere. Median survival after diagnosis of PC was 6 months compared to 15 months for patients with distant metastases in other organs. Patients with an advanced primary tumour stage, positive lymph nodes at initial diagnosis, primary mucinous adenocarcinoma, positive resection margin and a primary tumour located in the colon were at increased risk of developing metachronous PC. CONCLUSION Of the colorectal cancer patients who developed metachronous metastases, approximately one fifth is diagnosed with PC. Prognosis of these patients is poor with a median survival of 6 months after diagnosis. Identifying patients at high risk for developing metachronous PC is important as it may contribute to more accurate patient information, tailor-made follow-up schemes, and more adequate treatment.
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Affiliation(s)
- Y R B M van Gestel
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South (IKZ), P.O. Box 231, 5600 AE Eindhoven, The Netherlands.
| | - I Thomassen
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South (IKZ), P.O. Box 231, 5600 AE Eindhoven, The Netherlands; Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - V E P P Lemmens
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South (IKZ), P.O. Box 231, 5600 AE Eindhoven, The Netherlands; Department of Public Health, Erasmus MC University Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - J F M Pruijt
- Department of Internal Medicine, Jeroen Bosch Hospital, P.O. Box 90153, 5200 ME 's-Hertogenbosch, The Netherlands
| | - M P P van Herk-Sukel
- PHARMO Institute for Drug Outcome Research, P.O. Box 85222, 3508 AE Utrecht, The Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; Research Institute Growth & Development, P.O. Box 616, Maastricht University Medical Centre, 6200 MD, The Netherlands
| | - G J Creemers
- Department of Internal Medicine, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
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Hugen N, Verhoeven RHA, Radema SA, de Hingh IHJT, Pruijt JFM, Nagtegaal ID, Lemmens VEPP, de Wilt JHW. Prognosis and value of adjuvant chemotherapy in stage III mucinous colorectal carcinoma. Ann Oncol 2013; 24:2819-24. [PMID: 24057984 DOI: 10.1093/annonc/mdt378] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Colorectal mucinous adenocarcinoma (MC) has been associated with impaired prognosis compared with nonmucinous adenocarcinoma (NMC). Response to palliative chemotherapy is poor in metastatic disease, but the benefit of adjuvant chemotherapeutic treatment has never been assessed in large patient groups. This study analyses overall survival and efficacy of adjuvant chemotherapy in terms of survival in patients following radical resection for MC. PATIENTS AND METHODS This population-based study involved 27 251 unselected patients diagnosed with colorectal carcinoma between 1990 and 2010 and recorded in a prospective pathology-based registry. Kaplan-Meier analysis and log-rank testing were used to estimate survival. Cox proportional hazard model was used to calculate multivariate hazard ratios for death. RESULTS MC was found in 12.3% (N = 3052) of colorectal tumors with a different distribution compared with NMC, with 24.4% located in the rectum and 54.3% in the proximal colon (versus 38.0% and 30.6%), P < 0.0001. NMC was more often classified as stage I disease than MC (20.5% versus 10.9%), P < 0.0001. After adjustments for covariates, MC was associated with a higher risk of death only when located in the rectum [hazard ratio 1.22; 95% confidence interval (CI) 1.11-1.34]. Multivariate regression analysis showed a similar survival after adjuvant chemotherapy for stage III MC and NMC patients. CONCLUSIONS The poor prognosis for MC is only present in rectal cancer. In the adjuvant setting, there is no difference in the efficacy of chemotherapy between MC and NMC; therefore, current adjuvant treatment recommendations should not take histology into account.
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Affiliation(s)
- N Hugen
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen
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221
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Population-based incidence, treatment and survival of patients with peritoneal metastases of unknown origin. Eur J Cancer 2013; 50:50-6. [PMID: 24011935 DOI: 10.1016/j.ejca.2013.08.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/02/2013] [Accepted: 08/12/2013] [Indexed: 01/11/2023]
Abstract
AIM Until recently, peritoneal metastases (PM) were regarded as an untreatable condition, regardless of the organ of origin. Currently, promising treatment options are available for selected patients with PM from colorectal, appendiceal, ovarian or gastric carcinoma. The aim of this study was to investigate the incidence, treatment and survival of patients presenting with PM in whom the origin of PM remains unknown. METHODS Data from patients diagnosed with PM of unknown origin during 1984-2010 were extracted from the Eindhoven Cancer Registry. European age-standardised incidence rates were calculated and data on treatment and survival were analysed. RESULTS In total 1051 patients were diagnosed with PM of unknown origin. In 606 patients (58%) the peritoneum was the only site of metastasis, and 445 patients also had other metastases. Chemotherapy usage has increased from 8% in the earliest period to 16% in most recent years (p=.016). Median survival was extremely poor with only 42days (95% confidence interval (CI) 39-47days) and did not change over time. Median survival of patients not receiving chemotherapy was significantly worse than of those receiving chemotherapy (36 versus 218days, p<.0001). CONCLUSION The prognosis of PM of unknown origin is extremely poor and did not improve over time. Given the recent progress that has been achieved in selected patients presenting with PM, maximum efforts should be undertaken in order to diagnose the origin of PM as accurately as possible. Potentially effective treatment strategies should be further explored for patients in whom the organ of origin remains unknown.
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222
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Franko J, Goldman CD, Turaga KK. Role of Chemotherapy in Peritoneal Carcinomatosis in Metastatic Colorectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2013. [DOI: 10.1007/s11888-013-0173-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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223
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Thomassen I, van Gestel YR, van Ramshorst B, Luyer MD, Bosscha K, Nienhuijs SW, Lemmens VE, de Hingh IH. Peritoneal carcinomatosis of gastric origin: a population-based study on incidence, survival and risk factors. Int J Cancer 2013; 134:622-8. [PMID: 23832847 DOI: 10.1002/ijc.28373] [Citation(s) in RCA: 356] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 06/17/2013] [Indexed: 12/12/2022]
Abstract
Peritoneal carcinomatosis (PC) is an important cause of morbidity and mortality among patients with gastric cancer. The aim of the current study was to provide reliable population-based data on the incidence, risk factors and prognosis of PC of gastric origin. All patients diagnosed with gastric cancer in the area of the Eindhoven Cancer Registry between 1995 and 2011 were included. Incidence and survival were computed and risk factors for peritoneal carcinomatosis were determined using multivariate logistic regression analysis. In total, 5,220 patients were diagnosed with gastric cancer, of whom 2,029 (39%) presented with metastatic disease. PC was present in 706 patients (14%) of whom 491 patients (9%) had PC as the only metastatic site. Younger age (<60 years), female gender, advanced T- and N-stage, primary tumor of signet ring cells or linitis plastica and primary tumors covering multiple anatomical locations of the stomach were all associated with a higher odds ratios of developing PC. Median survival of patients without metastases was 14 months, but only 4 months for patients with PC. PC is a frequent condition in patients presenting with gastric cancer, especially in younger patients with advanced tumor stages. Given the detrimental influence of PC on survival, efforts should be undertaken to further explore the promising results that were obtained in preventing or treating this condition with multimodality strategies.
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Affiliation(s)
- Irene Thomassen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands; Eindhoven Cancer Registry, Comprehensive Cancer Centre South (IKZ), Eindhoven, The Netherlands
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224
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Kuijpers AMJ, Mirck B, Aalbers AGJ, Nienhuijs SW, de Hingh IHJT, Wiezer MJ, van Ramshorst B, van Ginkel RJ, Havenga K, Bremers AJ, de Wilt JHW, Te Velde EA, Verwaal VJ. Cytoreduction and HIPEC in the Netherlands: nationwide long-term outcome following the Dutch protocol. Ann Surg Oncol 2013; 20:4224-30. [PMID: 23897008 PMCID: PMC3827901 DOI: 10.1245/s10434-013-3145-9] [Citation(s) in RCA: 165] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Indexed: 12/27/2022]
Abstract
PURPOSE This nationwide study evaluated results of cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal metastasis of colorectal origin in the Netherlands following a national protocol. METHODS In a multi-institutional study prospective databases of patients with peritoneal carcinomatosis (PC) from colorectal cancer and pseudomyxoma peritonei (PMP) treated according to the Dutch HIPEC protocol, a uniform approach for the CRS and HIPEC treatment, were reviewed. Primary end point was overall survival and secondary end points were surgical outcome and progression-free survival. RESULTS Nine-hundred sixty patients were included; 660 patients (69 %) were affected by PC of colorectal carcinoma and the remaining suffered from PMP (31 %). In 767 procedures (80 %), macroscopic complete cytoreduction was achieved. Three-hundred and thirty one patients had grade III-V complications (34 %). Thirty-two patients died perioperatively (3 %). Median length of hospital stay was 16 days (range 0-166 days). Median follow-up period was 41 months (95 % confidence interval (CI), 36-46 months). Median progression-free survival was 15 months (95 % CI 13-17 months) for CRC patients and 53 months (95 % CI 40-66 months) for PMP patients. Overall median survival was 33 (95 % CI 28-38 months) months for CRC patients and 130 months (95 % CI 98-162 months) for PMP patients. Three- and five-year survival rates were 46 and 31 % respectively in case of CRC patients and 77 and 65 % respectively in case of PMP patients. CONCLUSIONS The results underline the safety and efficacy of cytoreduction and HIPEC for PC from CRC and PMP. It is assumed the uniform Dutch HIPEC protocol was beneficial.
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Affiliation(s)
- Anke M J Kuijpers
- Department of Surgical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands,
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Ceelen W, De Somer F, Van Nieuwenhove Y, Vande Putte D, Pattyn P. Effect of perfusion temperature on glucose and electrolyte transport during hyperthermic intraperitoneal chemoperfusion (HIPEC) with oxaliplatin. Eur J Surg Oncol 2013; 39:754-9. [DOI: 10.1016/j.ejso.2012.07.120] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 07/13/2012] [Accepted: 07/23/2012] [Indexed: 11/29/2022] Open
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Braam HJ, Boerma D, Wiezer MJ, van Ramshorst B. Hyperthermic intraperitoneal chemotherapy during primary tumour resection limits extent of bowel resection compared to two-stage treatment. Eur J Surg Oncol 2013; 39:988-93. [PMID: 23810334 DOI: 10.1016/j.ejso.2013.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 04/24/2013] [Accepted: 06/06/2013] [Indexed: 12/19/2022] Open
Abstract
AIM To compare the clinical outcome of a one-stage, primary tumour resection and hyperthermic intraperitoneal chemotherapy (HIPEC) procedure, versus a two-stage procedure of tumour resection and secondary HIPEC in colorectal cancer (CRC) patients with synchronous peritoneal carcinomatosis. METHODS A prospective database of all patients treated with HIPEC in the St. Antonius Hospital in the Netherlands between 2005 and 2012 was analysed. RESULTS A total of 72 patients with synchronous peritoneal carcinomatosis (PC) from CRC were included. In 20 patients (27.8%) the primary tumour was resected simultaneously with HIPEC (early referral). In the other 52 patients (72.2%) the primary tumour was resected prior to the HIPEC procedure (late referral). During CRS + HIPEC following late referral, 22 (59.5%) of the 37 anastomoses of the earlier operation were resected, revealing malignancy in 12 (54.5%) on histopathological examination. In twenty (27.8%) patients a permanent colostomy was constructed after HIPEC. Ten of these patients had complete bowel continuity after earlier primary resection. The relaparotomy rate was higher in patients after a resection of a previous anastomosis (36.4%) compared to 12% in the rest of the patients (P = 0.02). CONCLUSIONS Resection of the primary tumour simultaneously with HIPEC in patients with synchronous PC from CRC may prevent extended bowel resections and permanent colostomy. Our data support early referral of patients with PC from colorectal cancer.
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Affiliation(s)
- H J Braam
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands.
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227
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Addition of biological therapies to palliative chemotherapy prolongs survival in patients with peritoneal carcinomatosis of colorectal origin. Am J Clin Oncol 2013; 36:157-61. [PMID: 22314003 DOI: 10.1097/coc.0b013e3182438c55] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Combination chemotherapy regimens have shown promising results in patients with metastatic colorectal cancer. However, only very few studies have studied the effect of palliative chemotherapy in peritoneal carcinomatosis (PC) and no data are present incorporating biological therapies in the treatment of PC in colorectal cancer. METHODS By means of merging with the regional Eindhoven Cancer Registry, all consecutive patients diagnosed with synchronous PC of colorectal origin since the year 2000 treated with palliative chemotherapy in our hospital were included. Data on chemotherapeutic agents used were collected retrospectively. The effect of biological therapies on survival was investigated. RESULTS Fifty consecutive patients were included. Chemotherapeutic treatment consisted mainly of 5-fluorouracil-based chemotherapy with oxaliplatin. In 22 patients biological therapies were added. Overall survival was 12.5 months [95% confidence interval (CI), 9.2-15.5]. In patients receiving chemotherapy in combination with a biological therapy, overall survival was significantly prolonged as compared with those treated without (18.2 months, 95% CI, 9.5-27.0 vs. 10.1 mo, 95% CI, 6.2-14.1, respectively; P=0.001). Prolongation of survival of patients receiving biological therapies in first-line treatment was even more pronounced, being 22.4 months (95% CI, 15.0-29.5). Similar effects were observed on progression-free survival. CONCLUSIONS Systemic chemotherapy, once regarded as futile in patients suffering from PC, resulted in an overall survival of 12 months in this unselected group of PC-patients. Addition of biological therapies in the first line of treatment prolonged overall survival to 22.4 months. Although the results of this small study should be interpreted with caution, this promising finding warrants further research.
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228
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Goéré D, Allard MA, Honoré C, Dumont F, Elias D. Incidence and prognosis of synchronous colorectal carcinomatosis. Future Oncol 2013; 9:541-9. [DOI: 10.2217/fon.12.206] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The aim of this article was to review the literature on synchronous peritoneal carcinomatosis (PC) from colorectal cancer. Synchronous PC of colorectal cancer origin is a rare disease with an incidence ranging from 4 to 7% of colorectal cancer patients and is exclusively peritoneal in half of cases. Synchronous PC is more frequently associated with primary tumors that are at an advanced stage. After macroscopically complete resection (R0/R1) of synchronous PC, without associated intraperitoneal chemotherapy, the 5-year survival rates range from 24 to 36%. Complete cytoreductive surgery plus intraperitoneal chemotherapy at the time of diagnosis is probably the best therapeutic option. If no intraperitoneal treatment can be given, no resection should be performed and an accurate description should be made. If a limited synchronous PC has been resected with the primary tumor without intraperitoneal treatment, the authors recommend a systematic second-look surgery in an experienced center.
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Affiliation(s)
- Diane Goéré
- Department of Surgical Oncology, Institut Gustave Roussy, 114 rue Edouard Vaillant, 94805 Villejuif Cedex, France.
| | - Marc-Antoine Allard
- Department of Surgical Oncology, Institut Gustave Roussy, 114 rue Edouard Vaillant, 94805 Villejuif Cedex, France
| | - Charles Honoré
- Department of Surgical Oncology, Institut Gustave Roussy, 114 rue Edouard Vaillant, 94805 Villejuif Cedex, France
| | - Frédéric Dumont
- Department of Surgical Oncology, Institut Gustave Roussy, 114 rue Edouard Vaillant, 94805 Villejuif Cedex, France
| | - Dominique Elias
- Department of Surgical Oncology, Institut Gustave Roussy, 114 rue Edouard Vaillant, 94805 Villejuif Cedex, France
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229
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Klaver YLB, Lemmens VEPP, de Hingh IHJT. Outcome of surgery for colorectal cancer in the presence of peritoneal carcinomatosis. Eur J Surg Oncol 2013; 39:734-41. [PMID: 23523316 DOI: 10.1016/j.ejso.2013.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 02/18/2013] [Accepted: 03/04/2013] [Indexed: 12/15/2022] Open
Abstract
AIM The detection of peritoneal carcinomatosis (PC) in colorectal cancer patients frequently results in a dilemma with regard to the optimal treatment strategy, especially when PC is encountered unexpectedly during surgery. The aim of this study was to evaluate outcomes of patients undergoing surgery for colorectal carcinoma in the presence of synchronous PC. METHODS Patients diagnosed with primary colorectal cancer and synchronous PC in three community hospitals were selected from the Eindhoven Cancer Registry database. Outcomes of postoperative complications, in-hospital mortality and overall survival were collected and analyzed according to the type of intervention performed. RESULTS Between 1995 and 2009, 169 colorectal cancer patients were diagnosed with synchronous PC, most of them unexpectedly during surgery (n = 130). 142 patients underwent surgery: primary tumor resection (n = 91), palliative procedure (n = 46) or exploration only (n = 5). In-hospital mortality was 41% after palliative surgery and 14% after primary tumor resection. Median survival was 12 weeks after palliative surgery or exploration as opposed to 55 weeks after primary tumor resection. CONCLUSION PC is most often encountered unexpectedly during surgery for colorectal cancer. Results of palliative procedures are very poor with a high in-hospital mortality rate and short survival. Resection of the primary tumor can be performed safely with relatively good outcomes but some patients could have benefited from an even more radical approach when the presence of PC would have been diagnosed at an earlier stage. Improvement of imaging techniques to detect PC prior to surgery is therefore urgently needed. Until this is the case, a high index of suspicion is required when subtle signs of PC are encountered.
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Affiliation(s)
- Y L B Klaver
- Department of Medical Oncology, Catharina Hospital, Post Box 1350, 5602 ZA Eindhoven, The Netherlands
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230
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Kerscher AG, Chua TC, Gasser M, Maeder U, Kunzmann V, Isbert C, Germer CT, Pelz JOW. Impact of peritoneal carcinomatosis in the disease history of colorectal cancer management: a longitudinal experience of 2406 patients over two decades. Br J Cancer 2013; 108:1432-9. [PMID: 23511564 PMCID: PMC3629432 DOI: 10.1038/bjc.2013.82] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Recent therapeutic developments demand for an update of information on natural history, risk factors and prognosis of peritoneal carcinomatosis (PC) of colorectal origin. Therefore, prospective registry data should provide information about incidence, predictors and outcome. Methods: From a prospectively expanded single-institutional database with 2406 consecutive patients with colorectal cancer (CRC), clinical, histological and survival data were analysed for independent risk factors and prognosis. Findings were then stratified to the era of treatment without chemotherapy, 5-Fluorouracil-only and contemporary systemic chemotherapy, respectively. Results: Overall, 256 (10.6%) patients were diagnosed with PC thereof 141 (5.85%) with metachronous PC. Independent risk factors for the development of metachronous PC were age <62 years, N2-status, T4-status, location of the primary in the left colon or appendix. In the era of contemporary systemic chemotherapy, prognosis for PC improved only not-significantly (median survival of 17.9 months vs 7.03 months, P=0.054). Conclusion: Despite improvement in the overall outcome with prolonged median survival for the complete patient cohort with CRC, those patients with PC have not experienced the same benefit. In the era of contemporary systemic chemotherapy, progress in treatment resulted in only limited survival benefit. Thus, continuous efforts for further therapeutic advancements should be undertaken in these patients diagnosed with PC.
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Affiliation(s)
- A G Kerscher
- Department of General-, Visceral-, Vascular- and Pediatric Surgery, University of Wuerzburg, Wuerzburg D-97080, Germany
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Ishida H, Kumamoto K, Ishibashi K, Hatano S, Matsuzawa T, Okada N, Kumagai Y, Baba H, Haga N. Should isolated peritoneal carcinomatosis from colorectal cancer be sub-classified into stage IVB in era of modern chemotherapy? Tech Coloproctol 2013; 17:647-52. [PMID: 23389285 DOI: 10.1007/s10151-012-0972-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 12/29/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND According to the 7th edition of the TNM staging system, stage IV metastatic colorectal cancer (CRC) at the time of initial diagnosis is sub-classified into stage IVA or IVB disease. Peritoneal carcinomatosis (PC), considered to have a dismal prognosis, is exclusively sub-classified into stage IVB, even though other metastases to a sole organ are sub-classified into stage IVA, which is considered to be associated with better survival. This retrospective study was undertaken to investigate the overall survival in metastatic CRC patients, focusing on PC patients. METHODS We reviewed data on patients with metastatic CRC at initial diagnosis surgically treated between January 2006 and June 2011. A survival analysis was performed paying special attention to PC and sub-classifying patients with PC into three categories according to metastatic sites. RESULTS There were 69 stage IVA patients (IVA group) and 83 stage IVB. Among stage IVB patients, 20 had isolated PC (PC-I group), 28 had PC with one or more other sites of metastasis (PC-II group), and 35 had at least 2 metastatic without peritoneal involvement (NPC group). Of 152 stage IV patients, 132 (87 %) underwent resection of the primary tumor and 19 (12 %) underwent radical resection of metastatic disease with microscopic free margins (R0 resection) including 5/20 (25 %) patients in the PC1 group. A total of 139 patients received oxaliplatin-based chemotherapy in a palliative (n = 125), neoadjuvant (n = 3), or adjuvant setting after R0 resection (n = 11). Compared with 36.6 months in the PC-I group, median survival was 32.5 months (P = 0.48) in the IVA group, 14.7 months (P = 0.07) in the PC-II group, and 12.9 months (P < 0.01) in the NPC group. CONCLUSIONS The sub-classification of isolated PC into stage IVA instead of IVB might be more appropriate in the era of modern chemotherapy. Further investigation is warranted.
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Affiliation(s)
- H Ishida
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan,
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232
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Klaver YLB, Lemmens VEPP, Nienhuijs SW, Nieuwenhuijzen GAP, Rutten HJT, de Hingh IHJT. Intraoperative radiotherapy and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Five consecutive case reports of locally advanced rectal cancer with synchronous peritoneal carcinomatosis. Strahlenther Onkol 2013; 189:256-60. [PMID: 23329276 DOI: 10.1007/s00066-012-0282-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 11/15/2012] [Indexed: 12/17/2022]
Abstract
PURPOSE Treatment of rectal cancer has markedly improved since the introduction of neoadjuvant strategies and better surgical techniques. However, treatment remains troublesome for patients with locally advanced rectal cancer (LARC) or with peritoneal carcinomatosis (PC). Patients presenting with LARC may now benefit from the integration of intra-operative radiotherapy (IORT) into multimodality treatment. Selected patients with PC now undergo cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) resulting in improved survival. Some patients present with locally advanced disease and synchronous peritoneal carcinomatosis and fulfill the eligibility criteria for both HIPEC and IORT, raising the question whether the combined application of both modalities within one operative procedure is feasible. CASE SERIES This report includes five consecutive cases of rectal cancer patients presenting with LARC and synchronous PC who were treated with a multimodality treatment including IORT and HIPEC after cytoreductive surgery. Postoperative complications and survival are described. RESULTS The combination of cytoreductive surgery with HIPEC and IORT appeared to be feasible and well tolerated. The observed complications did not differ from the morbidity associated with extensive pelvic surgery without HIPEC or IORT. No inhospital mortality occurred. One patient died after 11 months of recurrent disease. All other patients are currently alive with one patient already surviving 38 months. CONCLUSION The current case series shows that a multimodality treatment containing IORT and HIPEC is feasible and safe with promising survival rates. This strategy may, therefore, be considered in selected rectal cancer patients presenting with both LARC and synchronous PC.
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Affiliation(s)
- Y L B Klaver
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
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233
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Incidence, prognosis, and possible treatment strategies of peritoneal carcinomatosis of pancreatic origin: a population-based study. Pancreas 2013; 42:72-5. [PMID: 22850624 DOI: 10.1097/mpa.0b013e31825abf8c] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Peritoneal carcinomatosis (PC) is an important cause of morbidity and mortality among patients with pancreatic cancer. In an era where therapeutic options for PC of multiple origins are emerging, our aim was to provide population-based data on incidence, treatment, and prognosis of PC of pancreatic origin. METHODS All patients with a condition diagnosed as nonendocrine pancreatic cancer between 1995 and 2009 in the area of the Eindhoven Cancer Registry were included. RESULTS In total, 2924 patients had a diagnosis of pancreatic cancer of which 265 patients (9%) presented with synchronous PC. An increasing trend could be noted in patients treated with chemotherapy in more recent years (11% in 1995-1999 and 22% in 2005-2009; P = 0.060). Median survival in patients presenting with PC was only 6 weeks (95% confidence interval, 5-7 weeks) and did not improve over time, contrasting improvements among patients with nonmetastasized disease (19-30 weeks) and patients with metastasized disease confined to the liver (8-12 weeks). CONCLUSION Prognosis of patients with pancreatic cancer presenting with PC remains extremely poor. Treatment options are scarce and, given the magnitude of the problem, efforts should be undertaken to develop effective treatments in experimental and clinical studies.
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234
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Klaver YL, Chua TC, Verwaal VJ, de Hingh IH, Morris DL. Secondary cytoreductive surgery and peri-operative intraperitoneal chemotherapy for peritoneal recurrence of colorectal and appendiceal peritoneal carcinomatosis following prior primary cytoreduction. J Surg Oncol 2012; 107:585-90. [DOI: 10.1002/jso.23303] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 11/14/2012] [Indexed: 11/09/2022]
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235
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Honoré C, Goéré D, Souadka A, Dumont F, Elias D. Definition of Patients Presenting a High Risk of Developing Peritoneal Carcinomatosis After Curative Surgery for Colorectal Cancer: A Systematic Review. Ann Surg Oncol 2012; 20:183-92. [DOI: 10.1245/s10434-012-2473-5] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Indexed: 12/17/2022]
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Klaver YLB, Lemmens VEPP, Nienhuijs SW, Luyer MDP, de Hingh IHJT. Peritoneal carcinomatosis of colorectal origin: Incidence, prognosis and treatment options. World J Gastroenterol 2012; 18:5489-94. [PMID: 23112540 PMCID: PMC3482634 DOI: 10.3748/wjg.v18.i39.5489] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 05/31/2012] [Accepted: 06/08/2012] [Indexed: 02/06/2023] Open
Abstract
Peritoneal carcinomatosis (PC) is one manifestation of metastatic colorectal cancer (CRC). Tumor growth on intestinal surfaces and associated fluid accumulation eventually result in bowel obstruction and incapacitating levels of ascites, which profoundly affect the quality of life for affected patients. PC appears resistant to traditional 5-fluorouracil-based chemotherapy, and surgery was formerly reserved for palliative purposes only. In the absence of effective treatment, the historical prognosis for these patients was extremely poor, with an invariably fatal outcome. These poor outcomes likely explain why PC secondary to CRC has received little attention from oncologic researchers. Thus, data are lacking regarding incidence, clinical disease course, and accurate treatment evaluation for patients with PC. Recently, population-based studies have revealed that PC occurs relatively frequently among patients with CRC. Risk factors for developing PC have been identified: right-sided tumor, advanced T-stage, advanced N-stage, poor differentiation grade, and younger age at diagnosis. During the past decade, both chemotherapeutical and surgical treatments have achieved promising results in these patients. A chance for long-term survival or even cure may now be offered to selected patients by combining radical surgical resection with intraperitoneal instillation of heated chemotherapy. This combined procedure has become known as hyperthermic intraperitoneal chemotherapy. This editorial outlines recent advancements in the medical and surgical treatment of PC and reviews the most recent information on incidence and prognosis of this disease. Given recent progress, treatment should now be considered in every patient presenting with PC.
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237
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Matsuda K, Hotta T, Takifuji K, Yokoyama S, Oku Y, Hashimoto T, Iwamoto H, Yamaue H. Clinical outcome of up-front surgery in patients with asymptomatic, incurable synchronous peritoneal carcinomatosis. Surg Today 2012; 43:984-9. [PMID: 23052739 DOI: 10.1007/s00595-012-0348-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 07/03/2012] [Indexed: 10/27/2022]
Abstract
PURPOSES The purpose of this study was to show the clinical features of up-front surgery of the primary tumor in asymptomatic patients with incurable colorectal PC. METHODS Forty-six patients that were diagnosed between 1998 and 2007 with asymptomatic colorectal PC who could not be successfully cured by surgery were assessed retrospectively. RESULTS A univariate analysis revealed the presence of liver metastases, without the use of oxaliplatin (OX)/irinotecan (IRI) and without a primary tumor resection to be poor prognostic factors for survival (p = 0.044, p = 0.030, p < 0.001, respectively). According to a multivariate analysis, no use of OX/IRI and no primary tumor resection, were found to be independent poor prognostic factors for survival (HR 2.57; p = 0.047, HR 6.62; p = 0.003, respectively). The median survival time of patients treated with and without OX/IRI was 18 and 7 months, respectively. The median survival time of patients with and without primary tumor resection was 10 and 2 months, respectively. The number of patients needing surgical intervention for intestinal obstruction after surgery significantly increased in patients treated with OX/IRI (p = 0.001). CONCLUSION Improvement of survival may be related to widespread use of modern systemic chemotherapy and primary tumor resection. However, an increased number of patients that needed surgery for an intestinal obstruction were observed, even after up-front surgery, when patients were treated with modern systemic chemotherapy.
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Affiliation(s)
- Kenji Matsuda
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama 641-8510, Japan
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238
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Klaver YLB, Simkens LHJ, Lemmens VEPP, Koopman M, Teerenstra S, Bleichrodt RP, de Hingh IHJT, Punt CJA. Outcomes of colorectal cancer patients with peritoneal carcinomatosis treated with chemotherapy with and without targeted therapy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2012; 38:617-23. [PMID: 22572106 DOI: 10.1016/j.ejso.2012.03.008] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 03/20/2012] [Accepted: 03/26/2012] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although systemic therapies have shown to result in survival benefit in patients with metastatic colorectal cancer (mCRC), outcomes in patients with peritoneal carcinomatosis (PC) are poor. No data are available on outcomes of current chemotherapy schedules plus targeted agents in mCRC patients with PC. METHODS Previously untreated mCRC patients treated with chemotherapy in the CAIRO study and with chemotherapy and targeted therapy in the CAIRO2 study were included and retrospectively analysed according to presence or absence of PC at randomisation. Patient demographics, primary tumour characteristics, progression-free survival (PFS), overall survival (OS), and occurrence of toxicity were evaluated. RESULTS Thirty-four patients with PC were identified in the CAIRO study and 47 patients in the CAIRO2 study. Median OS was decreased for patients with PC compared with patients without PC (CAIRO: 10.4 versus 17.3 months, respectively (p ≤ 0.001); CAIRO2: 15.2 versus 20.7 months, respectively (p < 0.001)). Median number of treatment cycles did not differ between patients with or without PC in both studies. Occurrence of major toxicity was more frequent in patients with PC treated with sequential chemotherapy in the CAIRO study as compared to patients without PC. This was not reflected in reasons to discontinue treatment. In the CAIRO2 study, no differences in major toxicity were observed. CONCLUSION Our data demonstrate decreased efficacy of current standard chemotherapy with and without targeted agents in mCRC patients with PC. This suggests that the poor outcome cannot be explained by undertreatment or increased susceptibility to toxicity, but rather by relative resistance to treatment.
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Affiliation(s)
- Y L B Klaver
- Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands.
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Crawford C, Janjua AZ, Chandrakumaran K, Moran B. Operability and early outcome in 48 Irish patients with peritoneal malignancy treated by surgery and intraperitoneal chemotherapy in a specialized centre. Surgeon 2012; 11:30-4. [PMID: 22633149 DOI: 10.1016/j.surge.2012.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 03/12/2012] [Accepted: 03/19/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND In selected cases of peritoneal malignancy a novel approach of complete macroscopic tumour removal by extensive surgical cytoreduction, combined with intraperitoneal chemotherapy, provides a possibility of cure. The experience with 48 consecutive Irish cases undergoing laparotomy in a specialized centre is reported. PATIENTS AND METHODS A subset of 48 Irish patients out of a total of 120 cases with peritoneal malignancy underwent surgery between September 1999 and March 2011 in an English National referral centre. Overall 37/48 (77%) had appendiceal mucinous tumours with pseudomyxoma peritonei type syndrome. The treatment strategy involved macroscopic complete tumour removal (complete cytoreduction) combined with intra-operative, intraperitoneal chemotherapy. RESULTS Overall 30/48 (62.5%) had complete cytoreduction, 15/48 (31.3%) had major debulking and 3 (4.2%) had laparotomy and biopsy only. The median (range) operating time in hours was 9.8 (4.8-16) in the 30 who had complete cytoreduction compared with 6.3 (4.5-11) in the 15 who had debulking (p = 0.019). There was no post-operative mortality. Overall five year survival for the complete tumour removal group was 66% compared with 12% for those only amenable to major debulking. CONCLUSION This novel strategy of cytoreduction combined with intraperitoneal chemotherapy is effective in selected patients with peritoneal malignancy. The complex surgery is particularly effective for appendiceal tumours and provides the only possibility of cure in this challenging disease.
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Affiliation(s)
- Caitriona Crawford
- Pseudomyxoma Peritonei Centre, Basingstoke and North Hampshire Foundation Trust Hospital, Aldermaston Road, Basingstoke, Hampshire RG24 9NA, UK
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Prevention of Peritoneal Metastases from Colon Cancer in High-Risk Patients: Preliminary Results of Surgery plus Prophylactic HIPEC. Gastroenterol Res Pract 2012; 2012:141585. [PMID: 22645605 PMCID: PMC3356888 DOI: 10.1155/2012/141585] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 02/17/2012] [Indexed: 02/07/2023] Open
Abstract
The study compared the outcome in patients with advanced colonic cancer at high risk of peritoneal metastases (mucinous or signet-ring cell) without peritoneal or systemic spread, treated with standard colectomy or a more aggressive combined surgical approach. The study included patients with colonic cancer with clinical T3/T4, any N, M0, and mucinous or signet ring cell histology. The 25 patients in the experimental group underwent hemicolectomy, omentectomy, bilateral adnexectomy, hepatic round ligament resection, and appendectomy, followed by HIPEC. The control group comprised 50 patients treated with standard surgical resection during the same period in the same hospital by different surgical teams. Outcome data, morbidity, peritoneal recurrence rate, and overall, and disease-free survival, were compared. Peritoneal recurrence developed in 4% of patients in the experimental group and 22% of controls without increasing morbidity (P < 0.05). Actuarial overall survival curves disclosed no significant differences, whereas actuarial disease-free survival curves showed a significant difference between groups (36.8 versus 21.9 months, P < 0.01). A more aggressive preventive surgical approach combined with HIPEC reduces the incidence of peritoneal recurrence in patients with advanced mucinous colonic cancer and also significantly increases disease-free survival compared with a homogeneous control group treated with a standard surgical approach without increasing morbidity.
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241
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Mulsow J, Merkel S, Agaimy A, Hohenberger W. Outcomes following surgery for colorectal cancer with synchronous peritoneal metastases. Br J Surg 2011; 98:1785-91. [PMID: 22034185 DOI: 10.1002/bjs.7653] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND The optimal treatment of peritoneal carcinomatosis of colorectal origin appears to be a combination of systemic chemotherapy and complete surgical cytoreduction with synchronous intraperitoneal chemotherapy. The aim of this study was to assess the feasibility of, and outcomes following, surgical treatment and systemic chemotherapy alone. METHODS Prospectively collated data from the Erlangen Registry for Colorectal Cancer were analysed for patients presenting with peritoneal carcinomatosis of colorectal origin between 1990 and 2006. Operative and adjuvant treatment, along with details of postoperative morbidity, were evaluated and correlated with survival outcomes after 5 years. RESULTS Some 125 patients underwent surgical resection for colorectal cancer and synchronous peritoneal carcinomatosis. Two-thirds also had non-peritoneal distant metastases. R0/R1 resection was possible in 24 (59 per cent) of 41 patients with peritoneal metastases alone, and in a further seven patients with both peritoneal and distant metastases (overall R0/R1 resection rate 24·8 per cent). In-hospital morbidity and mortality rates were 32·0 and 12·0 per cent respectively. Twenty-three of the 31 patients who underwent R0/R1 resection developed recurrent disease. Median survival for the entire group was 12 months. Following R0/R1 resection median survival was 25 months and the 5-year survival rate 22 per cent. Six (4·8 per cent) of the 125 patients survived for more than 5 years. CONCLUSION Complete resection of all metastatic disease was associated with improved survival and was possible in almost 60 per cent of patients with peritoneal metastases alone.
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Affiliation(s)
- J Mulsow
- Department of Surgery, University of Erlangen-Nuremberg, Erlangen, Germany.
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Klaver YLB, Hendriks T, Lomme RMLM, Rutten HJT, Bleichrodt RP, de Hingh IHJT. Intraoperative versus early postoperative intraperitoneal chemotherapy after cytoreduction for colorectal peritoneal carcinomatosis: an experimental study. Ann Surg Oncol 2011; 19 Suppl 3:S475-82. [PMID: 21837528 DOI: 10.1245/s10434-011-1984-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Indexed: 12/28/2022]
Abstract
BACKGROUND Perioperative intraperitoneal chemotherapy is used as an adjunct to cytoreductive surgery (CS) for peritoneal carcinomatosis (PC) in order to prolong survival. Worldwide, hyperthermic intraperitoneal chemotherapy (HIPEC), early postoperative intraperitoneal chemotherapy (EPIC), and combinations of the two are used. It remains unclear which regimen is most beneficial. METHODS The rat colon carcinoma cell line CC-531 was injected into the peritoneal cavity of 80 WAG/Rij rats to induce PC. Animals were randomized into four treatment groups (n = 20): CS only, CS followed by HIPEC (mitomycin 35 mg/m(2) at 41.5°C), CS followed by EPIC during 5 days (i.p. injection of mitomycin on day 1 and 5-fluorouracil on days 2-5), and CS followed by HIPEC plus EPIC. Primary outcome was survival. RESULTS In rats treated with CS only, median survival was 53 days (95% confidence interval (CI) 49-57 days). In rats treated with CS followed by HIPEC, survival was significantly (P = 0.001) increased (median survival 94 days, 95% CI 51-137 days). In the group treated with EPIC after CS, 12 out of 20 rats were still alive at the end of the experiment (P < 0.001 as compared with CS only). In the group receiving both treatments, 11 rats died of toxicity, and therefore this group was not included in the survival analysis. CONCLUSIONS Both EPIC and HIPEC were effective in prolonging survival. The beneficial effect of EPIC on survival seemed to be more pronounced than that of HIPEC. Further research is indicated to evaluate and compare the possible benefits and adverse effects associated with both treatments.
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Affiliation(s)
- Yvonne L B Klaver
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, Eindhoven, The Netherlands.
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243
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Klaver YLB, Chua TC, de Hingh IHJT, Morris DL. Outcomes of elderly patients undergoing cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal cancer peritoneal carcinomatosis. J Surg Oncol 2011; 105:113-8. [PMID: 21780124 DOI: 10.1002/jso.22019] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 06/16/2011] [Indexed: 12/25/2022]
Abstract
BACKGROUND The combined treatment of cytoreductive surgery (CRS) and perioperative chemotherapy (PIC) for colorectal peritoneal carcinomatosis (PC) is a rigorous surgical treatment most suited for fit and young patients. With technical maturity and improved perioperative care, we examined the outcomes of elderly patients undergoing CRS and PIC for colorectal PC. METHODS All consecutive patients treated in two tertiary centers for PC of colorectal cancer who were 70 years of age or older at the time of surgery were included. Data on patient characteristics, concomitant diseases, operation details, perioperative course, and follow-up were retrieved from medical charts. Primary outcomes were perioperative morbidity and mortality. Secondary outcomes were disease-free and overall survival. RESULTS Twenty-four patients (11 male) were included in this study (mean age 73.5 years). In eight patients major complications occurred. In six patients the postoperative course was complicated by minor adverse events. There was no perioperative mortality. Median overall survival was 35 months with a 6, 12, and 18 months survival rate of 94%, 83%, and 68%, respectively. CONCLUSIONS CRS and PIC for colorectal PC may be safely performed with acceptable morbidity in selected elderly patients. When considering patients for surgery, performance status, and the disease extent should be used as eligibility criteria rather than age.
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Affiliation(s)
- Yvonne L B Klaver
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
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Bruin SC, Klijn C, Liefers GJ, Braaf LM, Joosse SA, van Beers EH, Verwaal VJ, Morreau H, Wessels LF, van Velthuysen MLF, Tollenaar RAEM, Van't Veer LJ. Specific genomic aberrations in primary colorectal cancer are associated with liver metastases. BMC Cancer 2010; 10:662. [PMID: 21126340 PMCID: PMC3027605 DOI: 10.1186/1471-2407-10-662] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 12/02/2010] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Accurate staging of colorectal cancer (CRC) with clinicopathological parameters is important for predicting prognosis and guiding treatment but provides no information about organ site of metastases. Patterns of genomic aberrations in primary colorectal tumors may reveal a chromosomal signature for organ specific metastases. METHODS Array Comparative Genomic Hybridization (aCGH) was employed to asses DNA copy number changes in primary colorectal tumors of three distinctive patient groups. This included formalin-fixed, paraffin-embedded tissue of patients who developed liver metastases (LM; n = 36), metastases (PM; n = 37) and a group that remained metastases-free (M0; n = 25).A novel statistical method for identifying recurrent copy number changes, KC-SMART, was used to find specific locations of genomic aberrations specific for various groups. We created a classifier for organ specific metastases based on the aCGH data using Prediction Analysis for Microarrays (PAM). RESULTS Specifically in the tumors of primary CRC patients who subsequently developed liver metastasis, KC-SMART analysis identified genomic aberrations on chromosome 20q. LM-PAM, a shrunken centroids classifier for liver metastases occurrence, was able to distinguish the LM group from the other groups (M0&PM) with 80% accuracy (78% sensitivity and 86% specificity). The classification is predominantly based on chromosome 20q aberrations. CONCLUSION Liver specific CRC metastases may be predicted with a high accuracy based on specific genomic aberrations in the primary CRC tumor. The ability to predict the site of metastases is important for improvement of personalized patient management.
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Affiliation(s)
- Sjoerd C Bruin
- Division of Experimental Therapy, Department of Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066CX Amsterdam, The Netherlands
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