Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: a consensus statement. Society of Surgical Oncology

Variation in the peritoneal cancer index scores between surgeons and according to when they are determined (before or after cytoreductive surgery)

INTRODUCTION

The prognosis of peritoneal carcinomatosis (PC) is highly dependent on the extent of the PC. This extent is calculated by the peritoneal cancer index (PCI). In the future, the indications for complete cytoreductive surgery (CRS) + hyperthermic intraperitoneal chemotherapy (HIPEC) should be partially based on the PCI. This raises the question of the concordance between the PCI scores calculated by different surgeons, and a possible variation before and after CRS.

OBJECTIVE

To analyze variations in the PCI score between surgeons and according to when it is determined (before and after surgery).

PATIENTS AND METHODS

Prospective recording of the PCI score independently calculated by senior and junior surgeons, before CRS (when the surgeon decided to perform this procedure), and after CRS, in 75 consecutive patients. A concordance analysis was conducted.

RESULTS

The origins of the PC were colorectal (n = 38), pseudomyxoma (n = 22), mesothelioma (n = 8) and miscellaneous lesions (n = 7). Concordance between the PCI score was very high (close to 90%) among the senior surgeons and junior surgeons before and after CRS. After CRS, the mean PCI score increased by 1.75 (IC-95%: 2.09-1.41). This high concordance was similar whatever the level of the PCI score and whatever the origin of the tumor.

CONCLUSION

The PCI is a reliable tool for measuring the extent of PC. It is easy to use and inter-surgeon concordance is high. It increases by approximately 2 before and after CRS.

Post-operative critical care management of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC)

Background

Cytoreductive surgery (CRS) and Heated Intraperitoneal Chemotherapy (HIPEC) results in a number of physiological changes with effects on the cardiovascular system, oxygen consumption and coagulation. The Critical Care interventions required by this cohort of patients have not yet been quantified.

Methods

This retrospective audit examines the experience of a Specialist Tertiary Centre in England over an 18 month period (January 2009-June 2010) during which 69 patients underwent CRS and HIPEC. All patients were extubated in the operating theatre and transferred to the Critical Care Unit (CCU) for initial post-operative management.

Results

Patients needed to remain on the CCU for 2.4 days (0.8-7.8). There were no 30 day mortalities. The majority of patients (70.1%) did not require post-operative organ support. 2 patients who developed pneumonia post-operatively required respiratory support. 18 (26.1%) patients required vasopressor support with norepinephrine with a mean duration of 13.94 hours (5-51 hours) and mean dose of 0.04 mcg/kg/min. Post-operative coagulopathy peaked at 24 hours. A significant drop in serum albumin was observed.

Conclusion

The degree of organ support required post-operatively is minimal. Early extubation is efficacious with the aid of epidural analgesia. Critical Care monitoring for 48 hours is desirable in view of the post-operative challenges.

Multimodal treatment approaches for peritoneal carcinosis in colorectal cancer

BACKGROUND

15% to 20% of patients with metastatic colorectal cancer show isolated peritoneal carcinomatosis with significat clinical relevance. Their prognosis is poor, with a reported mean survival of less than one year. Moreover, there is a lack of knowledge regarding treatment optimally tailored to individual patients.

METHODS

To identify and characterize the current treatment options for this condition, we reviewed pertinent literature retrieved by a PubMed search on the terms "peritoneal carcinomatosis," "colorectal cancer," "treatment," "hyperthermic intraperitoneal chemotherapy," "cytoreductive surgery," and "humans."

RESULTS

Most patients with peritoneal carcinomatosis are treated with systemic chemotherapy in addition to best supportive care. Some undergo surgical or interventional treatment, such as ostomy or stent placement for intestinal obstruction. About one-third are candidates for multimodal treatment, consisting of surgical cytoreduction with intraoperative hyperthermic intraperitoneal chemotherapy. The main selection criteria are limited tumor mass (peritoneal cancer index <20), absence of organ metastases, feasibility of complete macroscopic cytoreduction (absence of disseminated small bowel disease), and approval of the interdisciplinary tumor board. Patients selected in this way have a 5-year survival rate of 30% to 50% after multimodal treatment.

CONCLUSION

The treatment of peritoneal carcinomatosis is usually considered to be purely palliative, in view of the extensive spread of the disease. However, for a subgroup of patients multimodal treatment can be provided with curative intent. The available survival data support the provision of multimodal strategies, including cytoprotective surgery, intraoperative intraperitoneal and systemic chemotherapy, for patients with peritoneal carcinomatosis in specialized centers. This type of treatment should be incorporated into treatment algorithms and guidelines.

Development of regional chemotherapies: feasibility, safety and efficacy in clinical use and preclinical studies

Conventional oral and intravenous chemotherapies permeate throughout the body, exposing healthy tissues to similar cytotoxic drug levels as tumors. This leads to significant dose-limiting toxicities that may prevent patients from receiving sufficient treatment to overcome cancers. Therefore, a number of locoregional drug-delivery strategies have been evaluated and implemented in preclinical studies, clinical trials and in practice, in the past decades to minimize systemic toxicities from chemotherapeutic agents and to improve treatment outcomes. Localized treatment is beneficial because many cancers, such as melanoma, peritoneal cancer and breast cancer, advance locally adjacent to the site of the primary tumors prior to their circulatory invasion. In this article, we will review the feasibility, safety and efficacy of multiple localized chemotherapies in clinical use and preclinical development.

Selection criteria for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in gastric cancer

Peritoneal carcinomatosis in gastric cancer is associated with a dismal prognosis. Systemic chemotherapy is not effective because of the existence of a blood-peritoneal barrier. Cytoreductive surgery and intraperitoneal chemotherapy can improve survival and quality of life in selected patients. Patient selection for this multimodal approach is one of the most critical issues, and calls for interdisciplinary evaluation by radiologists, medical and surgical oncologists, and anaesthetists. This article sets forth criteria for selection of gastric cancer patients suffering from peritoneal carcinomatosis.

Cytoreductive surgery with intraperitoneal chemotherapy to treat pseudomyxoma peritonei at nonspecialized hospitals

PURPOSE

It has been reported that complete cytoreduction using peritonectomy combined with intraperitoneal chemotherapy improves the prognosis of patients with pseudomyxoma peritonei (PMP); however, this treatment strategy remains controversial, especially at nonspecialized institutes, because of its high morbidity rate.

METHODS

We reviewed the clinical records of 15 consecutive patients with PMP, treated in nonspecialized hospitals and observed by one of us between 1999 and 2010. Cytoreductive surgery was done using peritonectomy procedures with intraperitoneal chemotherapy and was performed with curative intent, |in accordance with Sugarbaker.

RESULTS

All patients had mucinous tumors disseminated in the peritoneal cavity. Complete cytoreduction was achieved in 12 patients. Morbidity was 40% (6/15) and mortality was 0% (0/15). After a median follow-up period of 43 months, the 12 patients who underwent complete cytoreduction were disease-free with good quality of life, and 1 of the 3 patients who underwent incomplete cytoreduction was alive with disease.

CONCLUSIONS

These findings suggest that peritonectomy with intraperitoneal chemotherapy for PMP can provide prognostic benefit, even at nonspecialized hospitals. Considering the treatment risk, it should ideally be performed at a referral center, or at least by an experienced surgeon.

Management of peritoneal carcinomatosis from colorectal cancer

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

Cyto-reductive Surgery combined with Hyperthermic Intra-peritoneal Chemotherapy for Peritoneal Surface Malignancies: current treatment and results

Cyto-reductive Surgery (CS) combined with Hyperthermic Intra-peritoneal Chemotherapy (HIPEC) as loco-regional treatment of Peritoneal Surface Malignancies (PSM) has increasingly gained acceptance in clinical practice. This review summarizes the more relevant studies on this topic. Indications, pre-operative work-up, technical aspects, outcome and future directions of this combined approach in the treatment of Peritoneal Surface Malignancies are discussed here and proposed in an informative and didactic manner.

Treatment recommendations for metastatic colorectal cancer

Metastatic colorectal cancer (CRC) represents an important health problem in which several biological predictive and prognostic factors have been identified, including clinical features and molecular markers that might influence the response to treatment. Actually, certain prognostic factors are considered key elements, along with disease extent, for deciding the therapeutic approach. However, a distinction between resectable/potentially resectable and unresectable patients must be made in order to establish an adequate therapeutic strategy. Different drugs and chemotherapy regimens are currently available, and their administration depends on patient characteristics, disease-related factors and the treatment objective. Moreover, special situations such as peritoneal carcinomatosis and local treatment of CRC in the setting of metastatic disease should be considered when deciding the most appropriate treatment strategy. This article reviews all the previously mentioned issues involved in the management of metastatic CRC and suggests some general recommendations for its treatment.

A new standard of care for the management of peritoneal surface malignancy

Cancer dissemination to peritoneal surfaces was, in the past, a lethal condition with a limited survival. Clinical and pharmacologic research have shown that options for both treatment and prevention are now reality. The diseases most commonly treated include peritoneal dissemination from appendiceal malignancy, colorectal malignancy, and peritoneal mesothelioma. Selection factors are important to minimize the number of treated patients who will experience short-term benefit. Treatments involve cytoreductive surgery and perioperative chemotherapy. The intraperitoneal chemotherapy in the operating room is used with heat. Although this combined approach has been criticized, the informed oncologist will seek to identify those patients that may benefit from this more optimistic concept of peritoneal dissemination of cancer.

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

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

Antitumour efficacy of two paclitaxel formulations for hyperthermic intraperitoneal chemotherapy (HIPEC) in an in vivo rat model

PURPOSE

To evaluate the tumour growth delay of a peritoneal carcinomatosis (PC) of colorectal origin after intraperitoneal chemotherapy with paclitaxel/randomly-methylated-β-cyclodextrin (Pac/RAME-β-CD) versus Taxol® at normo- and hyperthermic conditions in rats.

METHODS

Hyperthermic intraperitoneal chemotherapy (HIPEC) was performed 7 days post implantation of the tumour with both formulations at a Pac concentration of 0.24 mg/ml. Tumour evaluation was performed via positron emission tomography (PET) and magnetic resonance imaging (MRI) imaging, measuring tumour activity and tumour volume, respectively. Scans were taken at 2 and 7 days post treatment.

RESULTS

PET and MRI data showed a significant reduction in tumour activity and tumour volume for rats treated with Pac/RAME-β-CD (at normo- and hyperthermic conditions), compared to the control group. Treatment with Taxol® did not result in a significant reduction of tumour activity and tumour volume. No significant differences between the normo- and hyperthermic conditions were observed for both formulations, indicating that hyperthermia and paclitaxel were not synergistic despite the direct cytotoxic effect of hyperthermia.

CONCLUSION

Monitoring tumour growth via PET and MRI indicated that Pac/RAME-β-CD inclusion complexes had a significantly higher efficacy compared to Taxol® in a rat model for peritoneal carcinomatosis.

SEOM clinical guidelines for the treatment of advanced colorectal cancer

Colorectal cancer is the first cause of cancer diagnosis in Spain. Over half of the patients are diagnosed with or will eventually develop distant metastasis. The current manuscript aims to provide synthetic practical guidelines for the therapeutic approaches in advanced disease. Available systemic therapeutic options, and integration and sequencing of chemotherapy with surgical procedures are discussed. Extent of disease, treatment objective, tumor kras mutation status, as well as patient's functional and comorbid conditions shall be considered to properly design the most adequate therapeutic strategy.

Tumor associated mesenchymal stem cells protects ovarian cancer cells from hyperthermia through CXCL12

Hyperthermic intraperitoneal chemotherapy (HIPEC) has shown promise in treatment of ovarian carcinosis. Despite its efficiency for the treatment of peritoneal carcinosis from digestive tract neoplasia, it has failed to demonstrate significant benefit in ovarian cancers. It is therefore essential to understand the mechanism underlying resistance to HIPEC in ovarian cancers. Mesenchymal stem cells (MSC) play an important role in the development of ovarian cancer metastasis and resistance to treatments. A recent study suggests that MSCs may be cytotoxic for cancer cells upon heat shock. In contrast, we describe the protective role of MSC against hyperthermia. Using cytokine arrays we determined that the tumor associated MSC (TAMC) secrete pro-tumoral cytokines. We studied the effect of hyperthermia in co-culture setting of TAMC or BM-MCS associated with ovarian cancer cell lines (SKOV3 and CaOV3) with polyvariate flow cytometry. We demonstrate that hyperthermia does not challenge survival of TAMC or bone marrow derived MSC (BM-MSC). Both TAMC and BM-MSC displayed strong protective effect inducing thermotolerance in ovarian cancer cells (OCC). Transwell experiments demonstrated the role of secreted factors. We showed that CXCL12 was inducing thermotolerance and that inhibition of CXCL12/CXCR4 interaction restored cytotoxicity of hyperthermia in co-culture experiments. Contrary to the previous published study we demonstrated that TAMC and BM-MSC co-cultured with OCC induced thermotolerance in a CXCL12 dependant manner. Targeting the interaction between stromal and cancer cells through CXCL12 inhibition might restore hyperthermia sensitivity in ovarian cancers, and thus improve HIPEC efficiency.

Surgical treatment of patients with peritoneal surface malignancy: cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

A peritoneal surface malignancy is one of an assortment of tumors that result in widespread peritoneal involvement, can affect multiple organs, and may arise from the appendix, colon, rectum, stomach, ovaries, or peritoneal lining. The combined treatment modality of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy has gained recognition as a promising, potentially life-extending surgical treatment option for the management of peritoneal surface malignancies. This type of surgical treatment is not without risks and complications, often resulting in the formation of fistulas and the need for a diverting ostomy. This article presents a review of peritoneal surface malignancies, cytoreductive surgery, the perioperative management of the surgical patient with focus on complications and implications for the WOC nurse providing care for patients undergoing this complex surgical treatment.

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

Peritoneal carcinomatosis (PC) had long been regarded as a terminal disease, characterized by a very poor survival and worth treating with palliative therapy. A new strategy combining maximal surgery (cytoreductive surgery, CRS), with maximal regional chemotherapy (hyperthermic intraperitoneal chemotherapy, HIPEC), has been proposed to treat PC, resulting in long-term survival rates in selected patients. The emerging trend is to view localised peritoneal carcinomatosis, in the absence of other metastases, as a regional metastatic disease that is amenable to locoregional therapy. In spite of the need for more high quality studies, many international experts now agree that the use of this new strategy is a gold standard for treating selected patients with PC with the intent of curing. The best results are achieved in patients with limited disease who have completed macroscopic tumor removal. To offer a comprehensive review, we summarized the present status and possible future progress of this treatment modality, in particular outlining its rationale, current practice and general outcome.

Accuracy and clinical relevance of computed tomography scan interpretation of peritoneal cancer index in colorectal cancer peritoneal carcinomatosis: a multi-institutional study

BACKGROUND

Evaluation of peritoneal metastases by computed tomography (CT) scans is challenging and has been reported to be inaccurate.

METHODS

A multi-institutional prospective observational registry study of patients with peritoneal carcinomatosis from colorectal cancer was conducted and a subset analysis was performed to examine peritoneal cancer index (PCI) based on CT and intraoperative exploration.

RESULTS

Fifty-two patients (mean age 52.6 ± 12.4 years) from 16 institutions were included in this study. Inaccuracies of CT-based assessment of lesion sizes were observed in the RUQ (P = 0.004), LLQ (P < 0.0005), RLQ (P = 0.003), distal jejunum (P = 0.004), and distal ileum (P < 0.0005). When CT-PCI was classified based on the extent of carcinomatosis, 17 cases (33%) were underestimations, of which, 11 cases (21%) were upstaged from low to moderate, 4 cases (8%) were upstaged from low to severe, and 2 cases (4%) were upstaged from moderate to severe. Relevant clinical discordance where an upstage occurred to severe carcinomatosis constituted a true inaccuracy and was observed in six cases (12%).

CONCLUSIONS

The actual clinical impact of inaccuracies of CT-PCI was modest. CT-PCI will remain as a mandatory imaging tool and may be supplemented with other tools including positron emission tomography scan or diagnostic laparoscopy, in the patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion versus systemic chemotherapy alone for colorectal peritoneal carcinomatosis

BACKGROUND

Survival benefit of cytoreductive surgery combined with hyperthermic intraperitoneal chemoperfusion was demonstrated by a prospective randomized trial for colorectal peritoneal carcinomatosis. Because of a recent substantial improvement in chemotherapy, the authors analyzed treatment options of colorectal carcinomatosis in the current era.

METHODS

Consecutive patients with colorectal carcinomatosis treated by cytoreductive surgery combined with hyperthermic intraperitoneal chemoperfusion from 2001 to 2007 were included. The control group patients with carcinomatosis received contemporary chemotherapy alone. Overall survival was the primary endpoint.

RESULTS

All patients underwent systemic chemotherapy. The cytoreductive surgery combined with hyperthermic intraperitoneal chemoperfusion group (n=67) was similar to the control group (n=38) in sex, tumor grade, site of tumor origin, T status, and N status. The control group was, however, older (59 vs 51 years; P<.001). Median survival measured from the diagnosis of peritoneal disease was longer with cytoreductive surgery combined with hyperthermic intraperitoneal chemoperfusion (34.7 months vs 16.8 months; P<.001). Presence of liver metastasis was a significant negative predictor of survival (hazard ratio, 2.13).

CONCLUSIONS

The authors concluded that 1) contemporary chemotherapy is associated with prolonged survival among patients with carcinomatosis as compared with historical controls, and 2) addition of cytoreductive surgery combined with hyperthermic intraperitoneal chemoperfusion to modern chemotherapy regimens may significantly prolong survival. Cytoreductive surgery combined with hyperthermic intraperitoneal chemoperfusion and systemic chemotherapy are not competitive therapies, and they both have a role in a multidisciplinary approach to patients with carcinomatosis.

Predictors and survival of synchronous peritoneal carcinomatosis of colorectal origin: a population-based study

The aim of our study was to provide population-based data on incidence and prognosis of synchronous peritoneal carcinomatosis and to evaluate predictors for its development. Diagnosed in 1995-2008, 18,738 cases of primary colorectal cancer were included. Predictors of peritoneal carcinomatosis were analysed by multivariable logistic regression analysis. Median survival in months was calculated by site of metastasis. In the study period, 904 patients were diagnosed with synchronous peritoneal carcinomatosis (4.8% of total, constituting 24% of patients presenting with M1 disease). The risk of peritoneal carcinomatosis was increased in case of advanced T stage [T4 vs. T1,2: odds ratio (OR) 4.7, confidence limits 4.0-5.6), advanced N stage [N0 vs. N1,2: OR 0.2 (0.1-0.2)], poor differentiation grade [OR 2.1 (1.8-2.5)], younger age [<60 years vs. 70-79 years: OR 1.4 (1.1-1.7)], mucinous adenocarcinoma [OR 2.0 (1.6-2.4)] and right-sided localisation of primary tumour [left vs. right: OR 0.6 (0.5-0.7)]. Median survival of patients with peritoneum as single site of metastasis remained dismal [1995-2001: 7 (6-9) months; 2002-2008: 8 (6-11) months], contrasting the improvement among patients with liver metastases [1995-2001: 8 (7-9) months; 2002-2008: 12 (11-14) months]. To conclude, synchronous peritoneal metastases from colorectal cancer are more frequent among younger patients and among patients with advanced T stage, mucinous adenocarcinoma, right-sided tumours and tumours that are poorly differentiated. The prognosis of synchronous peritoneal carcinomatosis remains poor with a median survival of 8 months and even worse if concomitant metastases in other organs are present.

Surgical treatment for peritoneal carcinomatosis from gastric cancer

This review describes the latest surgical treatments for peritoneal carcinomatosis (PC) arising from gastric cancer. Systemic chemotherapy is less effective against PC because of the existence of the blood-peritoneal barrier. Accordingly, perioperative intraperitoneal chemotherapy plus cytoreductive surgery (CRS) is a new trend of multidisciplinary therapy for PC. Intraperitoneally administered drugs penetrate directly into the peritoneal dissemination, resulting in the high loco-regional intensity of drugs. A new bidirectional chemotherapy called neoadjuvant intraperitoneal/systemic chemotherapy (NIPS) has been developed. After NIPS, the disappearance of PFCCs has been reported, and the incidence of complete cytoreduction has increased accordingly. Complete cytoreduction, a low peritoneal carcinomatosis index, and negative PFCCs are significant favorable prognostic factors. Hyperthermic intraperitoneal chemotherapy (HIPEC) after CRS is associated with improved survival with an acceptable postoperative mortality and morbidity. Early postoperative intraperitoneal chemotherapy (EPIC) has also contributed to improving survival after CRS.

Intraperitoneal therapy for peritoneal cancer

Cancers originating from organs in the peritoneal cavity (e.g., ovarian, pancreatic, colorectal, gastric and liver) account for approximately 250,000 new cancer cases annually in the USA. Peritoneal metastases are common owing to locoregional spread and distant metastases of extraperitoneal cancers. A logical treatment is intraperitoneal therapy, as multiple studies have shown significant targeting advantage for this treatment, including significant survival benefits in stage III, surgically debulked ovarian cancer patients. However, the clinical use of intraperitoneal therapy has been limited, in part, by toxicity, owing to the use of indwelling catheters or high drug exposure, by inadequate drug penetration into bulky tumors (>1 cm) and by the lack of products specifically designed and approved for intraperitoneal treatments. This article provides an overview on the background of peritoneal metastasis, clinical research on intraperitoneal therapy, the pharmacokinetic basis of drug delivery in intraperitoneal therapy and our development of drug-loaded tumor-penetrating microparticles.

Validation and use of microdialysis for determination of pharmacokinetic properties of the chemotherapeutic agent mitomycin C - an experimental study

BACKGROUND

Mitomycin C is a chemotherapeutic agent used in the treatment of peritoneal surface malignancies, administered as hyperthermic intraperitoneal chemotherapy after cytoreductive surgery. Pharmacokinetic studies have been based on analyses of blood, urine and abdominal perfusate, but actual tissue concentrations of the drug have never been determined. Microdialysis is an established method for continuous monitoring of low-molecular substances in tissues, and in the present study microdialysis of mitomycin C was studied in vitro and in vivo.

METHODS

Using in vitro microdialysis, relative recovery was determined when varying drug concentration, temperature and perfusion flow rate. In vivo microdialysis was performed in rats to verify long-term stability of relative recovery in four compartments (vein, peritoneum, extraperitoneal space and hind leg muscle). Subsequently, intravenous and intraperitoneal bolus infusion experiments were performed and pharmacokinetic parameters were calculated.

RESULTS

In vitro, compatibility of mitomycin C and microdialysis equipment was demonstrated, and relative recovery was stable over an adequate concentration range, moderately increased by raising medium temperature and increased when flow rate was reduced, all according to theory. In vivo, stable relative recovery was observed over seven hours. Mitomycin C exhibited fast and even distribution in rat tissues, and equal bioavailability was achieved by intravenous and intraperitoneal infusion. The half-life of mitomycin C calculated after intravenous infusion was 40 minutes.

CONCLUSIONS

Mitomycin C concentration can be reliable monitored in vivo using microdialysis, suggesting that this technique can be used in pharmacokinetic studies of this drug during hyperthermic intraperitoneal chemotherapy.

Peritoneal seeding from appendiceal carcinoma: A case report and review of the literature

Non-carcinoid appendiceal malignancies are rare entities, representing less than 0.5% of all gastrointestinal malignancies. Because of their rarity and particular biological behavior, a substantial number of patients affected by these neoplasms do not receive appropriate surgical resection. In this report, we describe a rare case of primary signet-ring cell carcinoma of the appendix with peritoneal seeding which occurred in a 40-year old man admitted at the Emergency Surgery Department with the clinical suspicion of acute appendicitis. After a surgical debulking and right hemicolectomy, the patient had systemic chemotherapy according to FOLFOX protocol. After completion of the latter, the patient underwent cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy. This report offers a brief review of the literature and suggests an algorithm for the management of non-carcinoid appendiceal tumors with peritoneal dissemination.

Early results on the use of biomaterials as adjuvant to abdominal wall closure following cytoreduction and hyperthermic intraperitoneal chemotherapy

Background

Hyperthermic chemotherapy applies thermal energy to both abdominal wall as well as the intra-abdominal viscera. The combination of the hyperthemia, chemotherapy and cytoreductive surgery (CRS) is associated with a defined risk of abdominal wall and intestinal morbidity reported to be as high as 15%, respectively to date, no studies have evaluated the use of biomaterial mesh as adjuvant to abdominal wall closure in this group of patients. In the present report, we hypothesized that post HIPEC closure with a biomaterial can reduce abdominal wall morbidity after CRS and hyperthermic intraperitoneal chemotherapy.

Materials and methods

All patients treated with HIPEC in a tertiary care center over 12 months (2008-2009) period were included. Eight patients received cytoreductive surgery followed by HIPEC for 90 minutes using Mitomycin C (15 mg q 45 minutes × 2). Abdominal wall closure was performed using Surgisis (Cook Biotech.) mesh in an underlay position with 3 cm fascial overlap-closure. Operative time, hospital length of stay (LOS) as well as postoperative outcome with special attention to abdominal wall and bowel morbidity were assessed.

Results

Eight patients, mean age 59.7 ys (36-80) were treated according to the above protocol. The primary pathology was appendiceal mucinous adenocarcinoma (n = 3) colorectal cancer (n = 3), and ovarian cancer (n = 2). Four patients (50%) presented initially with abdominal wall morbidity including incisional ventral hernia (n = 3) and excessive abdominal wall metastatic implants (n = 1). The mean peritoneal cancer index (PCI) was 8.75. Twenty eight CRS were performed (3.5 CRS/patient). The mean operating time was 6 hours. Seven patients had no abdominal wall or bowel morbidity, the mean LOS for these patients was 8 days. During the follow up period (mean 6.3 months), one patient required exploratory laparotomy 2 weeks after surgery and subsequently developed an incisional hernia and enterocutaneous fistula.

Conclusion

The use of biomaterial mesh in concert with HIPEC enables the repair of concomitant abdominal wall hernia and facilitates abdominal wall closure following the liberal resection of abdominal wall tumors. Biomaterial mesh prevents evisceration on repeat laparotomy and resists infection in immunocompromised patients even when associated with bowel resection.

Hyperthermia potentiates oncolytic herpes viral killing of pancreatic cancer through a heat shock protein pathway

BACKGROUND

Oncolytic herpes simplex virus-1 (HSV-1) is designed to specifically infect, replicate in, and lyse cancer cells. This study investigates a novel therapeutic regimen, combining the effects of NV1066 (a recombinant HSV-1) and hyperthermia in the treatment of pancreatic cancer.

METHODS

NV1066 is an attenuated HSV-1 that replicates in cells resistant to apoptosis. Heat shock protein 72 (Hsp72) is a member of a family of proteins that is upregulated after hyperthermic insult, lending cellular protection by inhibiting apoptosis. In these experiments, we test the hypothesis that increased Hsp72 expression in response to hyperthermia enhances anti-apoptotic mechanisms, thereby increasing viral replication and tumor cell kill. Hs 700T pancreatic cancer cells were treated with hyperthermia alone (42 degrees C), NV1066 alone, and combination therapy. Cell survival and viral growth were measured. The effect of siRNA-directed Hsp72 knockdown was also measured.

RESULTS

Combining hyperthermia and viral treatment produced a synergistic effect on cell kill. Viral growth increased greater than 6-fold in the presence of hyperthermia (P < .05). Hyperthermia alone showed minimal cytotoxic activity against Hs 700T cells, while NV1066 infection resulted in approximately 50% cell kill. The combination of hyperthermia and viral infection significantly increased cell kill to approximately 80% (P < .01). Hsp72 knockdown attenuated this synergistic effect.

CONCLUSION

Hyperthermia enhances NV1066 replication, thereby potentiating the viral oncolytic response against pancreatic cancer cells. This finding has potential clinical application in the use of heated perfusion or permissive hyperthermia for delivery of oncolytic viral therapies.

5-FU-hydrogel inhibits colorectal peritoneal carcinomatosis and tumor growth in mice

Background

Colorectal peritoneal carcinomatosis (CRPC) is a common form of systemic metastasis of intra-abdominal cancers. Intraperitoneal chemotherapy is a preferable option for colorectal cancer. Here we reported that a new system, 5-FU-loaded hydrogel system, can improve the therapeutic effects of intraperitoneal chemotherapy.

Methods

A biodegradable PEG-PCL-PEG (PECE) triblock copolymer was successfully synthesized. The biodegradable and temperature sensitive hydrogel was developed to load 5-FU. Methylene blue-loaded hydrogel were also developed for visible observation of the drug release. The effects and toxicity of the 5-FU-hydrogel system were evaluated in a murine CRPC model.

Results

The hydrogel system is an injectable flowing solution at ambient temperature and forms a non-flowing gel depot at physiological temperature. 5-FU-hydrogel was subsequently injected into abdominal cavity in mice with CT26 cancer cells peritoneal dissemination. The results showed that the hydrogel delivery system prolonged the release of methylene blue; the 5-FU-hydrogel significantly inhibited the peritoneal dissemination and growth of CT26 cells. Furthermore, intraperitoneal administration of the 5-FU-hydrogel was well tolerated and showed less hematologic toxicity.

Conclusions

Our data indicate that the 5-FU-hydrogel system can be considered as a new strategy for peritoneal carcinomatosis, and the hydrogel may provide a potential delivery system to load different chemotherapeutic drugs for peritoneal carcinomatosis of cancers.

Pharmacokinetics of intraperitoneal irinotecan in a pig model

Complete surgical cytoreduction of peritoneal implants and immediate intraperitoneal (lP) chemotherapy offers the greatest survival in selected patients with peritoneal carcinomatosis. This study was undertaken to describe the metabolism and pharmacokinetics of normothermic intraperitoneal CPT-11, free and glucuronized SN-38, in a pig model. Thirteen pigs were used for experimentation. Animals were grouped for IV and IP CPT-1 1 administration. Eleven pigs underwent laparotomy through a midline incision and instillation of 100, 200, and 400mg IP CPT-11. Systemic venous blood, portal blood and peritoneal fluid samples were taken at 5, 10, 20, 30, and 45 min, then every hour up to 8 hr for the 100 mg. For the three groups, peritoneal CPT-11 exposition was on average 4.9 times greater in the peritoneum than in the systemic venous or portal circulations and the systemic CPT-11 fraction absorbed from the peritoneum linearly increased with time. Free SN-38 was measurable in the earliest peritoneal samples taken. The initial instillation dose of CPT-11 did not impact on the SN-38 converted fraction, which remained stable at approximately 0.04% during the first 4 hour. Mean peritoneal SN-38: CPT-11 AUC ratio was 0.043. OPT-11 peritoneal conversion into SN-38 appeared slightly Inferior to the systemic conversion ratio. This norrnothermic IP OPT-11 pharmacokinetic study performed in a pig model confirms the possibility to achieve at least a 30 times higher peritoneal than systemic exposure. Peritoneal exposure to active SN-38 begins at the moment of CPT-11 peritoneal instillation. A fixed and small traction of less than 0.1% of CPT-11 is converted into SN-38, underlying the importance of a sufficient initial IP dose of CPT-11.

Morbidity and mortality of 109 consecutive cytoreductive procedures with hyperthermic intraperitoneal chemotherapy (HIPEC) performed at a community hospital

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) is playing an increasing role in the management of isolated peritoneal dissemination of gastrointestinal malignancies. Historically this surgery is associated with a high morbidity and mortality. Recognizing this, our study was developed to prospectively evaluate morbidity and mortality after cytoreductive surgery with HIPEC performed at a community hospital.

METHODS

From January 19, 2005 to January 9, 2008, 109 consecutive patients successfully underwent cytoreductive surgery with HIPEC for peritoneal surface malignancies. All cases were performed by a single surgeon at a 323-bed community hospital. Using an institutional review board approved study we prospectively evaluated postoperative complications using the standard National Institutes of Health morbidity and mortality grading system.

RESULTS

There was no 30-day or inpatient mortality. Overall grade III and IV morbidity was 30.2% (33 of 109 patients); 29.3% of the patients had at least one grade III complication, with the most common being postoperative anemia requiring a blood transfusion in 20 of the 109 patients (18.3%). Eight patients (7.3%) had wound infections, and three patients (2.7%) developed pneumonia. One patient required computerized tomography guided drainage of a pelvic abscess. There were 3 (2.7%) grade IV complications, with only one patient requiring reoperation.

CONCLUSIONS

Recent studies at tertiary medical centers have shown acceptable morbidity and mortality with this procedure. Our study demonstrates that this procedure can be safely performed in the community setting as well if surgeons, other medical professionals, and ancillary caregivers have great experience in this procedure.

Current role of hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis from colorectal cancer

Peritoneal carcinomatosis is one of the most common routes of dissemination of colorectal cancer (CRC). It is encountered in 7% of patients at primary surgery, while it develops in about 4% to 19% of patients after curative surgery and in up to 44% of patients with recurrent CRC. Peritoneal involvement from colorectal malignancies has been considered traditionally as a manifestation of terminal disease, due to limited response to conventional surgical and chemotherapeutic treatments. In the past few years the introduction of cytoreductive surgery combined with hyperthermic intraperitoneal chemoperfusion has shown promising results in selected patients. Currently, the surgical management of peritoneal surface malignancies of colonic origin with this combined locoregional therapy has resulted in a significant improvement in survival of these patients. However, further controlled studies will help to standardize indications and the technique of this locoregional therapy in order to achieve an improvement of morbidity and mortality rates.

Peritoneal carcinomatosis of gastrointestinal origin: natural history and treatment options

BACKGROUND

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

OBJECTIVES

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

RESULTS

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

CONCLUSION

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

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

Peritoneal surface malignancies have been traditionally regarded as end-stage conditions amenable to merely palliative options. The combination of aggressive cytoreductive surgery (CRS), involving peritonectomy procedures and multivisceral resections, with intra-operative hyperthermic intra-peritoneal chemotherapy (HIPEC) and/or early postoperative intra-peritoneal chemotherapy (EPIC) to treat the microscopic residual tumor is a new concept. In recent years, promising results have been reported for peritoneal mesothelioma and carcinomatosis of gastrointestinal and gynaecologic origin treated by this combined protocol. However, CRS with HIPEC and/or EPIC is a complex procedure associated with high rates of potentially life-threatening complications. Furthermore, disease progression following comprehensive treatment is not uncommon and represents a relevant cause of treatment failure. The present paper reviews the available information on early postoperative management and long-term follow-up in patients treated with CRS and intraperitoneal chemotherapy. The peculiar clinical and biological alterations that can be expected during an uncomplicated postoperative course, as compared to standard digestive surgery, are discussed. Early recognition and appropriate management of the most common adverse events are addressed, in order to minimize the impact of treatment-related morbidity on survival and quality of life results. Since re-operative surgery with additional HIPEC, has proven to be useful in selected patients with recurrent disease, long-term surveillance aiming at early detection of postoperative disease progression has become a relevant issue. Current results on follow-up investigations are presented.

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

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

Treatments and outcomes of peritoneal surface tumors through a centralized national service (United kingdom)

PURPOSE

Treatment of peritoneal surface malignancies with combined cytoreductive surgery and heated intraperitoneal chemotherapy may improve oncologic outcome. To better define treatment pathways, five-year results in patients referred to one of two centralized national treatment centers in the United Kingdom were analyzed.

METHODS

A prospective database of patients referred to the Manchester Peritoneal Tumor Service, established in 2002, was analyzed. Outcomes were evaluated using Kaplan-Meier life tables and Cox models.

RESULTS

Two hundred seventy-eight patients (median age, 56.9 (range, 16-86) years) were considered by a dedicated multidisciplinary team and tracked on seven clinical pathways. Among the 118 surgically treated, the most common diagnosis was pseudomyxoma peritonei (101 patients, 86%). Major complications occurred in 11 patients (9%); there was no 30-day mortality. Where complete cytoreduction was achieved, three-year and five-year tumor-related survival rates were 94% and 86%, respectively. In the Cox model, incompleteness of cytoreduction (P = 0.001) and high-grade tumor (P < 0.0001) were independent prognosticators of poor outcome.

CONCLUSION

The establishment of a national treatment center has allowed refinement of techniques to achieve internationally recognized results. Having achieved low levels of morbidity and mortality in the treatment of mainly pseudomyxoma peritonei of appendiceal origin, the technique of cytoreductive surgery and heated intraperitoneal chemotherapy may be considered for peritoneal carcinomatosis of colorectal origin.

Perioperative management of patients with cytoreductive surgery for peritoneal carcinomatosis

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important tool in the management of patients with peritoneal malignancies. It is a complex surgical procedure with significant fluid loss during debulking leading to relevant pathophysiological alterations and therefore a challenge for anesthesiologists and critical care physicians. This review summarizes perioperative changes in hemodynamics, oxygen supply, coagulation, hematopoetic parameters and fluid status during cytoreductive surgery and HIPEC and how to deal with these pathophysiological alterations.

Evidence-based medicine in the treatment of peritoneal carcinomatosis: Past, present, and future

The current treatment of peritoneal surface malignancies (PSMs) is moving from a nihilistic approach, into a combined modality approach offering selected patients long-term survival. As primary PSM are rare, extrapolation of data from clinical trials of related disease is necessary to develop treatment guidelines. Secondary PSM are more common, and therefore, treatment guidelines should be developed based on prospective clinical trials. We reviewed the published and ongoing clinical trials studying the treatment of PSM.