Peritoneal Cancers and Hyperthermic Intraperitoneal Chemotherapy

Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy is an aggressive, potentially curative approach used to treat locoregional disease associated with primary and secondary malignancies of the peritoneum. It involves resection of all macroscopic disease larger than 2.5 mm, followed by instillation of hyperthermic chemotherapy directly into the peritoneum for higher drug exposure to microscopic disease. In select patients with primary peritoneal mesothelioma, pseudomyxoma peritonei, colorectal adenocarcinoma, appendiceal adenocarcinoma, or ovarian cancer, with no extra-abdominal metastasis and limited involvement of the peritoneum, the procedure can be performed to increase overall survival.

Treatment of PERItoneal disease in Stomach Cancer with cytOreductive surgery and hyperthermic intraPEritoneal chemotherapy: PERISCOPE I initial results

BACKGROUND

The role of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in gastric cancer is unknown. This non-randomized dose-finding phase I-II study was designed to assess the safety and feasibility of HIPEC, following systemic chemotherapy, in patients with gastric cancer and limited peritoneal dissemination. The maximum tolerated dose of normothermic intraperitoneal docetaxel in combination with a fixed dose of intraperitoneal oxaliplatin was also explored.

METHODS

Patients with resectable cT3-cT4a gastric adenocarcinoma with limited peritoneal metastases and/or tumour-positive peritoneal cytology were included. An open HIPEC technique was used with 460 mg/m² hyperthermic oxaliplatin for 30 min followed by normothermic docetaxel for 90 min in escalating doses (0, 50, 75 mg/m² ).

RESULTS

Between 2014 and 2017, 37 patients were included. Of 25 patients who completed the full study protocol, four were treated at dose level 1 (0 mg/m² docetaxel), six at dose level 2 (50 mg/m² ) and four at dose level 3 (75 mg/m² ). At dose level 3, two dose-limiting toxicities occurred, both associated with postoperative ileus. Thereafter, another 11 patients were treated at dose level 2, with no more dose-limiting toxicities. Based on this, the maximum tolerated dose was 50 mg/m² intraperitoneal docetaxel. Serious adverse events were scored in 17 of 25 patients. The reoperation rate was 16 per cent (4 of 25) and the treatment-related mortality rate was 8 per cent (2 patients, both in dose level 3).

CONCLUSION

Gastrectomy combined with cytoreductive surgery and HIPEC was feasible using 460 mg/m² oxaliplatin and 50 mg/m² normothermic docetaxel.

Small Bowel Adenocarcinomas: Impact of Location on Survival

BACKGROUND

Proximal (duodenal) small bowel adenocarcinomas have a worse prognosis than distal (jejuno-ileal) tumors, but differences in patient, tumor, and treatment factors between locations remain unclear.

METHODS

Patients in the National Cancer Database with surgically resected pathologic stage I-IV small bowel adenocarcinomas between 2004 and 2015 were analyzed. Clinical stage IV patients were excluded.

RESULTS

Proximal tumors (n = 3767) were more likely to be higher grade (OR 1.52, CI 1.22-1.85 for moderately; OR 1.83, CI 1.49-2.33 for poorly differentiated, P < 0.01 for both) and have positive lymph nodes (OR 2.04, CI 1.30-3.23, P < 0.01), while distal tumors (n = 3252) were likely to be larger (OR 1.31, CI 1.07-1.60 for size > 5 cm, P < 0.01). Proximal tumors were associated with worse overall survival (OS) and stage-specific survival compared with distal tumors (all P < 0.01). Cox regression analysis of the entire cohort showed worse survival with community versus academic cancer programs, higher comorbidity scores, pathologic stage IV, poorly differentiated histology, positive nodal or margin status, and proximal location, while female gender, larger tumor size, and chemotherapy predicted better survival. On separate Cox regression analyses of each location, neoadjuvant chemotherapy was associated with better OS in the proximal cohort (HR 0.70, CI 0.55-0.88, P < 0.01), while adjuvant chemotherapy was associated with better OS for both proximal (HR 0.49, CI 0.42-0.57, P < 0.01) and distal tumors (HR 0.68, CI 0.57-0.81, P < 0.01).

CONCLUSIONS

Proximal small bowel adenocarcinomas are associated with worse overall and stage-specific survival. This may be due to tumor biologic differences as proximal tumors were more likely to have higher grade. Future studies should further investigate differences between proximal and distal tumors to guide targeted treatment algorithms.

Desmoid fibromatosis following surgical resection of spinal meningioma

A 42-year-old female patient with a history of cervicothoracic junction meningioma World Health Organization grade I, resected in early 2011, was admitted to the hospital with intractable headache and lower extremity weakness. Magnetic resonance imaging (MRI) showed an epidural mass compressing the spinal cord at the prior surgical site, which was interpreted as recurrent meningioma. Following surgical resection, histopathological analysis revealed desmoid fibromatosis (desmoid tumor). In retrospect, dynamic contrast-enhanced magnetic resonance imaging performed prior to surgery should have allowed for prospective exclusion of meningioma as the recurrent mass and suggested an alternative diagnosis such as post-traumatic desmoid fibromatosis or the need for biopsy to confirm diagnosis.

Stop-Flow Pelvic Chemoperfusion for the Treatment of Malignant Pelvic Bone Tumors: A Preliminary Study

Objective

To preliminarily study the efficacy and safety of stop‐flow pelvic chemoperfusion, a novel therapeutic strategy for treating pelvic malignancies.

Methods

Stop‐flow chemoperfusion was performed six times in 5 patients with primary pelvic malignancies. Aortic and vena cave balloons and tourniquets were used to isolate pelvic blood flow from systemic circulation. Cisplatin was then perfused through a transarterial catheter to achieve exposure to a higher drug concentration. Pelvic and peripheral blood samples were collected to determine drug concentration during perfusion. The efficacy of stop‐flow pelvic perfusion was assessed by measuring the change in tumor size, the visual analogue scale, and the tumor necrosis rate after perfusion. Safety was assessed by classifying adverse events according to CTCAE v4.03.

Results

The mean area under the curve (AUC) and maximum drug concentration in the pelvis during perfusion were 246.23 min μg/mL and 17.29 μg/mL, respectively. These measures were significantly higher than the peripheral mean AUC and maximum drug concentration of 52.08 min μg/mL and 5.14 μg/mL, respectively. All 5 patients showed stable disease in response, with changes in tumor size of −4.7%, −5.4%, +4.7%, −8.4%, and 0.0%. Among the 5 patients, 3 (60%) experienced significant pain relief after perfusion. Three patients underwent surgery, with tumor necrosis of 63%, <60%, and 93%. No severe complications were observed in this study.

Conclusions

Stop‐flow pelvic chemoperfusion resulted in exposure to drug higher concentration with fewer serious complications. These preliminary results suggest that further studies are required to comprehensively assess the therapeutic potential of stop‐flow pelvic chemoperfusion in pelvic malignancies.

Colorectal cancer peritoneal metastases: Biology, treatment and next steps

The presence of peritoneal metastases in patients with advanced colorectal cancer is associated with poor prognosis but the mechanisms for this are unclear. This review summarises the current knowledge of the pathophysiology, clinical features, prevalence, prognosis, and molecular biology of peritoneal metastases and the risk factors for the development of peritoneal metastases following resection of a primary colorectal tumour. Furthermore, the evidence for treatment strategies are described including cytoreductive surgery, hyperthermic intraperitoneal chemotherapy, early post-operative intraperitoneal chemotherapy, sequential post-operative intraperitoneal chemotherapy and emerging novel strategies. Active areas of research should include the identification of individuals at high risk of peritoneal metastases after curative resection of primary tumour, development of a surveillance program for high-risk patients, optimisation of systematic therapies and further investigation of the use of intraperitoneal chemotherapy.

Extent of Peritoneal Metastases on Preoperative DW-MRI is Predictive of Disease-Free and Overall Survival for CRS/HIPEC Candidates with Colorectal Cancer

OBJECTIVE

The aim of this study was to determine whether the extent of peritoneal metastases (PMs) on preoperative diffusion-weighted magnetic resonance imaging (DW-MRI) can be used as a biomarker of disease-free and overall survival in patients with colorectal cancer who are considered for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).

METHODS

For this retrospective cohort study, patients with PMs considered for CRS/HIPEC who underwent DW-MRI for preoperative staging in 2016-2017 were included. The DW-MRI protocol consisted of diffusion-weighted, T2-weighted, and pre- and post-gadolinium T1-weighted imaging of the chest, abdomen, and pelvis. DW-MRI images were evaluated by two independent readers to determine the extent of PMs represented by the Peritoneal Cancer Index (MRI-PCI), as well as extraperitoneal metastases. Cox regression and Kaplan-Meier analysis was performed to determine the prognostic value of DW-MRI for overall and disease-free survival.

RESULTS

Seventy-eight patients were included. CRS/HIPEC was planned for 53 patients and completed in 50 patients (60.5%). Median follow-up after DW-MRI was 23 months (interquartile range 13-24). The MRI-PCI of both readers showed prognostic value for overall survival, independently of whether R1 resection was achieved (hazard ratio [HR] 1.06-1.08; p < 0.05). For the patients who received successful CRS/HIPEC, the MRI-PCI also showed independent prognostic value for disease-free survival for both readers (HR 1.09-1.10; p < 0.05).

CONCLUSION

The extent of PMs on preoperative DW-MRI is an independent predictor of overall and disease-free survival and should therefore be considered as a non-invasive prognostic biomarker.

Analysis and external validation of a nomogram to predict peritoneal dissemination in gastric cancer

OBJECTIVE

Peritoneal dissemination is difficult to diagnose by conventional imaging technologies. We aimed to construct a nomogram to predict peritoneal dissemination in gastric cancer (GC) patients.

METHODS

We retrospectively analyzed 1,112 GC patients in Sun Yat-sen University Cancer Center between 2001 and 2010 as the development set and 474 patients from The Sixth Affiliated Hospital, Sun Yat-sen University between 2010 and 2016 as the validation set. The clinicopathological variables associated with gastric cancer with peritoneal dissemination (GCPD) were analyzed. We used logistic regression analysis to identify independent risk factors for peritoneal dissemination. Then, we constructed a nomogram for the prediction of GCPD and defined its predictive value with a receiver operating characteristic (ROC) curve. External validation was performed to validate the applicability of the nomogram.

RESULTS

In total, 250 patients were histologically identified as having peritoneal dissemination. Logistic regression analysis demonstrated that age, sex, tumor location, tumor size, signet-ring cell carcinoma (SRCC), T stage, N stage and Borrmann classification IV (Borrmann IV) were independent risk factors for peritoneal dissemination. We constructed a nomogram consisting of these eight factors to predict GCPD and found an optimistic predictive capability, with a C-index of 0.791, an area under the curve (AUC) of 0.791, and a 95% confidence interval (95% CI) of 0.762-0.820. The results found in the external validation set were also promising.

CONCLUSIONS

We constructed a highly sensitive nomogram that can assist clinicians in the early diagnosis of GCPD and serve as a reference for optimizing clinical management strategies.

Quality indicators in enteroscopy. Enteroscopy procedure

Within the project "Quality Indicators in Gastrointestinal Endoscopy," under the leadership of the Sociedad Española de Patología Digestiva (SEPD), our goal is to propose the procedures and the structure, process, and outcome indicators required for the application and assessment of quality in enteroscopy. To this end a search was performed for quality indicators in enteroscopy. Quality of evidence was measured by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, and classified as high, moderate, low, and very low. A total of 10 process indicators (one preprocedure, eight procedure, one postprocedure) were identified for enteroscopy, with appropriate indication and choice of most efficient route being most significant.

Appendiceal tumours and pseudomyxoma peritonei: Literature review with PSOGI/EURACAN clinical practice guidelines for diagnosis and treatment

Pseudomyxoma Peritonei (PMP) is a rare peritoneal malignancy, most commonly originating from a perforated epithelial tumour of the appendix. Given its rarity, randomized controlled trials on treatment strategies are lacking, nor likely to be performed in the foreseeable future. However, many questions regarding the management of appendiceal tumours, especially when accompanied by PMP, remain unanswered. This consensus statement was initiated by members of the Peritoneal Surface Oncology Group International (PSOGI) Executive Committee as part of a global advisory role in the management of uncommon peritoneal malignancies. The manuscript concerns an overview and analysis of the literature on mucinous appendiceal tumours with, or without, PMP. Recommendations are provided based on three Delphi voting rounds with GRADE-based questions amongst a panel of 80 worldwide PMP experts.

Adding diagnostic laparoscopy to computed tomography for the evaluation of peritoneal metastases in patients with colorectal cancer: A retrospective cohort study

BACKGROUND

Despite its widespread use, computed tomography (CT) is not perfect for evaluating peritoneal metastases of colorectal origin before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). We therefore evaluated the value of adding diagnostic laparoscopy to CT when assessing patient eligibility for CRS + HIPEC.

METHODS

This was a retrospective study of a consecutive series of 112 patients evaluated systematically by diagnostic laparoscopy and CT between January 2012 and January 2018. Patient eligibility for CRS + HIPEC was assessed by the peritoneal cancer index (PCI) both at the time of initial diagnostic laparoscopy and during the retrospective review of CT images. Two experienced radiologists who were blinded to the PCI result at laparoscopy then independently estimated the PCI based on CT imaging. The primary outcome was the number of patients eligible for CRS + HIPEC by each method.

RESULTS

We identified 112 patients, of whom 95 (85%) were eligible for CRS + HIPEC based on diagnostic laparoscopy and 84 underwent CRS + HIPEC. Overall, 14 patients (17%) experienced an "open-and-close" procedure. In contrast to diagnostic laparoscopy, 100 patients (89%) were identified as being eligible for CRS + HIPEC by CT (p = 0.13), which would have resulted in an additional five open-and-close procedures.

CONCLUSIONS

Adding diagnostic laparoscopy to CT produced a clinically relevant, but statistically non-significant, reduction in the number of patients eligible for CRS + HIPEC. We conclude that diagnostic laparoscopy may be of use in preoperative assessments when systematic analysis by CT scores the PCI as greater than ten. Future research should focus on the cost-effectiveness of this approach.

Bidirectional treatment of peritoneal metastasis with Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) and systemic chemotherapy: a systematic review

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is used in the palliative treatment of peritoneal metastasis. The combination of intraperitoneal and systemic chemotherapy seems rational, and the aim of this systematic review was to compare PIPAC directed monotherapy with a bidirectional treatment approach (PIPAC in combination with systemic chemotherapy). Main outcomes were survival and quality of life.

METHODS

A systematic literature search in Medline, Embase, Cochrane and the "Pleura and Peritoneum" was conducted and analyzed according to PRISMA guidelines. Studies in English reporting on bidirectional treatment with PIPAC and systemic chemotherapy and published before April 2019 were included.

RESULTS

Twelve studies with a total of 386 patients were included. None were specifically designed to compare mono- versus bidirectional treatment, but 44% of the patients received bidirectional treatment. This was more frequent in women (non-gynecological cancers) and one-third of the bidirectional treated patients had received no prior chemotherapy. Data from the included studies provided no conclusions regarding survival or quality of life.

CONCLUSION

Bidirectional treatment with PIPAC and systemic chemotherapy is practised and feasible, and some patients are enrolled having received no prior systemic chemotherapy for their PM. The difficulty in drawing any conclusions based on this systematic review has highlighted the urgent need to improve and standardize reports on PIPAC directed therapy. We have, therefore, constructed a list of items to be considered when reporting on clinical PIPAC research.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews, PROSPERO. Registration number: 90352, March 5, 2018.

Eccrine Porocarcinoma with Zosteriform Metastasis

Eccrine porocarcinoma is a rare malignant tumor that develops in the eccrine glands, appearing as a primary tumor, or by malignant transformation of an eccrine poroma. It is a carcinoma with high metastatic and recurrent potential; it has the same incidence in both sexes, and mainly affects the elderly. Its diagnosis, rather than clinical, is histological, and due to the rarity of the disease, it is a pathological challenge. There are no standardized treatment guidelines for porocarcinoma, but surgical resection with tumor-free margins is considered the basis of treatment, in addition to sentinel node biopsy under risk factors and individualization of each patient. For the metastatic form, chemotherapy and radiotherapy are the treatment of choice. Herein, we present the case of a man with eccrine porocarcinoma with extensive zosteriform skin metastasis and lymph node involvement, treated with chemotherapy and concomitant radiotherapy.

Can [18F]F-FDG PET/CT be used to assess the pre-operative extent of peritoneal carcinomatosis in patients with colorectal cancer?

PURPOSE

To evaluate whether PET/CT could be used to assess the extent of colorectal peritoneal metastases.

METHODS

All patients who underwent a PET/CT scan before a CRS-HIPEC procedure between January 1, 2010 and December 31, 2013 were retrospectively included (n = 35). Two nuclear medicine physicians (observer 1 and observer 2) separately reviewed the scans on intraperitoneal abnormalities. A simplified PCI was used to compare the extent of rPCI versus sPCI.

RESULTS

Included patients had a median age of 60.6 years. Histology of primary tumors were 51.5% adenocarcinomas, 37.1% mucinous adenocarcinoma, and 11.4% SRCC. Median sPCI was 9.5 (5.0-11.8) and median rPCI was 5.0 (3.0-7.0) for observer 1 and 4.0 (3.0-6.0) for observer 2 (p = 0.02 and p = 0.01, respectively). When compared to the surgical data, PET/CT showed a poor correlation for assessing the extent of PC for both adenocarcinoma (observer 1 rho - 0.17, p = 0.51 and observer 2 rho 0.13, p = 0.61) as well as mucinous carcinoma or SRCC (observer 1 rho 0.44, p = 0.08 and observer 2 rho 0.38, p = 0.14).

CONCLUSION

PET/CT underestimates the extent of PC during surgery in both mucinous and non-mucinous CRC and is not recommended for intraperitoneal tumor scoring.

The volume-time index (VTI) is prognostic in patients with colorectal cancer peritoneal metastases undergoing cytoreductive surgery and intraperitoneal chemotherapy

BACKGROUND

Peritoneal cancer index (PCI) is an important prognostic factor in colorectal cancer peritoneal metastases (CRPM), however it fails to consider the time period over which disease burden develops. The volume-time index (VTI) is the ratio between PCI and time from primary tumour resection.

METHODS

A retrospective cohort study of 182 patients managed from 1996 to 2017 was performed.

RESULTS

As stratified by high vs low VTI groups, median overall survival (OS) was 23 months (95% 17-46) vs 44 months (95% 35-72) with a difference in 5-year OS of 20.3% (95%CI 10.2-40.4) vs 40.1% (95%CI 29.7-54.1), p = 0.002. No difference in 5-year recurrence free survival (RFS) exists. On multivariable analysis, an elevated VTI was independently associated with poorer OS (adjusted HR 3.20, 95%CI 1.64-6.23, p < 0.001) and RFS (adjusted HR 1.90, 95%CI 1.10-3.29, p = 0.02).

CONCLUSION

VTI is an independent prognostic factor for OS and RFs in patients with CRPM undergoing CRS/IPC, behaving as a surrogate of tumour aggressiveness.

Huge renal epithelioid angiomyolipoma - A case report of a giant, benign renal mass

INTRODUCTION

Renal angiomyolipoma (also called renal hamartoma) is a benign Tumor, composed of adipose tissue, smooth muscle tissue, and blood vessels. Tumors more than 10 cm (referred to as "giant" AMLs) are infrequent and a very small number of reported cases were measured more than 20 cm. Epithelioid angiomyolipoma (EAML), is a rare variant of angiomyolipoma with malignant potential. There are less than 10 cases of huge EAML reported in English literature, that were all associated with recurrence and complications.

CASE PRESENTATION

Here we report a rare case of renal EAML in a 48-year-old male patient that was not associated with tuberous sclerosis. He was admitted to our hospital with a complaint of severe abdominal pain. Computer Tomography Scan (CT-scan), revealed two masses attached to the left kidney with a size of 32 × 22 × 8 cm and 20 × 10 × 3 cm. The patient underwent a radical left nephrectomy. Postoperative histopathological examination confirmed the diagnosis of an EAML. The two-year follow-up CT-scan showed no recurrence.

CONCLUSION

Malignant EAML, although rare, does exist. Thus, besides evaluations required for ruling out the diagnosis of renal sarcomas, surgeons must follow patients after total nephrectomy for possible recurrence. Benign cases can be completely cured by surgery and do not show recurrence at the end of the follow-up period.

Overcoming Drug Resistance by Taking Advantage of Physical Principles: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC)

Theoretical considerations as well as comprehensive preclinical and clinical data suggest that optimizing physical parameters of intraperitoneal drug delivery might help to circumvent initial or acquired resistance of peritoneal metastasis (PM) to chemotherapy. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel minimally invasive drug delivery system systematically addressing the current limitations of intraperitoneal chemotherapy. The rationale behind PIPAC is: (1) optimizing homogeneity of drug distribution by applying an aerosol rather than a liquid solution; (2) applying increased intraperitoneal hydrostatic pressure to counteract elevated intratumoral interstitial fluid pressure; (3) limiting blood outflow during drug application; (4) steering environmental parameters (temperature, pH, electrostatic charge etc.) in the peritoneal cavity for best tissue target effect. In addition, PIPAC allows repeated application and objective assessment of tumor response by comparing biopsies between chemotherapy cycles. Although incompletely understood, the reasons that allow PIPAC to overcome established chemoresistance are probably linked to local dose intensification. All pharmacological data published so far show a superior therapeutic ratio (tissue concentration/dose applied) of PIPAC vs. systemic administration, of PIPAC vs. intraperitoneal liquid chemotherapy, of PIPAC vs. Hyperthermic Intraperitoneal Chemotherapy (HIPEC) or PIPAC vs. laparoscopic HIPEC. In the initial introduction phase, PIPAC has been used in patients who were quite ill and had already failed multiple treatment regimes, but it may not be limited to that group of patients in the future. Rapid diffusion of PIPAC in clinical practice worldwide supports its potential to become a game changer in the treatment of chemoresistant isolated PM of various origins.

Ruptured desmoid tumor imitating acute appendicitis - a rare reason for an emergency surgery

BACKGROUND

Desmoid tumors, also known as aggressive fibromatosis, are extremely rare, accounting for less than 3% of soft-tissue sarcomas and less than 0,03% of all neoplasms. The diagnosis is usually delayed because of the lack of specific symptoms, and can sometimes lead to serious and, even fatal complications.

CASE PRESENTATION

We report the case of a 27-year-old male patient presenting with the clinical picture of acute appendicitis. During the operation, we found a tumor in the jejunum with a necrotic zone and perforation on its surface, causing hemorrhagic effusion into the abdominal cavity and subsequent peritonitis. The tumor was removed with negative margins via resection of the small bowel. The final histological result showed aggressive fibromatosis.

CONCLUSIONS

Aggressive fibromatosis remains a serious problem with the possibility of locally aggressive behavior with high rates of recurrence. Sometimes, its clinical and macroscopic recognition can be immensely tricky. As shown by our patient, on rare occasions, desmoid tumors can lead to acute surgical abdomen requiring an emergency operation.

Efficacy of hyperthermic intraperitoneal chemotherapy in patients with epithelial ovarian cancer: a meta-analysis

Objective: The role of hyperthermic intraperitoneal chemotherapy (HIPEC) in epithelial ovarian cancer (EOC) is still controversial. Present analysis aims to evaluate the survival benefit of HIPEC in treatment of EOC patients. Methods: Articles related to 'HIPEC' and 'ovarian cancer' were comprehensively searched in four databases (PubMed, EMBASE, MEDLINE and Cochrane Library) up to 4 February 2018. Eligible studies were identified depending on the selection criteria. The survival outcome and adverse events were collected. The relationship between HIPEC and survival of EOC was assessed using random-effects models. Results: A total of 1464 patients from 17 trials were subjected to analysis. The pooled results showed that HIPEC significantly improved overall survival (OS, HR = 0.50, 95% CI 0.36-0.69; p = 0.000) and progression-free survival (PFS, HR = 0.57, 95% CI 0.47-0.69; p = 0.000) among EOC patients when compared with no HIPEC controls. Similar results were observed in each year rate of survival. Subgroup analysis didn't lead to the opposite results, except no significant increased 1-year of OS in primary EOC and 1- and 2-year of PFS in recurrent EOC treated with HIPEC were observed. No significant difference existed in the adverse events and mortality between HIPEC and no HIPEC. Conclusions: HIPEC is associated with improved OS and PFS in both primary and recurrent EOC. However, no significant increased 1- and 2-year of PFS were reached in recurrent EOC treated with HIPEC. Further prospective randomized controlled trials are warranted.

Pre-operative evaluation of epithelial ovarian cancer patients: Role of whole body diffusion weighted imaging MR and CT scans in the selection of patients suitable for primary debulking surgery. A single-centre study

PURPOSE

to evaluate the accuracy of Whole Body MRI including Diffusion-Weighted Imaging sequences (WB DWI MR) in the assessment of sites of disease in epithelial ovarian cancer (EOC), in comparison to CT; to evaluate whether a clinical-radiological score may predict suboptimal cytoreductive surgery.

METHODS

patients with suspected EOC who underwent pre-operative WB DWI MR were included; CT scans were recorded. Data recorded included: age, staging, dates of examinations and surgery; tumour markers; sites of disease at imaging scans and at surgery. For calculation of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of WB DWI MR and CT, surgical evaluation represented the gold standard. The accuracy of WB DWI MR and CT was compared. The association between clinical and radiological criteria with sub-optimal cytoreduction was tested to identify a final model to predict sub-optimal cytoreduction.

RESULTS

92 patients were included; 77/92 (83.7 %) were optimally cytoreduced. Sixty-six CT and 92 MR examinations were evaluated. WB DWI MR showed overall higher accuracy than CT in assessing all sites, but it performed significantly better than CT specifically for involvement of mesentery, lumbo-aortic lymph nodes, pelvis, large bowel, sigmoid-rectum. The predicting score for suboptimal cytoreduction included: mesenteric carcinomatosis; mesenteric retraction; large bowel carcinomatosis.

CONCLUSIONS

In pre-operative evaluation of EOC patients, WB DW MRI is accurate for assessment of multiple sites and it is significantly more accurate than CT for specific unresectable sites. In our series, significant sites of disease for suboptimal cytoreduction were mesenteric carcinomatosis, mesenteric retraction and large bowel carcinomatosis.

Systemic complications of the bidirectional intraoperative chemotherapy with intravenous ifosfamide and hyperthermic intraperitoneal chemotherapy (HIPEC) using cisplatin plus doxorubicin

Background

Ifosfamide has recently used as the intravenous component of bidirectional intraoperative chemotherapy (BDIC) with hyperthermic intraperitoneal chemotherapy (HIPEC) using cisplatin plus doxorubicin. Little is known about the systemic toxicities of this BDIC regimen. Therefore, this study aimed to assess the toxicities of this treatment.

Methods

A prospective, cohort study, of patients who underwent the BDIC using intravenous ifosfamide 1,300 mg/m² and a HIPEC regimen of cisplatin 50 mg/m² plus doxorubicin 15 mg/m², at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. Incidences and severity of leukopenia, neutropenia, thrombocytopenia, and erythrocytopenia were assessed over 45 days after BDIC. Nephrotoxicity was assessed according to the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) classification system. Haemorrhagic cystitis was assessed by cystoscopy.

Results

A total of 18 patients were enrolled in the study. Grade 1 leukopenia developed in 11.1% of the patients, with 5.5% developed neutropenia. Thrombocytopenia developed in 61.1% of patients; it was grade 1 or 2 in most patients, but grade 3 in 1 (5.5%) patient. All patients developed erythrocytopenia after BDIC. Leukopenia, neutropenia, and thrombocytopenia resolved without treatment in all patients. Nephrotoxicity developed in 33.3% of the patients. One patient progressed to the End-stage kidney disease classification. No patient developed haemorrhagic cystitis.

Conclusions

Intravenous ifosfamide combined with HIPEC using cisplatin plus doxorubicin yielded low rates of mild leukopenia. Mild thrombocytopenia was frequent, but severe suppression of platelets was uncommon. Nephrotoxicity developed in one-third of the patients, and haemorrhagic cystitis was absent.

The accuracy of multi-detector computed tomography and laparoscopy in the prediction of peritoneal carcinomatosis index score in primary ovarian cancer

RATIONALE AND OBJECTIVES

The purpose of this study was to compare the accuracy of MDCT and laparoscopy in the prediction of peritoneal carcinomatosis index score. Reproducibility of MDCT interpretation was also assessed.

METHODS

This prospective study included 85 ovarian cancer patients underwent MDCT and diagnostic laparoscopy before cytoreductive surgery. We calculated the accuracy of diagnostic modalities in the calculation of the peritoneal cancer index score (PCI). Radiologist interobserver agreement was calculated using kappa statistics.

RESULTS

Nine hundred-thirty (84.2%) of the 1105 regions had peritoneal deposits at exploratory laparotomy. Computed tomography (CT) and laparoscopy sensitivity were 94.9%, 98.3%, specificity 86.7%, 80.4%, PPV 97.9 %, 96.8%, NPV 72.2%, 88.8 %, and accuracy 93.8 %, 95.7%, respectively. However, computed tomography (CT) diagnostic performance is less accurate than laparoscopy in pelvic and small intestinal regions; no statistically significant differences were evident regarding total PCI score compared to surgery (p> 0.05). CT and laparoscopy correctly depicted peritoneal carcinomatosis in 88.2%, 90.6% of patients, respectively. Optimal cytoreduction was achieved in 68 (80%) patients.

CONCLUSION

Both CT and laparoscopy seems to be effective tools for assessment of peritoneal carcinomatosis using the PCI score. Dedicated MDCT protocol with routine use of a standardized PCI form may provide better comprehensive multi-regional analysis that may help surgeons referring patients to the best treatment option. Laparoscopy is a valuable tool in cases with a high risk of suboptimal cytoreduction related to disease extent.

Status of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis from colorectal cancer

Peritoneal carcinomatosis (PC) was previously considered an incurable disease with a poor survival outcome. As our understanding of its biology evolved, the paradigm of the management of PC from colorectal cancer (CRC) has changed, including the combination of macroscopic disease control, cytoreductive surgery (CRS), maximal regional chemotherapy to treat residual microscopic disease, and hyperthermic intraperitoneal chemotherapy (HIPEC). As with many surgical innovations, CRS with HIPEC has evolved faster than data to support it, leaving many skeptics and critics. This review highlights the recent evidence of current practice and outcome of CRS with HIPEC. Furthermore, it also summarizes the ongoing clinical trials and potential future progress of this treatment modality.

Value of imaging findings in predicting post-operative recurrence of desmoid-type fibromatosis

Desmoid-type fibromatosis is a rare type of soft-tissue tumor originating from connective tissue of the fascia or aponeurosis, which exhibits aggressive growth, high likelihood of relapse and less frequent distant metastasis. The present study aimed to predict the recurrence rate and time by retrospectively analyzing the clinical data (sex, age and recurrence time), imaging findings [tumor location, maximum diameter, border, computed tomography (CT) enhancement ratio, magnetic resonance enhancement ratio and T2 signal ratio] and pathological features (Ki-67 and microscopic margin) in a total of 102 cases of pathologically confirmed desmoid-type fibromatosis. The risk ratio of each factor was calculated using the Cox proportional hazards regression model and the cumulative recurrence-free survival rate was determined using the Kaplan-Meier method and the log-rank test. The cohort comprised of 73 females and 29 males, with mean age of 32.86±12.64 years (range, 6–78 years). The 1-year and 2-year recurrence rate was 31 and 54%, respectively. The median age at recurrence was 29 years. Univariate analysis indicated that sex, maximum tumor diameter, CT enhancement ratio and Ki-67 had a significant effect on the recurrence time. Furthermore, multivariate analysis revealed that sex, maximum tumor diameter, Ki-67 and T2 signal ratio were independently associated with the time of recurrence, and the risk ratios were 0.424, 1.100, 1.084 and 1.268, respectively. Therefore, in male patients with a larger maximum tumor diameter, positivity for Ki-67 and a higher T2 signal ratio, desmoid-type fibromatosis was more likely to recur after surgery.

[Prevention of carcinomatosis in colon cancer]

Colorectal cancer (CRC) is one of the leading forms of cancer. In 2017, over 72,000 of Russian citizens have been diagnosed with CRC. Cancer stage IV was diagnosed in 18 149 of them. Peritoneal carcinomatosis (PC) is one of the forms of metastatic dissemination throughout the peritoneum. There no any unified and standardized approaches to the treatment or prevention of PC associated with CRC. Therefore, it is advisable to identify PC predictors in patients with colon cancer and prevention measures.

A Case of Synchronous Primary Corpus and Ovarian Cancer with Pseudo-Meigs Syndrome: Utilization of a Diagnostic Laparoscopy for the Accurate Diagnosis

We report a case of synchronous primary corpus and ovarian cancer (SPC) with massive ascites due to Pseudo-Meigs syndrome (PMS). A 48-year-old woman presented with complaints of abnormal genital bleeding and abdominal discomfort. Massive ascites and tumors in the endometrium and right ovary were detected. Although imaging tests showed no evidence of dissemination, and ascites cytology was negative, we performed a diagnostic laparoscopy to exclude the possibility of microdissemination because pathological findings of the corpus tumor were suggested to be so-called Type-2 endometrial cancer. Laparoscopy clearly confirmed no dissemination in the peritoneum. We ultimately diagnosed this patient with SPC with massive nonmalignant ascites due to PMS and performed an appropriate treatment. This report is the first case of SPC that developed PMS.

A case of eccrine porocarcinoma characterized by a progressive increase in the level of Ki-67 index: case report and review of literature

Background

Eccrine porocarcinoma is an extremely rare skin adnexal malignant neoplasia with highly invasive and metastatic potential. We report an additional case of eccrine porocarcinoma with intracranial metastases. This case is characterized by a complete record of the progress of eccrine porocarcinoma, its immunohistochemistry after three operations showed a progressive increase in the level of Ki-67 index.

Case presentation

We herein report a case of a 37-year-old-male with eccrine carcinoma occurring on the left posterior occipital scalp which invaded the skull and dura, presenting with progressive headache. This patient has performed three surgeries in total. During the last hospitalization, he underwent an extended surgical resection, lymphadenectomy, myocutaneous flap transplantation and vascular anastomosis in our institution. After surgery, he was treating with radiotherapy at 200 Gray in 12 fractions. But one year after the operation, he developed chest tightness, imaging examination and biopsy puncture revealed pulmonary metastasis.

Conclusion

Intracranial metastasis of eccrine porocarcinoma is a late event with poor prognosis. This case emphases on that progressively increased level of Ki-67 index may predict more chance to occur the intracranial metastasis of scalp eccrine porocarcinoma, long-term follow-up and appropriately dense follow-up interval is necessary.

Reproductive outcomes following a stem cell transplant for a haematological malignancy in female cancer survivors: a systematic review and meta-analysis

PURPOSE

The use of high-dose chemotherapy and radiotherapy combined with haematopoietic stem cell transplantation (HSCT) may negatively affect a woman's reproductive potential. Reproductive outcomes such as infertility are a major concern for women who undergo treatment for a haematological cancer diagnosis.

OBJECTIVE

This systematic review and meta-analysis explores reproductive outcomes following a haematological cancer requiring HSCT.

METHODS

Electronic databases were searched to identify studies that reported on reproductive outcomes after treatment for a haematological cancer diagnosis. Studies were included that reported on pregnancy and reproductive outcomes following HSCT for a haematological malignancy.

RESULTS

The meta-analysis included 14 studies, collectively involving 744 female patients. The subgroup analysis showed an overall pooled estimated pregnancy rate, for autologous or allogeneic HSCT recipients, of 22.7% (n = 438). There were 25% (n = 240) of women who became pregnant after autologous HSCT compared with 22% (n = 198) who subsequently became pregnant following allogeneic HSCT.

CONCLUSIONS

This meta-analysis reflects low pregnancy rates for cancer survivors desiring a family. However, live births are improving over time with new technology and novel therapies. Hence, female cancer patients should be offered timely discussions, counselling and education around fertility preservation options prior to starting treatment with gonadotoxic therapy.

Versatility of the O-Z flap for back reconstruction after giant basal cell carcinoma resection: A case report and review of the literature

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Giant basal cell carcinomas are rare and potentially aggressive tumors.

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Aggressive surgical resection with suggested wide free margins is suggested.

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Soft tissue reconstruction for back lesions may be challenging.

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The O-Z flap represents a safe and reliable alternative for back reconstruction.

Introduction

Giant basal cell carcinomas are rare and potentially aggressive skin malignancies that are infrequently reported in the Literature, and they usually require aggressive surgical resection and immediate soft tissue reconstruction with skin grafts or flaps. The large size of GBCCs has relevant implications not only for the metastatic potential, but even for the reconstructive challenging due to the possible limited availability of tissues for flap coverage.

Presentation of case

We report the peculiar case of an old patient who underwent to GBCC resection of the back measuring 16 × 13 cm, and immediate reconstruction with a large O to Z flap harvested from the back; one-year follow-up examination revealed a satisfactory result and no recurrence of the disease was observed.

Discussion

The review of the Literature showed that reconstructive options are mainly determined by the site and extent of the defect, exposed structures and patient characteristics and comorbidities, and previous series reported the use of skin grafts only, pedicled myocutaneous or perforator flaps, exclusively free flaps and a combination of techniques. Therefore, in this scenario local flaps such as O-Z flaps are less invasive procedures, that usually have lower rate of postoperative complications and shorter hospitalization compared to more complex procedures.

Conclusions

Despite the use of O-Z flap is quite unusual for back reconstruction, we believe that this flap represents a valid and safe alternative in selected cases, particularly in the elderly and medically compromised patients with multiple comorbidities.

A real-time ex vivo model (eIBUB) for optimizing intraperitoneal drug delivery as an alternative to living animal models

BACKGROUND

Optimization of intraperitoneal drug delivery systems requires functional models. We proposed the Inverted Bovine Urinary Bladder Model (IBUB), but IBUB does not allow repeated measurements over time and there is a significant biological variability between organs.

METHODS

A further development of IBUB is presented, based on the physical principle of communicating vessels. Fresh bovine bladders were inverted so that the peritoneum lines up the inner surface. The IBUB and a second vessel were then interconnected under the same CO2 pressure and placed on two scales. The therapeutic solution (Doxorubicin 2.7 mg and Cisplatin 13.5 mg) was delivered via an aerosolizer. All experiments were in triplicate and blinded to the origin of samples, measurements in a GLP-certified laboratory.

RESULTS

The enhanced IBUB (eIBUB) model allows measurements of tissue drug concentration, depth of tissue penetration and spatial distribution. The homogeneous morphology of the peritoneum enables standardized, multiple tissue sampling. eIBUB minimizes biological variability between different bladders and eliminates the bias caused by the liquid collecting at the bottom of the model. Concentration of doxorubicin in the eIBUB (mean ± STDV: 18.5 ± 22.6 ng/mg) were comparable to clinical peritoneal biopsies (19.2 ± 38.6 ng/mg), as was depth of drug penetration (eIBUB: mean (min-max) 433 (381-486) µm, clinical ~ 500 µm).

CONCLUSIONS

The eIBUB model is a simple and powerful ex vivo model for optimizing intraperitoneal drug delivery and represents an attractive alternative to animal models. Results obtained are similar to those obtained in the human patient.

Badary D. Accuracy of radiologic- laparoscopic peritoneal carcinomatosis categorization in the prediction of surgical outcome

OBJECTIVE

To evaluate the agreement between multiple detector CT (MDCT) and laparoscopy in the preoperative categorization of peritoneal carcinomatosis, and to determine the impact of this categorization on the prediction of cytoreduction status.

METHODS

This prospective study included 80 consecutive females with primary ovarian cancer eligible for cytoreductive surgery (CRS). MDCT and diagnostic laparoscopy were performed prior to surgery for assessment of peritoneal carcinomatosis extent. Based on PCI (peritoneal cancer index) score, carcinomatosis was categorized into three groups. Categorization agreement between CT and laparoscopy was assessed and compared with the intraoperative-histopathologically proven PCI. Impact of PCI categorization on cytoreduction status was also evaluated.

RESULTS

The overall agreement between CT and laparoscopy in preoperative peritoneal carcinomatosis categorization was good (K =0.71-0.79) in low category group and excellent in both moderate and large group (interclass correlation coeeficient = 0.89-0.91). (p<0.01) Optimal cytoreduction was achieved in 62/80 (77.5%) patients, PCI < 20 was detected in 48/62 (77.4%), pre-operative PCI < 20 correctly predicted optimal cytoreductive surgery (OCS) in 40/48 (83.3%) cases. Suboptimal cytoreduction was performed in 18/80 (22.5%) patients. PCI > 20 was detected in (10/18) 55.6%, preoperative CT and laparoscopy PCI > 20 correctly predicted SCS in 8/10 (80%) cases. The area under receiver operating characteristic curve showed that PCI cut-off <20 was the best predictor of OCS with an accuracy 85%, sensitivity 97%, specificity 40%, negative predictive value 76%, and positive predictive value 93%.

CONCLUSION

Both laparoscopy and CT are equally effective in pre-operative peritoneal carcinomatosis categorization. PCI < 20 is accurate in the prediction of optimal cytoreduction. More than half of patients with suboptimal cytoreduction had PCI > 20 and interval debulking surgery can be recommended.

ADVANCES IN KNOWLEDGE

Both laparoscopy and CT are equally effective in pre-operative peritoneal carcinomatosis categorization. PCI < 20 is accurate in the prediction of optimal cytoreduction. More than half of patients with suboptimal cytoreduction had PCI > 20 and interval debulking surgery can be recommended.

The role of single-incision laparoscopic peritoneal exploration in the management of patients with peritoneal metastases

BACKGROUND

The outcome of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) depends on the extent of peritoneal metastases (PM) and the completeness of cytoreduction (CCR). The role of preoperative assessment of PM is to identify potential candidates for CRS/HIPEC and to prevent unwarranted laparotomy for those who are not. Laparoscopy has been utilized for that purpose but with concerns related to technical difficulties and risk of trocar site metastases. Single-incision laparoscopic peritoneal exploration (SILPE) has not yet been evaluated in this setting.

METHODS

This single-center retrospective study examined patients from January 2011 to December 2015 who underwent SILPE for diagnosis and staging of PM. Preoperative, intraoperative, and postoperative data were collected. For the patients who underwent subsequent laparotomy, a comparison between SILPE and laparotomy findings was made.

RESULTS

A total of 183 SILPE were performed. Primary sites were mostly colorectal in 72 cases (39.3%) and gastric in 47 (25.7%). Overall, 157 patients (85.8%) had at least one prior abdominal surgery and 48 (26.2%) had 3 or more. SILPE was successfully achieved in 90.2% of the cases. Two (1.2%) intraoperative complications and five (3%) postoperative complications were observed. Eighty-one patients had laparotomy, with a median of 27 days between SILPE and laparotomy (4-162 days). The peritoneal carcinomatosis index PCI was 9.7 ± 7.5 at SILPE, and 13.5 ± 9.6 at laparotomy. The positive predictive value of SILPE to predict CCR was 79.5%. SILPE sensitivity was 75% and specificity 97%. The lowest sensitivity was in regions 9-12 ranging from 44 to 53%.

CONCLUSION

SILPE can be safely incorporated in the management of patients with PM. It is a safe and feasible staging tool, allowing for preventing unwarranted laparotomy for patients not deemed candidate for CRS/HIPEC. Even though it may underestimate PCI, SILPE accurately predicts the possibility of CCR.

Postoperative intraperitoneal hyperthermic perfusion improve survival for advanced gastric cancer

To evaluate the value of intraperitoneal hyperthermic perfusion (IPHP) in the treatment of gastric cancer.Gastric cancer (GC) is a malignancy with poor prognosis, recent years have demonstrated advances in the use of IPHP for the treatment of advanced gastric cancer (AGC), but the outcome is controversial.Between January 2015 and January 2017, 134 patients with GC were treated with IPHP in our surgery department, 130 of them were advanced GC patients, and other 1439 cases were treated without IPHP for comparison. In this retrospective cohort study, demographic, perioperative data, and follow-up data were analyzed by univariant analysis, Kaplan-Meier and Cox regression survival analysis.We found the 1-year survival in IPHP group was significantly longer than it in non-IPHP group (85.5% vs 73.8%, P = .027). and IPHP decreased mortality 1.8 times in 2-year course (OR = 0.556, P = .004). The incidence rate of total complications in IPHP group was similar to that in the Non-IPHP group (6.67% vs 7.46%, respectively; P = .718). We classified all patients into four groups, operation alone, operation + chemotherapy, operation + IPHP, and operation + IPHP + chemotherapy. The 1-year survival in the groups was 70.2%, 77.5%, 83.1%, and 93.5%, respectively (P = .001), compared with the group of operation alone, the 2-year mortality risk was decreased 1.76 times (OR = 0.569, P = .030) and 2.59 times (OR = 0.385, P = .022) in operation + IPHP group and operation + IPHP + chemotherapy group.Our results suggest that IPHP could contribute to improve survival of patients with gastric cancer. And the modality of operation + IPHP + chemotherapy is the optimal treatment modality for gastric cancer.

[Hyperthermic intrathoracic chemotherapy in thoracic surgery]

In regional chemotherapy of the pleural space a differentiation is made between intrapleural hyperthermic perfusion (IHP) and hyperthermic intrathoracic chemotherapy (HITOC). The HITOC in particular is carried out as an additive procedure after surgical cytoreduction of the pleural tumor manifestation. The main indications are for malignant pleural mesothelioma and thymoma with pleural spread (stage IVa), whereas treatment of secondary pleural carcinomatosis is indicated only in selected patients suitable for resection followed by HITOC. Cisplatin is the standard chemotherapeutic agent and a concentration of 150-175 mg/m² body surface area is recommended. Postoperative, HITOC-related complications (e.g. renal insufficiency) can be minimized by an adapted perioperative management. Safety measures should be accomplished adhered to for the protection of personnel. The aim of HITOC is to achieve a better local tumor control with a corresponding longer recurrence-free and overall survival.

Improved Peritoneal Cavity and Abdominal Organ Imaging Using a Biphasic Contrast Agent Protocol and Spectral Photon Counting Computed Tomography K-Edge Imaging

OBJECTIVES

To validate in vitro the capability of a high-spatial-resolution prototype spectral photon-counting computed tomography (SPCCT) scanner to differentiate between 2 contrast agents and to assess in vivo the image quality and the feasibility to image the peritoneal cavity in rats using the 2 contrast agents simultaneously within the vascular and peritoneal compartments.

MATERIALS AND METHODS

The authors performed SPCCT imaging (100 mAs, 120 kVp) with energy bin thresholds set to 30, 51, 64, 72, and 85 keV in vitro on a custom-made polyoxymethylene cylindrical phantom consisting of tubes with dilutions of both contrast agents and in vivo on 2 groups of adult rats using 2 injection protocols. Approval from the institutional animal ethics committee was obtained. One group received macrocylic gadolinium chelate intraperitoneal (IP) and iodine intravenous (IV) injections (protocol A, n = 3), whereas the second group received iodine IP and gadolinium IV (protocol B, n = 3). Helical scans were performed 35 minutes after IP injection and 20 seconds after IV injection. The SPCCT and contrast material images, that is, iodine and gadolinium maps, were reconstructed with a field of view of 160 mm, an isotropic voxel size of 250 μm, and a matrix size of 640 × 640 pixels using a soft reconstruction kernel. The SPCCT images were reconstructed with 2 different spatial resolutions to compare the image quality (sharpness, diagnostic quality, and organ visualization) of SPCCT (250 μm) with single-energy computed tomography (CT) (600 μm). Two radiologists evaluated the peritoneal opacification index in 13 regions (score = 0-3 per region) on each type of image. Concentrations of contrast agents were measured in the organs of interest.

RESULTS

In vitro, the concentration measurements correlated well with the expected concentrations. The linear regressions both had R values of 0.99, slopes of 0.84 and 0.87, and offsets at -0.52 and -0.38 mg/mL for iodine and gadolinium, respectively. In vivo, the SPCCT images were of better diagnostic quality, with increased sharpness compared with the CT-like images (P < 0.0001). Intraperitoneal diffusion was excellent, with similar peritoneal opacification index on SPCCT images and overlay of contrast material maps (P = 1) without a significant difference between protocol A (37.0 ± 1.7) and protocol B (35.3 ± 1.5) (P = 0.34). Only the contrast material maps demonstrated clear visual separation of the contrast agents, allowing specific quantification of the physiological enhancement in the liver, spleen, and kidney and the urinary clearance in the renal pelvis and bladder. Renal excretion of the contrast agents injected IP was observed and was consistent with blood diffusion.

CONCLUSIONS

Spectral photon-counting CT can be used to perform a complete peritoneal dual-contrast protocol, enabling a good assessment of the peritoneal cavity and abdominal organs in rats.

Deep transfer learning methods for colon cancer classification in confocal laser microscopy images

PURPOSE

The gold standard for colorectal cancer metastases detection in the peritoneum is histological evaluation of a removed tissue sample. For feedback during interventions, real-time in vivo imaging with confocal laser microscopy has been proposed for differentiation of benign and malignant tissue by manual expert evaluation. Automatic image classification could improve the surgical workflow further by providing immediate feedback.

METHODS

We analyze the feasibility of classifying tissue from confocal laser microscopy in the colon and peritoneum. For this purpose, we adopt both classical and state-of-the-art convolutional neural networks to directly learn from the images. As the available dataset is small, we investigate several transfer learning strategies including partial freezing variants and full fine-tuning. We address the distinction of different tissue types, as well as benign and malignant tissue.

RESULTS

We present a thorough analysis of transfer learning strategies for colorectal cancer with confocal laser microscopy. In the peritoneum, metastases are classified with an AUC of 97.1, and in the colon the primarius is classified with an AUC of 73.1. In general, transfer learning substantially improves performance over training from scratch. We find that the optimal transfer learning strategy differs for models and classification tasks.

CONCLUSIONS

We demonstrate that convolutional neural networks and transfer learning can be used to identify cancer tissue with confocal laser microscopy. We show that there is no generally optimal transfer learning strategy and model as well as task-specific engineering is required. Given the high performance for the peritoneum, even with a small dataset, application for intraoperative decision support could be feasible.

[Lymphadenectomy in oncological visceral surgery-Part 2 : Cancer of the upper and lower intestinal tract]

In cancers of the upper and lower intestinal tract the risk of lymphatic metastases depends on the histological results, tumor grading, and depth of tumor infiltration (T-stage). Pretherapeutic staging is of particular importance for determining the surgical strategy (local excision vs. en bloc resection with regional lymphadenectomy) as well as for evaluating the necessity of neoadjuvant therapy. While the first part on "Lymphadenectomy in oncological visceral surgery" focused on hepatobiliary and pancreatic cancer, this second part contains an overview of anatomical conditions of lymphatic drainage of the esophagus, stomach, duodenum, small intestine, colon, rectum and anus. Based on this, the principles and techniques of lymphadenectomy for cancer in these organs and the requirements on systematic regional lymphadenectomy in the actual TNM classification (8th edition) are discussed.

An Examination of Lymph Node Sampling as a Predictor of Survival in Resected Node-Negative Small Bowel Adenocarcinoma: a SEER Database Analysis

BACKGROUND

Small bowel adenocarcinoma (SBA) is a rare disease. Current recommendations are largely extrapolated from the colorectal literature. For node-negative (N -ve) cases, optimally stratifying cases into high or low risk, may help define optimal management. The objective of this analysis was to determine the importance of lymph node sampling for prognostication and to define what number of lymph nodes sampled is adequate.

METHODS

Cases of non-metastatic SBA with complete staging, pathologic, and demographic information were selected from the SEER database and SAS 9.4 software was used. Variables included age, gender, race, grade, TNM staging, and number of lymph nodes were examined. Comparisons were made between N -ve and N +ve cases. Survival analysis using N -ve cases was performed to characterize the impact of nodal sampling on survival and to determine which nodal cut-offs best predict survival.

RESULTS

A total of 523 cases from 2004 to 2014 were included in this analysis. Statistically significant differences identified included the median number of nodes sampled between the N -ve and N +ve groups, and the distribution of T stage and grade. Survival analysis in the N -ve cases demonstrated that the strongest predictor of survival was sampling of 16 or more lymph nodes.

CONCLUSION

In this analysis, lymph node sampling was shown to be the most important pathologic predictor of survival in cases of N -ve SBA. Replicating these findings in a secondary dataset and determining whether a clinical benefit of adjuvant chemotherapy exists for SBA patients with inadequate sampling are both important next steps.

Can machine learning predict resecability of a peritoneal carcinomatosis?

BACKGROUND

Approximately 20% of initially eligible patients in a HIPEC procedure eventually underwent a simple surgical exploration. These procedures are called 'open & close' (O & C) representing up to 48% of surgery. The objective of this study was to predict the resecability of peritoneal carcinomatosis using a machine-learning model for decision-making support, for eligible patients of HIPEC.

METHODS

The study was conducted as an intention to treat based on three databases including a prospective, between January 2000 and December 2015. A propensity score allowed us to obtain two groups of comparable and matched patients. Subsequently, several algorithm models of classification were studied (simple classification, conditional tree, support vector machine, random forest) to determine the model having the best performance and accuracy.

RESULTS

Two groups of 155 patients were obtained: one group without resection and one group with resection. Nine criteria of non-resecability reflecting the organ involvement have been retained. They were coded according to their importance. Five classification algorithms were tested. The training data included 218 patients and 92 test data. The random forest model exhibited the best performance with an accuracy of close to 98%. Only two errors of predictions were observed.

DISCUSSION

The largest number of patients will allow us to improve the precision prediction. Gathering more data such as biologic, radiologic, and even laparoscopic features, should improve the knowledge of the disease and decrease the number of 'O & C' procedures.