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Ciftci Y, Radomski SN, Johnson BA, Johnston FM, Greer JB. Triphasic Learning Curve of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2024:10.1245/s10434-024-15945-y. [PMID: 39230850 DOI: 10.1245/s10434-024-15945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/17/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but costly procedure for select patients with peritoneal malignancies. The impact of progression along a learning curve on the cost of these procedures is unknown. PATIENTS AND METHODS We performed a retrospective cohort study of patients undergoing CRS-HIPEC from 2016 to 2022 at a single quaternary center. Our study cohort was temporally divided into four equally sized volume quartiles (A, B, C, and D). We utilized cumulative sum plots and split-group analysis to characterize the institutional learning curve based on cost, operative time, length of stay, and morbidity. Multivariable linear regression was performed to estimate costs after adjusting for covariates. Bivariate analysis was performed using a Kruskal-Wallis test to compare continuous variables and a χ2 test to compare categorical variables. RESULTS Of 201 patients, the median age [interquartile range (IQR)] was 57 (47-65) years, 113 (56%) patients were female, 143 (71%) were white, and 107 (53%) had private insurance. Median operating room charge [US$42,639 (US$32,477-54,872), p < 0.001] varied between volume quartiles, peaking in quartile C. Stabilization was achieved for 86 cases for operating room cost, 88 cases for routine cost, 96 cases for length of stay, 103 cases for operative time, 120 cases for intensive care unit length of stay, and 150 cases for overall and serious morbidity. The actual operating room and routine costs were similar to predicted costs at the end of the study period. CONCLUSIONS The CRS-HIPEC learning curve is triphasic, with cost stability achieved relatively early compared with other markers of surgical proficiency.
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Affiliation(s)
- Yusuf Ciftci
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Blake A Johnson
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Pastier C, De Hingh IHJT, Goéré D. New insights in the management of pseudomyxoma peritonei. J Surg Oncol 2024. [PMID: 39206531 DOI: 10.1002/jso.27842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/05/2024] [Accepted: 08/09/2024] [Indexed: 09/04/2024]
Abstract
While a rare entity, peritoneal pseudomyxoma treatment evolves. Decision-making criteria improve with imaging development and exploratory laparoscopy. Surgery remains at the core of the therapeutic strategy whatever disease progression. Complete cytoreduction plus hyperthermic intraperitoneal chemotherapy (HIPEC) is standard of care. Iterative cytoreduction or debulking is sometimes justified. Intraperitoneal chemotherapy modalities change with early postoperative HIPEC or pressurized intraperitoneal aerosol chemotherapy. Systemic or local treatment such as new chemo/immuno-therapies or BromAc should improve outcomes. Expertise and multicentric cooperation are more than ever needed.
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Affiliation(s)
- Clément Pastier
- Department of Digestive and Endocrine Surgery, Saint-Louis Hospital AP-HP, Université Paris Cité, Paris, France
| | - I H J T De Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Diane Goéré
- Department of Digestive and Endocrine Surgery, Saint-Louis Hospital AP-HP, Université Paris Cité, Paris, France
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3
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Moran B, Samuel MV, Lord A. ASO Author Reflections: The Paradox of Surgery for Pseudomyxoma Peritonei of Appendiceal Origin-Sometimes the Most Extensive Operations for Histologically Bland Disease. Ann Surg Oncol 2024:10.1245/s10434-024-16044-8. [PMID: 39164601 DOI: 10.1245/s10434-024-16044-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 07/31/2024] [Indexed: 08/22/2024]
Affiliation(s)
- B Moran
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - M V Samuel
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - A Lord
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK.
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Patel S, Bhatt A, Mehta S, Ramakrishnan AS. Two-stage cytoreductive surgery for 'extensive' pseudomyxoma peritonei: A legitimate alternative or salvage strategy? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108593. [PMID: 39121632 DOI: 10.1016/j.ejso.2024.108593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 08/06/2024] [Accepted: 08/06/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND AND AIM Two-stage cytoreductive surgery (CRS) has been proposed as an alternative to one-stage surgery in patients who have 'extensive' pseudomyxoma peritonei (PMP) and/or are unfit for very extensive surgery, to reduce morbidity. We review current evidence on two-stage CRS focusing on patient selection, interval between procedures, extent of surgery, use of HIPEC, perioperative and oncological outcomes. METHODS This is a narrative review. A literature search on PubMed and Embase was performed using keywords- 'Two-stage cytoreductive surgery', 'pseudomyxoma peritonei', 'high-volume PMP', 'huge PMP', 'cytoreductive surgery', 'HIPEC', 'staged surgery' and 'extensive pseudomyxoma peritonei'. RESULTS Five studies reported outcomes in a total of 114 patients. The indications for two-stage CRS were: in two studies, patients undergoing an incomplete cytoreduction due to undue surgical risk were reevaluated for a second surgery during routine surveillance; severe comorbidities in one; extensive disease with PCI>28 in another and in one, only HIPEC was performed as a second procedure due to intraoperative hemodynamic instability (the two-stage procedure was performed in interest of patient's safety). Major morbidity ranged from 0 to 37.5 % (first-stage) and 25%-38.9 % (second-stage). Short term follow-up demonstrated equivalent short-term oncological outcomes compared to historical data. Long term follow-up and quality-of-life data were not available. CONCLUSIONS The published studies showed different interpretations and applications of the two-stage CRS concept. The reported morbidity was similar to that after single-stage CRS for extensive PMP. Though short-term survival outcomes are acceptable, long-term follow-up is needed. Planned two-stage CRS should currently be reserved for highly selected clinical situations.
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Affiliation(s)
- Swapnil Patel
- Dept of Surgical Oncology, MPMMCC & HBCH, Tata Memorial Centre, Varanasi, India
| | - Aditi Bhatt
- Dept of Surgical Oncology, KD Hospital, Ahmedabad, India.
| | - Sanket Mehta
- Dept of Surgical Oncology, Specialty Surgical Oncology, Mumbai, India
| | - A S Ramakrishnan
- Dept. of Surgical Oncology, Cancer Institute, WIA, Chennai, India
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5
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Sugarbaker PH, Chang D. Critical appraisal of total gastrectomy plus total colectomy with hyperthermic intraperitoneal chemotherapy as a treatment for advanced pseudomyxoma peritonei. J Surg Oncol 2024. [PMID: 38935844 DOI: 10.1002/jso.27742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The absolute requirement for a long-term favorable result with cytoreductive surgery for pseudomyxoma peritonei is a complete resection of all visible disease. A combination of parietal peritonectomy procedures and visceral resections is required for this to occur. The cytoreductive surgery is supplemented by hyperthermic intraperitoneal chemotherapy. METHODS We searched our database and secured files for patients who required a total gastrectomy and a total colectomy to achieve a complete cytoreductive surgery. Survival of low-grade mucinous neoplasm (LAMN) and mucinous appendiceal adenocarcinoma (MACA) histologies were determined. Clinical and histologic variables were assessed for their impact on survival. RESULTS Thirteen of 450 patients (2.9%) with LAMN histology and 14 of 186 patients (7.5%) with MACA histology had these visceral resections. Median survival of these 27 patients was 10 years. LAMN and MACA patients showed the same survival. For LAMN histology, this requirement for extensive visceral resection markedly reduced survival (p < 0.0001). For MACA, there was no adverse impact on survival (p = 0.4359). Class 4 adverse events caused reduced survival (p = 0.0014). CONCLUSIONS A 10-year median survival accompanies total gastrectomy plus total colectomy for advanced pseudomyxoma peritonei. Systemic chemotherapy and class 4 adverse events reduced survival.
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Affiliation(s)
- Paul H Sugarbaker
- Program in Peritoneal Surface Malignancy, Washington Cancer Institute, Washington, District of Columbia, USA
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Li X, Liu G, Wu W. Progress in Biological Research and Treatment of Pseudomyxoma Peritonei. Cancers (Basel) 2024; 16:1406. [PMID: 38611084 PMCID: PMC11010892 DOI: 10.3390/cancers16071406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024] Open
Abstract
Pseudomyxoma peritonei (PMP) is a rare disease characterized by extensive peritoneal implantation and mass secretion of mucus after primary mucinous tumors of the appendix or other organ ruptures. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is currently the preferred treatment, with excellent efficacy and safety, and is associated with breakthrough progress in long-term disease control and prolonged survival. However, the high recurrence rate of PMP is the key challenge in its treatment, which limits the clinical application of multiple rounds of CRS-HIPEC and does not benefit from conventional systemic chemotherapy. Therefore, the development of alternative therapies for patients with refractory or relapsing PMP is critical. The literature related to PMP research progress and treatment was searched in the Web of Science, PubMed, and Google Scholar databases, and a literature review was conducted. The overview of the biological research, treatment status, potential therapeutic strategies, current research limitations, and future directions associated with PMP are presented, focuses on CRS-HIPEC therapy and alternative or combination therapy strategies, and emphasizes the clinical transformation prospects of potential therapeutic strategies such as mucolytic agents and targeted therapy. It provides a theoretical reference for the treatment of PMP and the main directions for future research.
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Affiliation(s)
- Xi Li
- Department of Geriatric Surgery, Xiangya Hospital, Central South University, Changsha 410008, China;
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Guodong Liu
- Department of Geriatric Surgery, Xiangya Hospital, Central South University, Changsha 410008, China;
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Wei Wu
- Department of Geriatric Surgery, Xiangya Hospital, Central South University, Changsha 410008, China;
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, China
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Chatani PD, Manzella A, Gribkova YY, Ecker BL, Beninato T, Kennedy T, Pitt HA, Alexander HR. Does Hospital Operative Volume Influence the Outcomes of Patients After Heated Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis? Ann Surg Oncol 2024; 31:1049-1057. [PMID: 37906385 DOI: 10.1245/s10434-023-14450-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND For some cancer operations, center volume is associated with improved patient outcomes. Whether this association is true for cytoreductive surgery/heated intraperitoneal chemotherapy (CRS/HIPEC) is unclear. Given the rapidly expanding use of CRS/HIPEC, the aim of this analysis was to determine whether a volume-outcome relationship exists for this strategy. METHODS The Vizient Clinical Database® was queried for CRS/HIPEC cases from January 2020 through December 2022. Low-, medium-, and high-volume designations were made by sorting hospitals by case volume and creating equal tertiles based on total number of cases. Analysis was performed via one-way ANOVA with post-hoc Tukey test, as indicated. RESULTS In the 36-month study period, 5165 cases were identified across 149 hospitals. Low- (n = 113), medium- (n = 25), and high-volume (n = 11) centers performed a median of 4, 21, and 47 cases per annum, respectively. Most cases were performed for appendiceal (39.3%) followed by gynecologic neoplasms (20.4%). Groups were similar with respect to age, gender, race, comorbidities, and histology. Low-volume centers were more likely to utilize the ICU post-operatively (59.6% vs. 40.5% vs. 36.3%; p = 0.02). No differences were observed in morbidity (9.4% vs. 7.1% vs. 9.0%, p = 0.71), mortality (0.9% vs. 0.6% vs. 0.7%, p = 0.93), length of stay (9.3 vs. 9.4 vs. 10 days, p = 0.83), 30-day readmissions (5.6% vs. 5.6% vs. 5.6%, p = 1.0), or total cost among groups. CONCLUSIONS No association was found between CRS/HIPEC hospital volume and post-operative outcomes. These data suggest that in academic medical centers with HIPEC programs, outcomes for commonly treated cancers are not associated with hospital volume.
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Affiliation(s)
- Praveen D Chatani
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alexander Manzella
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Yelizaveta Y Gribkova
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Brett L Ecker
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Toni Beninato
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Timothy Kennedy
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Henry A Pitt
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
| | - Henry Richard Alexander
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
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8
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Bai M, Li Y, Pu H, Xu Y, Chen J, Xu H, Wei H, Liang G, Ma R, Feng J. Optimal peritoneal cancer index cutoff point for predicting surgical resectability of pseudomyxoma peritonei in treatment-naive patients. World J Surg Oncol 2024; 22:39. [PMID: 38297355 PMCID: PMC10829395 DOI: 10.1186/s12957-024-03318-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND The peritoneal cancer index (PCI) has been used to predict surgical outcomes for pseudomyxoma peritonei (PMP). The present study aimed to establish the optimal cutoff point for PCI to predict surgical resectability of PMP. METHODS A total of 366 PMP patients were included. The patients were divided into low-grade and high-grade groups. Based on the completeness of the cytoreduction (CC) score, both low-grade and high-grade PMP patients were further divided into complete cytoreductive surgery (CRS) and maximal tumor debulking (MTD) subgroups. The ability to predict surgical resectability of total and selected PCI (regions 2 + 9 to 12) was analyzed through receiver operating characteristic (ROC) curves. RESULTS Both total and selected PCI demonstrated excellent discriminative ability in predicting surgical resectability for low-grade PMP patients (n = 266), with the ROC-AUC of 0.940 (95% CI: 0.904-0.965) and 0.927 (95% CI: 0.889-0.955). The corresponding optimal cutoff point was 21 and 5, respectively. For high-grade PMP patients (n = 100), both total and selected PCI exhibited good performance in predicting surgical resectability, with the ROC-AUC of 0.894 (95% CI: 0.816-0.946) and 0.888 (95% CI: 0.810-0.943); correspondingly, the optimal cutoff point was 25 and 8, respectively. The discriminative ability between total and selected PCI in predicting surgical resectability did not show a statistical difference. CONCLUSIONS Both total and selected PCI exhibited good performance and similarity in predicting complete surgical resection for both low-grade and high-grade PMP patients. However, the selected PCI was simpler and time-saving in clinical practice. In the future, new imaging techniques or predictive models may be developed to better predict PCI preoperatively, which might assist in confirming whether complete surgical resection can be achieved.
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Affiliation(s)
- Mingjian Bai
- Department of Clinical Laboratory, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, Beijing, 100049, China
| | - Yunxiang Li
- Department of Clinical Laboratory, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, Beijing, 100049, China
| | - Hairong Pu
- Institute of Genetics and Department of Human Genetics, Zhejiang University School of Medicine, Hangzhou, 310058, China
| | - Yueming Xu
- Department of Literature and Science, University of Wisconsin-Madison, Madison, WI, 50155, USA
| | - Jingliang Chen
- Department of Clinical Laboratory, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, Beijing, 100049, China
| | - Hongbin Xu
- Department of Myxoma, Aerospace Center Hospital, Beijing, 100049, China
| | - Hongjiang Wei
- Department of Radiology, Aerospace Center Hospital, Beijing, 100049, China
| | - Guowei Liang
- Department of Clinical Laboratory, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, Beijing, 100049, China
| | - Ruiqing Ma
- Department of Myxoma, Aerospace Center Hospital, Beijing, 100049, China.
| | - Jing Feng
- Department of Clinical Laboratory, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, Beijing, 100049, China.
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9
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Leebmann H, Blaj S, Piso P. [Surgical treatment for recurrent intra-abdominal mucinous neoplasms]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:845-849. [PMID: 37432477 DOI: 10.1007/s00104-023-01925-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND The gold standard in the treatment of mucinous intra-abdominal neoplasms is cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Despite complete cytoreduction up to 45% of patients develop recurrences. METHOD A search and analysis of the current literature were carried out. RESULTS There is still controversy regarding the best treatment strategy for patients with recurrent pseudomyxoma peritonei (PMP) after CRS and HIPEC. The clinical management of these patients depends on many factors, such as the site and volume of recurrence, histological subtype and symptoms. Treatment options range from repeated surgery with curative intent with or without HIPEC to watch and wait strategies. In selected patients redo surgery is feasible and safe with low morbidity and mortality. Iterative complete CRS can result in a median 5‑year overall survival of more than 80%. Debulking surgery leads to a prolonged survival and to symptom control fora period with of nearly 2 years. CONCLUSION Repeated complete cytoreduction of recurrent PMP can result in long-term survival. Tumor debulking surgery may be particularly beneficial for symptomatic patients.
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Affiliation(s)
- H Leebmann
- Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049, Regensburg, Deutschland.
| | - S Blaj
- Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049, Regensburg, Deutschland
| | - P Piso
- Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049, Regensburg, Deutschland
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Karpes JB, Shamavonian R, Dewhurst S, Cheng E, Wijayawardana R, Ahmadi N, Morris DL. Malignant Peritoneal Mesothelioma: An In-Depth and Up-to-Date Review of Pathogenesis, Diagnosis, Management and Future Directions. Cancers (Basel) 2023; 15:4704. [PMID: 37835398 PMCID: PMC10571654 DOI: 10.3390/cancers15194704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/12/2023] [Accepted: 09/23/2023] [Indexed: 10/15/2023] Open
Abstract
Malignant peritoneal mesothelioma (MPM) is an extremely rare malignancy usually confined to the abdominal cavity. With an aggressive natural history, morbidity and mortality are consequences of progressive locoregional effects within the peritoneal cavity. The first reported case was in the early 20th century, however, due to the rare nature of the disease and a large gap in understanding of the clinicopathological effects, the next reported MPM cases were only published half a decade later. Since then, there has been exponential growth in our understanding of the disease, however, there are no prospective data and a paucity of literature regarding management. Traditionally, patients were treated with systemic therapy and the outcomes were very poor, with a median survival of less than one year. However, with the advent of cytoreductive surgery and locoregional chemotherapy, there have been significant improvements in survival. Even more recently, with an improved understanding of the molecular pathogenesis of MPM, there have been reports of improved outcomes with novel therapies. Given the disastrous natural history of MPM, the limited data, and the lack of universal treatment guidelines, an in-depth review of the past, present, and future of MPM is critical to improve treatment regimens and, subsequently, patient outcomes.
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Affiliation(s)
- Josh B. Karpes
- Hepatobiliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia
- St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW 2217, Australia
| | - Raphael Shamavonian
- Hepatobiliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia
- St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW 2217, Australia
| | - Suzannah Dewhurst
- Hepatobiliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia
- St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW 2217, Australia
| | - Ernest Cheng
- Hepatobiliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia
- St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW 2217, Australia
| | - Ru Wijayawardana
- Hepatobiliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia
- St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW 2217, Australia
| | - Nima Ahmadi
- Hepatobiliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia
- St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW 2217, Australia
| | - David L. Morris
- Hepatobiliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia
- St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW 2217, Australia
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11
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Chandrakumaran K, Carr NJ, Mohamed F, Cecil TD, Moran BJ. Development and Validation of Nomograms to Predict Survival in Patients Undergoing Complete Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei of Appendiceal Origin. JAMA Surg 2023; 158:522-530. [PMID: 36920381 PMCID: PMC10018403 DOI: 10.1001/jamasurg.2023.0112] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 11/05/2022] [Indexed: 03/16/2023]
Abstract
Importance Pseudomyxoma peritoni, a rare condition characterized by mucinous ascites and peritoneal deposits, mainly originates from a ruptured mucinous appendix tumor and is considered an indolent disease but can progress and become fatal. Optimal treatment to improve cure and survival rates involves complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Accurate predictive models are useful in supporting and informing treatment strategies and stratifying patient follow-up. Objective To evaluate the prognostic significance of clinically important variables and generate validated nomograms to predict overall (OS) and disease-free survival (DFS) following CCRS and hyperthermic intraperitoneal HIPEC for pseudomyxoma peritonei (PMP) of appendiceal origin. Design, Setting, and Participants This retrospective study used prospectively collected data on patients who had cytoreductive surgery (CRS) and HIPEC in a single institution between 1994 and 2018. The cohort was randomly allocated into development (70%) and validation (30%) sets. Univariate and multivariate analyses were performed with Cox proportional hazards regression. Main Outcomes and Measures A prediction model was developed with significant prognostic factors identified by multivariate analysis. The model's prognostic performance was evaluated with the concordance index (C index). The nomogram was calibrated by comparing the predicted and observed probabilities. Results Of 2637 CRS and HIPEC operations, 1102 patients (female, 64.4%; median age [IQR], 57.0 [48.0-66.0] years) (41.8%) had CCRS for PMP of appendiceal origin. Elevated tumor markers, peritoneal carcinomatosis index, gastrectomy, and tumor grade were independent predictive factors for DFS. Gender, age, elevated tumor makers, peritoneal carcinomatosis index, and tumor grade influenced OS. The nomograms were generated with respective prognostic factors. The nomograms showed good performance in predicting survival. Median OS of the cohort was 16.5 years (95% CI, 13.7-19.2) with a 5-year probability of survival of 80.2%. The median DFS was 10.3 years (95% CI, 7.2- 13.3) and the 5-year probability of recurrence-free survival was 60.5%. Conclusions and Relevance Clinically important independent predictors for survival and recurrence were selected to develop the nomograms for OS and DFS. These 2 nomograms are user friendly and useful tools for patient management with clinical trial design applications.
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Affiliation(s)
- Kandiah Chandrakumaran
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | - Norman John Carr
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | - Faheez Mohamed
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | - Thomas Desmond Cecil
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | - Brendan John Moran
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
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12
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Scalloping of the Liver and Spleen on Preoperative CT-Scan of Pseudomyxoma Peritonei Patients: Impact on Prediction of Resectability, Grade, Morbidity and Survival. Cancers (Basel) 2022; 14:cancers14184434. [PMID: 36139595 PMCID: PMC9496987 DOI: 10.3390/cancers14184434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/02/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Liver and/or spleen scalloping is a common radiologic sign visible on preoperative computed tomography scans of pseudomyxoma peritonei patients. While several studies have reported a predictive value of this scalloping regarding resectability, histologic grade, postoperative morbidity risk and long-term oncologic outcomes, few data are available regarding splenic scalloping. The predictive value of hepatic and splenic scalloping characteristics (measures and density) was assessed. It appeared that scalloping was associated for a more extensive disease, requiring more complex cytoreduction, but it was not associated with resectability, histologic grade, postoperative complications, or survival. Abstract Pseudomyxoma peritonei (PMP) is ideally treated by cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC), leading to significant morbidity. Beyond the histologic grade, the prognosis lies in the completeness of cytoreduction (CC-score of 0/1 vs. 2/3) and the severe complication rate. The mucinous nature of the peritoneal implants sometimes induces liver and/or spleen scalloping on imaging. The predictive value of scalloping was assessed regarding resectability, grade, survival and severe morbidity. This monocentric, retrospective analysis compared CC-0/1 with CC-2/3 groups regarding liver and spleen scalloping parameters, assessed on pre-operative computed tomography (CT) scan, reviewed for the study. In addition, prognostic factors of severe complications and recurrence-free and overall survivals were explored in the CC-0/1 population. Overall, 129 patients were included (109 CC-0/1, 20 CC-2/3), with 58 (45%) exhibiting scalloping. All patients with splenic scalloping also had a liver one. Scalloping was more frequent (75% vs. 39%), with greater median maximal depth (21 vs. 11 mm) and higher PCI (32 vs. 14) in the CC-2/3 population, but was not predictive of either grade or survival. In CC-0/1 patients, survivals and postoperative complications were not affected by scalloping parameters. Scalloping appeared as a marker of advanced PMP, but was not predictive of grade, severe complications, or long-term outcomes.
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Kepenekian V, Bhatt A, Péron J, Alyami M, Benzerdjeb N, Bakrin N, Falandry C, Passot G, Rousset P, Glehen O. Advances in the management of peritoneal malignancies. Nat Rev Clin Oncol 2022; 19:698-718. [PMID: 36071285 DOI: 10.1038/s41571-022-00675-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2022] [Indexed: 11/09/2022]
Abstract
Peritoneal surface malignancies (PSMs) are usually associated with a poor prognosis. Nonetheless, in line with advances in the management of most abdominopelvic metastatic diseases, considerable progress has been made over the past decade. An improved understanding of disease biology has led to the more accurate prediction of neoplasia aggressiveness and the treatment response and has been reflected in the proposal of new classification systems. Achieving complete cytoreductive surgery remains the cornerstone of curative-intent treatment of PSMs. Alongside centralization in expert centres, enabling the delivery of multimodal and multidisciplinary strategies, preoperative management is a crucial step in order to select patients who are most likely to benefit from surgery. Depending on the specific PSM, the role of intraperitoneal chemotherapy and of perioperative systemic chemotherapy, in particular, in the neoadjuvant setting, is established in certain scenarios but questioned in several others, although more prospective data are required. In this Review, we describe advances in all aspects of the management of PSMs including disease biology, assessment and improvement of disease resectability, perioperative management, systemic therapy and pre-emptive management, and we speculate on future research directions.
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Affiliation(s)
- Vahan Kepenekian
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France
| | - Aditi Bhatt
- Department of Surgical Oncology, Zydus hospital, Ahmedabad, Gujarat, India
| | - Julien Péron
- Medical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, UCBL1, Lyon, France
| | - Mohammad Alyami
- Department of General Surgery and Surgical Oncology, Oncology Center, King Khalid Hospital, Najran, Saudi Arabia
| | - Nazim Benzerdjeb
- CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France.,Department of Pathology, Institut de Pathologie Multisite, Hospices Civils de Lyon, UCBL1, Lyon, France
| | - Naoual Bakrin
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France
| | - Claire Falandry
- Department of Onco-Geriatry, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Guillaume Passot
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France
| | - Pascal Rousset
- CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France.,Department of Radiology, Hôpital Lyon Sud, Hospices Civils de Lyon, UCBL1, Lyon, France
| | - Olivier Glehen
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France. .,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France.
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Current Trends in Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Peritoneal Disease from Appendiceal and Colorectal Malignancies. J Clin Med 2022; 11:jcm11102840. [PMID: 35628966 PMCID: PMC9143396 DOI: 10.3390/jcm11102840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 12/10/2022] Open
Abstract
Peritoneal carcinomatosis (PC) is a poor prognostic factor for all malignancies. This extent of metastatic disease progression remains difficult to treat with systemic therapies due to poor peritoneal vascularization resulting in limited drug delivery and penetration into tissues. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are surgical interventions that directly target peritoneal tumors and have improved outcomes for PC resulting from appendiceal and colorectal cancer (CRC). Despite these radical therapies, long-term survival remains infrequent, and recurrence is common. The reasons for these outcomes are multifactorial and signal the need for the continued development of novel therapeutics, techniques, and approaches to improve outcomes for these patients. Here, we review landmark historical studies that serve as the foundation for current recommendations, recent discoveries, clinical trials, active research, and areas of future interest in CRS/HIPEC to treat PC originating from appendiceal and colorectal malignancies.
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Fung X, Li I, Chandrakumaran K, Cecil T, Dayal S, Tzivanakis A, Moran B, Mohamed F. Early postoperative intraperitoneal chemotherapy (EPIC) following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in 632 patients with pseudomyxoma peritonei of appendiceal origin: A single institution experience. Eur J Surg Oncol 2022; 48:1614-1618. [DOI: 10.1016/j.ejso.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/14/2022] [Accepted: 02/01/2022] [Indexed: 11/28/2022] Open
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Abstract
Peritoneal surface malignancies comprise a heterogeneous group of primary tumours, including peritoneal mesothelioma, and peritoneal metastases of other tumours, including ovarian, gastric, colorectal, appendicular or pancreatic cancers. The pathophysiology of peritoneal malignancy is complex and not fully understood. The two main hypotheses are the transformation of mesothelial cells (peritoneal primary tumour) and shedding of cells from a primary tumour with implantation of cells in the peritoneal cavity (peritoneal metastasis). Diagnosis is challenging and often requires modern imaging and interventional techniques, including surgical exploration. In the past decade, new treatments and multimodal strategies helped to improve patient survival and quality of life and the premise that peritoneal malignancies are fatal diseases has been dismissed as management strategies, including complete cytoreductive surgery embedded in perioperative systemic chemotherapy, can provide cure in selected patients. Furthermore, intraperitoneal chemotherapy has become an important part of combination treatments. Improving locoregional treatment delivery to enhance penetration to tumour nodules and reduce systemic uptake is one of the most active research areas. The current main challenges involve not only offering the best treatment option and developing intraperitoneal therapies that are equivalent to current systemic therapies but also defining the optimal treatment sequence according to primary tumour, disease extent and patient preferences. New imaging modalities, less invasive surgery, nanomedicines and targeted therapies are the basis for a new era of intraperitoneal therapy and are beginning to show encouraging outcomes.
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Cusumano C, Carrere S, Bouillin A, Nougaret S, Khellaf L, Quénet F, Sgarbura O. Laparoscopic cytoreductive surgery and HIPEC in LAMN with small volume of peritoneal disease: a valuable option of treatment for good patient-related experience measures (PREMs). Surg Endosc 2021; 36:4757-4763. [PMID: 34845545 DOI: 10.1007/s00464-021-08816-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 10/17/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the best effective treatment for pseudomyxoma peritonei (PMP). In the last years, the advances in histopathology have stratified PMP lesions in different degrees of aggressivity suggesting the possibility of a tailored treatment. In a subset of patients with small volume peritoneal disease, laparoscopic CRS and HIPEC is feasible. The aim of this study is to analyze the results of laparoscopic CRS + HIPEC in a monocentric series of patients under patient-related experience measures (PREMs). METHODS All consecutive patients who underwent laparoscopic CRS-HIPEC with curative intent at Cancer Institute of Montpellier were retrieved from a prospectively maintained database and analyzed. Selection criteria for laparoscopic approach were low-grade PMP with pathological confirmation prior to CRS-HIPEC, age < 75 years, no extra-peritoneal disease, peritoneal cancer index (PCI) < 10, and a limited history of abdominal surgery. A PREMS interview was conducted before analysis with all the included patients. Outcomes of interest included postoperative morbidity, medium-term survival, and PREMs. RESULTS Fourteen patients were operated on for low-grade PMP with a laparoscopic approach at our institution. Conversions to laparotomy were necessary in three patients, and postoperative complications were observed in three patients (Clavien 3b in one patient). In-hospital postoperative median stay was 9.5 days. No death or recurrence was observed during the study period. CONCLUSIONS Laparoscopic CRS-HIPEC for LAMN in presence of small peritoneal disease is feasible in terms of postoperative morbidity and mortality. According to our PREMs questionnaire, patients' expectations were satisfied.
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Affiliation(s)
- Caterina Cusumano
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de HautepierreHôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France
| | - Sébastien Carrere
- Department of Surgical Oncology, Cancer Institute Montpellier, University of Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex 05, France
| | - Alix Bouillin
- Department of Surgical Oncology, Cancer Institute Montpellier, University of Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex 05, France
| | - Stéphanie Nougaret
- Department of Radiology, Cancer Institute Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex 05, France
| | - Lakhdar Khellaf
- Department of Pathology, Cancer Institute Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex 05, France
| | - François Quénet
- Department of Surgical Oncology, Cancer Institute Montpellier, University of Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex 05, France
| | - Olivia Sgarbura
- Department of Surgical Oncology, Cancer Institute Montpellier, University of Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex 05, France. .,IRCM, Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Institut Régional du Cancer de Montpellier, Université de Montpellier, 34298, Montpellier, France.
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Novel Perspectives in Pseudomyxoma Peritonei Treatment. Cancers (Basel) 2021; 13:cancers13235965. [PMID: 34885075 PMCID: PMC8656832 DOI: 10.3390/cancers13235965] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/11/2021] [Accepted: 11/23/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Pseudomyxoma Peritonei (PMP) represents a rare entity which greatly benefits from Cytoreductive Surgery (CRS) associated with Hyperthermic Intraperitoneal Chemotherapy (HIPEC). In fact, CRS-HIPEC represents the treatment with potential chances of cure and long-term disease control of patients affected by PMP. This therapeutic strategy should be performed in referral centers, where a consolidated know-how of this locoregional treatment and a multidisciplinary approach are available. CRS-HIPEC provides excellent results for PMP patients in terms of postoperative outcome, overall and disease-free survival, and quality of life. However, in patients with an extensive or recurrent disease, few therapeutic opportunities are available. This review is focused on the most recent clinical evidence and provides a better understanding of the molecular prognostic factors and potential therapeutic targets in this rare malignancy. Abstract Pseudomyxoma Peritonei (PMP) is an anatomo-clinical condition characterized by the implantation of neoplastic cells on peritoneal surfaces with the production of a large amount of mucin. The rarity of the disease precludes the evaluation of treatment strategies within randomized controlled trials. Cytoreductive Surgery (CRS) combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) has proven to be the only therapeutic option with potential chances of cure and long-term disease control. The present review discusses the epidemiology, pathogenesis, clinical presentation and treatment of PMP, focusing on the molecular factors involved in tumor progression and mucin production that could be used, in the upcoming future, to improve patient selection for surgery and to expand the therapeutic armamentarium.
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Chidambarasamy ES, Chia CS, Johnny Ong CA, Soo KC, Ching Teo MC, Ching Tan GH. The effect of the learning curve of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in treating colorectal peritoneal metastasis. Asian J Surg 2021; 45:339-345. [PMID: 34148748 DOI: 10.1016/j.asjsur.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/04/2021] [Accepted: 06/01/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) are increasingly utilised in the management of colorectal peritoneal metastases (CPM). This combined modality is associated with a significant learning curve (LC) and is often criticised for its associated morbidity. This study aims to inspect the LC of this procedure in our institute. METHODS A retrospective review of the institution's prospectively maintained database of CRS-HIPEC cases was performed. Patients treated for CPM were stratified into two groups: Group 1 consists of patients in our initial 100 cases of CRS-HIPEC and Group 2 comprises patients treated subsequently. Perioperative prognostic factors and oncological outcomes were analysed. RESULTS Between 2001 and 2016, 77 patients with CPM underwent CRS-HIPEC, of which 31 patients (40.3%) were in Group 1 and 46 patients (59.7%) in Group 2. Median follow-up duration was 96 months in Group 1 and 25 months in Group 2. There were no differences in OS (35 months vs 46 months, p = 0.054) and DFS (13 months vs 14 months, p = 0.676) between the groups. There were more patients with higher PCI (≥12) (57.1% vs 22.2%, p = 0.006) and high-grade complications (25.8% vs 8.7%, p = 0.045) in Group 1. Group 2 patients had a shorter hospitalisation (14 days vs 11 days, p = 0.015) and SICU stay (1 day vs 0 days, p < 0.001). CONCLUSION An improvement in the perioperative outcomes after CRS-HIPEC for CPM may be partly attributed to overcoming the LC and incorporation of better patient selection methods.
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Affiliation(s)
- Ezhir Selvan Chidambarasamy
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore; Department of Surgical Oncology, KMCH Institute of Health Sciences and Research, India
| | - Claramae Shulyn Chia
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore; SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Chin-Ann Johnny Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore; SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore; Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore; Institute of Molecular and Cell Biology, A∗STAR Research Entities, Singapore
| | - Khee Chee Soo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore; SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Melissa Ching Ching Teo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore; SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Grace Hwei Ching Tan
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.
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Souadka A, Essangri H, Majbar MA, Benkabbou A, Boutayeb S, Amrani L, Ghannam A, El Ahmadi B, Belkhadir ZH, Mohsine R, Souadka A, Elias D. Mid-Term Audit of a National Peritoneal Surface Malignancy Program Implementation in a Low Middle Income Country: The Moroccan Experience. Cancers (Basel) 2021; 13:cancers13051088. [PMID: 33802609 PMCID: PMC7962020 DOI: 10.3390/cancers13051088] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/27/2020] [Accepted: 12/30/2020] [Indexed: 12/02/2022] Open
Abstract
Simple Summary Complete cytoreductive surgery (CRS) is the backbone of peritoneal surface malignancies (PSM) management and a major prognostic factor to better survival outcomes. Implementing a PSM program is a steep and complex process, particularly in low-middle income countries (LMIC), where limited resources are an additional challenge to overcome. In this study, we present the results of a mid-term audit of the implementation of a PSM program in Morocco. The latter was successfully and safely launched according to predicted initiation, transition and consolidation periods and allowed the significant improvement of short term surgical and oncological outcomes and completeness of cytoreduction procedures. Abstract Implementing a multimodal management of peritoneal surface malignancies is a steep and complex process, especially as complete cytoreductive surgery (CRS) is the backbone and the major prognostic factor for hyperthermic intraperitoneal chemotherapy (HIPEC) procedures. The implementation of such a program is a challenging process, particularly in low-middle income (LMIC) countries where ressource restrictions may represent a major hurdle to HIPEC appliances acquisition. Herein is the first audit of the implementation of a national peritoneal malignancy program in a north African country. The audit process was performed according to the three implementation steps, namely initiation (“1”:2005–2008), transition (“2”:2009–2013) and consolidation (“3”:2014–2017). We included all consecutive CRS without HIPEC performed with curative intent for ovarian, gastric, colorectal and pseudomyxoma peritonei type of malignancies with an Eastern Cooperative Oncology Group (ECOG) performance Status ≤ 2. Target outcomes for incomplete cytoreduction (ICRS), serious complications ≥ 3b according to the Clavien-Dindo scoring, and early oncologic failure (EOF; disease progression within 2 years of treatment) were compared between the three phases. Independent risk factors correlated to these three outcomes were calculated using a logistic regression model.198 CRS procedures were completed with 49, 60 and 89 cases performed in the three phases, respectively. Overall, patients were comparable except for ECOG and ASA scores which were more severe in the third phase. The comparison of ICRS, serious complications and EOF rates showed a significant reduction between the three phases with (34%, 18% and 4% p = <0.001), (30.6%, 20% and 11.2%, p = 0.019) and (38.8%, 23.3% and 12.4% p = 0.002) respectively. Undergoing CRS in phase 3 on the other hand was a predictive factor of better short term surgical and oncological outcomes and completeness of cytoreduction, while ECOG performance status and spleno-pancreatectomy were also predictive factors of serious complications.
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Affiliation(s)
- Amine Souadka
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco; (H.E.); (M.A.M.); (A.B.); (L.A.); (R.M.); (A.S.)
- Correspondence:
| | - Hajar Essangri
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco; (H.E.); (M.A.M.); (A.B.); (L.A.); (R.M.); (A.S.)
| | - Mohammed Anass Majbar
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco; (H.E.); (M.A.M.); (A.B.); (L.A.); (R.M.); (A.S.)
| | - Amine Benkabbou
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco; (H.E.); (M.A.M.); (A.B.); (L.A.); (R.M.); (A.S.)
| | - Saber Boutayeb
- Medical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco;
| | - Laila Amrani
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco; (H.E.); (M.A.M.); (A.B.); (L.A.); (R.M.); (A.S.)
| | - Abdelilah Ghannam
- Intensive Care Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco; (A.G.); (B.E.A.); (Z.H.B.)
| | - Brahim El Ahmadi
- Intensive Care Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco; (A.G.); (B.E.A.); (Z.H.B.)
| | - Zakaria Houssaïn Belkhadir
- Intensive Care Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco; (A.G.); (B.E.A.); (Z.H.B.)
| | - Raouf Mohsine
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco; (H.E.); (M.A.M.); (A.B.); (L.A.); (R.M.); (A.S.)
| | - Abdelilah Souadka
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat 10100, Morocco; (H.E.); (M.A.M.); (A.B.); (L.A.); (R.M.); (A.S.)
| | - Dominique Elias
- Department of Surgical Oncology, Gustave Roussy, Cancer Campus, 114 Rue Edouard Vaillant, 94805 Villejuif, France;
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Loaec C, Guérin-Charbonnel C, Vignaud T, Paineau J, Thibaudeau E, Dumont F. Individual learning curve of cytoreductive surgery for peritoneal metastasis from colorectal cancer: A process with an impact on survival. Eur J Surg Oncol 2021; 47:2031-2037. [PMID: 33618910 DOI: 10.1016/j.ejso.2021.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/08/2020] [Accepted: 02/08/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study aimed to assess the learning curve (LC) of cytoredutive surgery (CRS) of peritoneal metastasis (PM) from colorectal cancer (CRC). Information about learning curves is important for developing teaching tools and well-structured training programs for the implementation of this complex procedure in new healthcare centers. The aim of this study was to estimate how many procedures an inexperienced surgeon must perform (the length of the learning period) in order to demonstrate an acceptably low rate of locoregional recurrence. METHODS All consecutive 74 patients with CRS for CRC performed by a novice surgeon between 2012 and 2017 in a tertiary cancer center were included. The learning curve was calculated by a cumulative sum control chart (CUSUM) graph. Two groups were formed based on the length of the learning period and were compared on overall and disease free survival. RESULTS The risk of locoregional recurrence decreased after surgeons had performed 19 cases, suggesting a learning period of this length. Overall survival and postoperative morbidity were not significantly different between learning and proficiency periods. Multiple linear regression analysis showed that the learning period and peritoneal cancer index are the only factors affecting disease free survival. A second learning period was observed in cases where patient care became more complex. CONCLUSIONS This study confirms that learning period has negative impacts on disease-free survival. An initial experience supervised in specialized centers allow to have a short learning curve for CRS for peritoneal metastases for CRC.
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Affiliation(s)
- Cécile Loaec
- Department of Surgical Oncology, Comprehensive Cancer Center Institut de Cancérologie de l'Ouest, Saint-Herblain, France.
| | - Catherine Guérin-Charbonnel
- Départment de Biométrie et économie de santé, Biostatistiques, Comprehensive Cancer Center Institut Cancérologique de l'Ouest, Saint-Herblain, France
| | - Timothée Vignaud
- Department of Surgical Oncology, Comprehensive Cancer Center Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Jacques Paineau
- Department of Surgical Oncology, Comprehensive Cancer Center Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Emilie Thibaudeau
- Department of Surgical Oncology, Comprehensive Cancer Center Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Frédéric Dumont
- Department of Surgical Oncology, Comprehensive Cancer Center Institut de Cancérologie de l'Ouest, Saint-Herblain, France
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Seretis C, Gill J, Malik A, Elhassan AM, Shariff U, Youssef H. Low Preoperative Serum Albumin Levels Are Associated With Impaired Outcome After Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies. J Clin Med Res 2020; 12:773-779. [PMID: 33447310 PMCID: PMC7781284 DOI: 10.14740/jocmr4362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/09/2020] [Indexed: 12/03/2022] Open
Abstract
Preoperative hypoalbuminemia is known to be associated with postoperative morbidity and mortality, as well as with poor survival after gastrointestinal cancer surgery. However, limited data exist regarding the prognostic significance of hypoalbuminemia in patients with peritoneal metastases undergoing cytoreductive surgery, combined with perioperative intraperitoneal chemotherapy. We performed a systematic literature review of the previously published studies addressing the potential association between preoperative albumin levels and overall surgical outcomes after the performance of cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal surface malignancies. Our research yielded a total of nine retrospective studies which met our inclusion criteria, and despite their heterogeneity; and we can conclude that preoperatively low albumin levels are associated with greater likelihood of overall and major morbidity, as well as less favorable oncological outcome after the performance of cytoreductive surgery and perioperative intraperitoneal chemotherapy.
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Affiliation(s)
| | - Jagjit Gill
- George Eliot Hospital NHS Trust, Warwickshire, UK
| | - Adnan Malik
- George Eliot Hospital NHS Trust, Warwickshire, UK
| | | | - Umar Shariff
- General Surgery Department, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Haney Youssef
- General Surgery Department, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
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The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis: a systematic review including evidence from Japan. Surg Today 2020; 51:1085-1098. [PMID: 33185798 DOI: 10.1007/s00595-020-02180-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/29/2020] [Indexed: 02/07/2023]
Abstract
The prognosis of peritoneal carcinomatosis is poor. However, the emergence of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) as a treatment option has prolonged survival and it can even potentially cure patients with peritoneal carcinomatosis. Randomized controlled studies and other observational studies indicated that this combined therapy potentially improved the prognosis of patients with colon, gastric, and ovarian cancers with acceptable morbidity and mortality rates. Even in rarer diseases, such as pseudomyxoma peritonei and malignant peritoneal mesothelioma, CRS + HIPEC markedly improved the prognoses over those with conventional treatment. Based on the accumulated evidence, clinical guidelines recommend CRS + HIPEC for selected patients with peritoneal carcinomatosis. However, several issues still need to be overcome. A standard method for HIPEC has not yet been established. Furthermore, the criteria employed for patient selection need to be clarified to achieve real benefits. The peritoneal cancer index, chemo-sensitivity and several biological markers are considered to be key factors.
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Centralization and Oncologic Training Reduce Postoperative Morbidity and Failure-to-rescue Rates After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies: Study on a 10-year National French Practice. Ann Surg 2020; 272:847-854. [PMID: 32833761 DOI: 10.1097/sla.0000000000004326] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Evaluate at a national level the postoperative mortality (POM), major morbidity (MM) and failure-to-rescue (FTR) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) across time and according to hospital-volume. BACKGROUND CRS/HIPEC is an effective therapeutic strategy commonly used to treat peritoneal surface malignancies. However, this aggressive approach has the reputation to be associated with a high POM and MM. METHODS All patients treated with CRS/HIPEC between 2009 and 2018 in France were identified through a national medical database. Patients and perioperative outcomes were analyzed. A cut-off value of the annual CRS/HIPEC caseload affecting the 90-day POM was calculated using the Chi-squared Automatic Interaction Detector method. A multivariable logistic model was used to identify factors mediating 90-day POM. RESULTS A total of 7476 CRS/HIPEC were analyzed. Median age was 59 years with a mean Elixhauser comorbidity index of 3.1, both increasing over time (P < 0.001). Ninety-day POM was 2.6%. MM occurred in 44.2% with a FTR rate of 5.1%. The threshold of CRS/HIPEC number per center per year above which the 90-day POM was significantly reduced was 45 (3.2% vs 1.9%, P = 0.01). High-volume centers had more extended surgery (P < 0.001) with increased MM (55.8% vs 40.4%, P < 0.001) but lower FTR (3.1% vs 6.3%, P = 0.001). After multivariate analysis, independent factors associated with 90-day POM were: age >70 years (P = 0.002), Elixhauser comorbidity index ≥8 (P = 0.006), lower gastro-intestinal origin, (P < 0.010), MM (P < 0.001), and <45 procedures/yr (P = 0.002). CONCLUSION In France, CRS/HIPEC is a safe procedure with an acceptable 90-day POM that could even be improved through centralization in high-volume centers.
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Stewart JH, Blazer DG, Calderon MJG, Carter TM, Eckhoff A, Al Efishat MA, Fernando DG, Foster JM, Hayes-Jordan A, Johnston FM, Lautz TB, Levine EA, Maduekwe UN, Mangieri CW, Moaven O, Mogal H, Shen P, Votanopoulos KI. The Evolving Management of Peritoneal Surface Malignancies. Curr Probl Surg 2020; 58:100860. [PMID: 33832580 DOI: 10.1016/j.cpsurg.2020.100860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/04/2020] [Indexed: 02/07/2023]
Affiliation(s)
| | - Dan G Blazer
- Division of Surgical Oncology, Duke University Medical Center, Durham, NC
| | | | | | | | | | | | - Jason M Foster
- Fred and Pamela Buffet Cancer Center, University of Nebraska, Omaha, NE
| | | | - Fabian M Johnston
- Complex General Surgical Oncology Program, Johns Hopkins University, Baltimore, MD
| | - Timothy B Lautz
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Ugwuji N Maduekwe
- Division of Surgical Oncology and Endocrine Surgery, University of North Carolina, Chapel Hill, NC
| | | | | | | | - Perry Shen
- Wake Forest University School of Medicine, Winston-Salem, NC
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Bouchard-Fortier G, Cusimano MC, Fazelzad R, Sajewycz K, Lu L, Espin-Garcia O, May T, Bouchard-Fortier A, Ferguson SE. Oncologic outcomes and morbidity following heated intraperitoneal chemotherapy at cytoreductive surgery for primary epithelial ovarian cancer: A systematic review and meta-analysis. Gynecol Oncol 2020; 158:218-228. [PMID: 32387131 DOI: 10.1016/j.ygyno.2020.03.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 03/31/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Heated intraperitoneal chemotherapy (HIPEC) has not been universally adopted at the time of interval cytoreductive surgery for primary epithelial ovarian cancer (EOC) despite evidence of a 12-month overall survival (OS) benefit in a recent landmark randomized trial. We performed a systematic review and meta-analysis to assess oncologic outcomes and perioperative morbidity following HIPEC among primary EOC patients. METHODS We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, from inception to August 2019, for observational and randomized studies of primary EOC patients undergoing HIPEC. We assessed risk of bias using the Institute of Health Economics Quality Appraisal Checklist for single-arm cohort studies, Newcastle-Ottawa Scale for comparative cohort studies, and Cochrane Collaboration's Tool for randomized trials. We qualitatively summarized survival outcomes and calculated the pooled proportion of 30-day grade III-IV morbidity and postoperative death. RESULTS We identified 35 articles including 2252 primary EOC patients; one study was a randomized trial, and only six studies included a comparator group of surgery alone. The timing, temperature, and chemotherapeutic agents used for HIPEC differed across studies. Reported OS was highly variable (3-year OS range: 46-77%); three comparative cohort studies and the sole randomized trial reported statistically significant survival benefits for HIPEC over surgery alone, while two comparative cohort studies did not. The pooled proportions for grade III-IV morbidity and postoperative death at 30 days were 34% (95% CI 20-52) and 0% (95% CI 0-5) respectively. CONCLUSION One randomized trial suggests that HIPEC at time of interval cytoreductive surgery should be considered in patients with primary EOC. However, there is significant heterogeneity in literature with respect to an appropriate HIPEC regimen, short- and long-term outcomes. High-quality prospective randomized trials are urgently needed to clarify the role of HIPEC in the first-line treatment of primary EOC.
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Affiliation(s)
- Genevieve Bouchard-Fortier
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| | - Maria C Cusimano
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada
| | - Rouhi Fazelzad
- Princess Margaret Cancer Centre, University Health Network Library and Information Services, Toronto, ON, Canada
| | - Katrina Sajewycz
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Lin Lu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Osvaldo Espin-Garcia
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Taymaa May
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Sarah E Ferguson
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Baron E, Milovanov V, Gushchin V, Sittig M, Neiroda C, Sardi A. Predicting Aborted Hyperthermic Intraperitoneal Chemotherapy (AHIPEC) with Preoperative Tumor and Inflammatory Markers in Potentially Resectable Appendiceal Cancer Patients with Peritoneal Carcinomatosis. Ann Surg Oncol 2020; 27:2548-2556. [DOI: 10.1245/s10434-019-08117-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Indexed: 11/18/2022]
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Klos D, Riško J, Loveček M, Skalický P, Svobodová I, Krejčí D, Melichar B, Mohelníková-Duchoňová B, Lemstrová R. Trends in peritoneal surface malignancies: evidence from a Czech nationwide population-based study. World J Surg Oncol 2019; 17:182. [PMID: 31694646 PMCID: PMC6836516 DOI: 10.1186/s12957-019-1731-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
Abstract
Background The aim of this study is to identify the incidence trends of primary and secondary peritoneal surface malignancies in a representative Czech population. Methods Data were obtained from patients registered in the Czech National Cancer Registry between 1979 and 2016. The incidence rates were analyzed between 2012 and 2016. To observe the incidence trends, we analyzed the data from two time periods, 1979–2005 and 2006–2016. The analyzed data included age, sex, and the histological types and primary origins of the malignancies. The Cochrane-Armitage test for linear trends was used for verification of the null hypothesis. The significance level established for hypothesis testing was p = 0.05. Results Between 2012 and 2016, 230 patients with primary peritoneal tumors were identified and divided into the following groups according to their “International Statistical Classification of Diseases and Related Health Problems, 10th revision” codes: malignant neoplasm of specified parts of the peritoneum (C48.1); malignant neoplasm of the peritoneum, unspecified (C48.2); and malignant neoplasm of overlapping sites of the retroperitoneum and peritoneum (C48.8). Moreover, 549 primary tumors of the appendix (C18.1, encompassing all appendiceal malignancies) and 3137 secondary synchronous peritoneal carcinomatoses of other primary origins were documented. The age-adjusted incidence of primary peritoneal tumors in 2012–2016 was 4.36/year/1,000,000 inhabitants. The age-adjusted incidence of synchronous secondary peritoneal malignancies in 2014–2016 was 99.0/year/1,000,000 inhabitants. The diagnoses of primary peritoneal malignancies followed a stable trend between 1979 and 2016. However, the incidences of primary tumors of the appendix increased by 76.7%. Conclusions The data produced in our study ought to clarify the status of peritoneal surface malignancies in the Czech Republic, which can lead to improved planning and development of therapeutic interventions as well as physician training.
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Affiliation(s)
- Dušan Klos
- Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Juraj Riško
- Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Loveček
- Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Pavel Skalický
- Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Ivana Svobodová
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Denisa Krejčí
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Bohuslav Melichar
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Hněvotínská 3, CZ-779 00, Olomouc, Czech Republic
| | - Beatrice Mohelníková-Duchoňová
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Hněvotínská 3, CZ-779 00, Olomouc, Czech Republic.,Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Radmila Lemstrová
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Hněvotínská 3, CZ-779 00, Olomouc, Czech Republic.
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Webb C, Day R, Velazco CS, Pockaj BA, Gray RJ, Stucky CC, Young-Fadok T, Wasif N. Implementation of an Enhanced Recovery After Surgery (ERAS) Program is Associated with Improved Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2019; 27:303-312. [PMID: 31605328 DOI: 10.1245/s10434-019-07900-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with increased postoperative complications and a prolonged length of stay (LOS). We report on our experience following implementation of an Enhanced Recovery After Surgery (ERAS) program for CRS and HIPEC. METHODS Patients were divided into pre- and post-ERAS groups. Modifications in the ERAS group included routine use of transversus abdominis plane blocks, intra- and postoperative fluid restriction, and minimizing the use of narcotics, drains, and nasogastric tubes. RESULTS Of a total of 130 procedures, 49 (38%) were in the pre-ERAS group and 81 (62%) were in the ERAS group. Mean LOS was reduced from 10.3 ± 8.9 days to 6.9 ± 5.0 days (p = 0.007) and the rate of grade III/IV complications was reduced from 24 to 15% (p = 0.243) following ERAS implementation. The ERAS group received less intravenous fluid during hospitalization (19.2 ± 18.7 L vs. 32.8 ± 32.5 L, p = 0.003) and used less opioids than the pre-ERAS group (median of 159.7 mg of oral morphine equivalents vs. 272.6 mg). There were no significant changes in the rates of 30-day readmission or acute kidney injury between the two groups (p = non-significant). On multivariable analyses, ERAS was significantly associated with a reduction in LOS (- 2.89 days, 95% CI - 4.84 to - 0.94) and complication rates (odds ratio 0.22, 95% CI 0.08-0.57). CONCLUSIONS Implementation of an ERAS program for CRS and HIPEC is associated with a reduction in overall intravenous fluids, postoperative narcotic use, complication rates, and LOS.
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Affiliation(s)
- Christopher Webb
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Ryan Day
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Cristine S Velazco
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Barbara A Pockaj
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Richard J Gray
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Chee-Chee Stucky
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Tonia Young-Fadok
- Department of Surgery, Division of Colorectal Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Nabil Wasif
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA.
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Kitai T, Yamanaka K, Sugimoto N, Inamoto O. Surgical management for peritoneal carcinomatosis of appendiceal origin with a high-tumor burden. Surg Today 2019; 50:171-177. [PMID: 31363844 DOI: 10.1007/s00595-019-01856-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/17/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is the active treatment for peritoneal carcinomatosis of appendiceal origin. However, surgical management is sometimes difficult in patients with a high-tumor burden. METHODS A high-tumor burden was defined as a peritoneal cancer index (PCI) ≥ 28. Among 49 patients receiving CRS + HIPEC, 29 had a PCI ≥ 28. RESULTS Complete cytoreduction (CC-0/1) was achieved in 20 of the 29 patients with a PCI ≥ 28 and in all 20 patients with a PCI < 28. Among the patients achieving CC-0/1, gastrectomy or total colectomy was performed more frequently, the hospital stay was longer and postoperative complications were more frequent in those with a PCI ≥ 28 than in those with a PCI < 28. If CC-0/1 was achieved, the overall survival was comparable between patients with a PCI ≥ 28 and a PCI < 28. However, the recurrence-free survival was significantly worse for patients with a PCI ≥ 28 than for those with a PCI < 28 (5-year survival: 73.7% vs. 5.9%). Patients with recurrence who underwent repeat CRS showed a better overall survival than those without repeat CRS. Among patients with a PCI ≥ 28, a performance status (PS) of 2/3 was a significant prognostic factor (hazard ratio = 5.132). CONCLUSIONS In patients with a high-tumor burden undergoing CRS + HIPEC, postoperative complications were more frequent, and the recurrence rate was higher than in those without a high-tumor burden. Repeat CRS improved the survival of patients with recurrence. The PS was a key indicator when selecting patients suitable for aggressive resection.
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Affiliation(s)
- Toshiyuki Kitai
- Department of Surgery, Kishiwada City Hospital, 1001 Gakuhara-cho, Kishiwada, Osaka, 596-8501, Japan.
| | - Kenya Yamanaka
- Department of Surgery, Kishiwada City Hospital, 1001 Gakuhara-cho, Kishiwada, Osaka, 596-8501, Japan
| | - Naoko Sugimoto
- Department of Surgery, Kishiwada City Hospital, 1001 Gakuhara-cho, Kishiwada, Osaka, 596-8501, Japan
| | - Osamu Inamoto
- Department of Surgery, Kishiwada City Hospital, 1001 Gakuhara-cho, Kishiwada, Osaka, 596-8501, Japan
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Fichmann D, Roth L, Raptis DA, Kajdi ME, Gertsch P, Vonlanthen R, de Rougemont O, Moral J, Beck-Schimmer B, Lehmann K. Standard Operating Procedures for Anesthesia Management in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Improve Patient Outcomes: A Patient Cohort Analysis. Ann Surg Oncol 2019; 26:3652-3662. [DOI: 10.1245/s10434-019-07644-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Indexed: 12/12/2022]
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Ansari N, Brown KGM, McBride KE, Steffens D, Koh CE, Young CJ, Solomon MJ, Moran BJ. Accelerating the learning curve in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy using an external mentor model. ANZ J Surg 2019; 89:1097-1101. [PMID: 31280498 DOI: 10.1111/ans.15331] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/24/2019] [Accepted: 05/25/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an accepted therapeutic approach in selected patients with peritoneal malignancy. The aim of this study was to describe early outcomes in the first 50 patients managed with CRS and HIPEC in a newly established peritoneal malignancy centre in Sydney, Australia, under the guidance of an experienced peritoneal malignancy mentor. METHODS This is a retrospective review of a prospective maintained database of early outcomes in the first 50 patients who underwent CRS and HIPEC between April 2017 and April 2018 at a newly established peritoneal malignancy centre. Type of primary, surgery time, length of hospital stay, blood loss, peritoneal carcinomatosis index, completeness of surgery, complications, recurrence rate and 30-day mortality were reviewed. RESULTS A total of 135 patients were referred and reviewed at the multidisciplinary team meeting with 50 (26 male) patients undergoing CRS and HIPEC. Of these 50 patients, 47 (94%) underwent complete cytoreduction while three (6%) had maximal tumour debulking surgery. Tumour pathology was of appendix origin (44%) and colorectal peritoneal metastases (44%). Median surgical time was 7.4 h (interquartile range 5.7-10.0). Median length of hospital stay was 13 days (interquartile range 9.7-19.0). Six (12%) patients experienced a grade III or IV Clavien-Dindo complication. There was no 30-day mortality. CONCLUSION This study reports the successful establishment of a peritoneal malignancy centre under the guidance of an experienced peritoneal malignancy mentor. The short-term surgical outcomes observed in the first 50 cases are promising and comparable to other more experienced centres.
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Affiliation(s)
- Nabila Ansari
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kate E McBride
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher J Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brendan J Moran
- Peritoneal Malignancy Institute, North Hampshire Hospital, Basingstoke, UK
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Ellis RJ, Schlick CJR, Yang AD, Barber EL, Bilimoria KY, Merkow RP. Utilization and Treatment Patterns of Cytoreduction Surgery and Intraperitoneal Chemotherapy in the United States. Ann Surg Oncol 2019; 27:214-221. [PMID: 31187369 DOI: 10.1245/s10434-019-07492-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) is an effective treatment option for selected patients with peritoneal metastases (PM), but national utilization patterns are poorly understood. The objectives of this study were to (1) describe population-based trends in national utilization of CRS/IPC; (2) define the most common indications for the procedure; and (3) characterize the types of hospitals performing the procedure. METHODS The National Inpatient Sample (NIS) was used to identify patients from 2006 to 2015 who underwent CRS/IPC, and to calculate national estimates of procedural frequency and oncologic indication. Hospitals performing CRS/IPC were classified based on size and teaching status. RESULTS The estimated annual number of CRS/IPC cases increased significantly from 189 to 1540 (p < 0.001). Overall, appendiceal cancer was the most common indication (25.7%), followed by ovarian cancer (23.3%), colorectal cancer (22.5%), and unspecified PM (15.0%). Remaining cases (13.5%) were performed for other indications. Most cases were performed in large teaching hospitals (65.9%), compared with smaller teaching hospitals (25.1%), large non-teaching hospitals (5.3%), or small non-teaching hospitals (3.2%). Patients were more likely to undergo CRS/IPC without a diagnosis based on level I evidence (appendiceal, ovarian, or colorectal) at large non-academic hospitals (odds ratio 2.00, 95% confidence interval 1.18-3.38, p = 0.010) compared with large academic hospitals. CONCLUSIONS Utilization of CRS/IPC is increasing steadily in the US, is performed at many types of facilities, and often for a variety of indications that are not supported by high-level evidence. Given associated morbidity of CRS/IPC, a national registry dedicated to cases of IPC is necessary to further evaluate use and outcomes.
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Affiliation(s)
- Ryan J Ellis
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, USA.,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Cary Jo R Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, USA
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, USA
| | - Emma L Barber
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, USA
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, USA.,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, USA. .,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA.
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Bhatt A, Mehta S, Seshadri RA. The Current Status of Peritoneal Surface Oncology in India. Indian J Surg Oncol 2019; 10:41-48. [PMID: 30886493 PMCID: PMC6397124 DOI: 10.1007/s13193-018-00871-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 12/27/2018] [Indexed: 01/19/2023] Open
Abstract
With the increasing acceptance of cytoreductive surgery and HIPEC as a potentially curative treatment for primary and secondary peritoneal surface malignancies, peritoneal surface oncology has emerged as a distinct sub-specialty of surgical oncology. In the last 10 years, the acceptance of a conceptually different approach towards the management of peritoneal metastases has increased in India. During this period, over 1000 combined procedures have been performed in the country and most of the major cities have centers performing offering this treatment. Indian surgeons have formed collaborative groups to promote research and development of this specialty across the country. This article provides a detailed account of current practices pertaining to peritoneal surface oncology in the country and a future perspective.
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Affiliation(s)
- Aditi Bhatt
- Department of Surgical Oncology, Zydus Hospital, Zydus Hospital Road, SG Highway, Thaltej, Ahmedabad, 380054 India
| | - Sanket Mehta
- Department of Surgical Oncology, Saifee Hospital, Mumbai, India
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Gani F, Conca-Cheng AM, Nettles B, Ahuja N, Johnston FM. Trends in Outcomes After Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy. J Surg Res 2019; 234:240-248. [DOI: 10.1016/j.jss.2018.09.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 08/13/2018] [Accepted: 09/11/2018] [Indexed: 12/19/2022]
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Kusamura S, González-Moreno S, Nizri E, Baratti D, Guadagni S, Guaglio M, Battaglia L, Deraco M. Learning Curve, Training Program, and Monitorization of Surgical Performance of Peritoneal Surface Malignancies Centers. Surg Oncol Clin N Am 2018; 27:507-517. [PMID: 29935686 DOI: 10.1016/j.soc.2018.02.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is a complex procedure with high cost and significant morbidity and mortality. The associated learning curve is steep and could reliably be evaluated using specific statistics. Risk-adjusted sequential probability ratio test is an effective and robust method to monitor surgical performance in the learning and audit phase of a peritoneal surface malignancies center development. The most critical factor associated with surgical performance is mentoring of the trainee by an expert. A well-structured tutor-based training program has been implemented in Europe. This initiative will improve the standardization of the combined procedure and improve quality of services across the continent.
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Affiliation(s)
- Shigeki Kusamura
- Peritoneal Surface Malignancies unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, Milano, Milan cap 20133, Italy
| | | | - Eran Nizri
- Department of General Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Weizmann Street 6, Tel Aviv, Israel
| | - Dario Baratti
- Peritoneal Surface Malignancies unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, Milano, Milan cap 20133, Italy
| | - Stefano Guadagni
- Department of Biotechnological and Applied Clinical Sciences, Università degli Studi dell'Aquila, Via Giovanni di Vincenzo, 16/B, L'Aquila, Italy
| | - Marcello Guaglio
- Peritoneal Surface Malignancies unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, Milano, Milan cap 20133, Italy
| | - Luigi Battaglia
- Colorectal Cancer unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, Milano, MI, cap 20133, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancies unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, Milano, Milan cap 20133, Italy.
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Babcock B, Jabo B, Selleck M, Reeves M, Garberoglio C, Namm J, Kazanjian K, Senthil M. Factors Predictive of Outcomes after Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy for Colon and Appendiceal Carcinomatosis: A Single-Institution Experience. Am Surg 2018. [DOI: 10.1177/000313481808401007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), although considered an acceptable treatment option in the management of selected patients with colon and appendiceal peritoneal carcinomatosis (PC), concerns about morbidity have limited its acceptance. Our objective was to evaluate the short- and long-term outcomes of CRS/HIPEC for appendix and colon PC performed at our institution and to elucidate factors predictive of patient outcomes. All patients who underwent CRS/HIPEC for appendix or colon PC from 2011 to 2017 were identified from our institution's prospective database. Postoperative outcomes, overall survival, and recurrence-free survival were assessed. Of 125 patients who underwent CRS/HIPEC during the study period, 45 patients were eligible (appendix n = 26; colon n = 19). The median postoperative length of stay was nine days (5–28 days). Grade III/IV complications occurred in 4/45 (8.8%) patients. There were no postoperative mortalities. Median DFS and overall survival have not yet been reached, in both the colon and appendix groups. As of the study conclusion date, 37/45 (82.2%) patients were alive with or without disease. Lymph node status was predictive of recurrence in appendix PC. In our experience, CRS/HIPEC can be safely performed with acceptable short- and long-term outcomes. Lymph node status is an important predictor of recurrence.
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Affiliation(s)
- Blake Babcock
- Loma Linda University Cancer Center, Loma Linda, California
| | - Brice Jabo
- Loma Linda University Cancer Center, Loma Linda, California
| | | | - Mark Reeves
- Loma Linda University Cancer Center, Loma Linda, California
| | | | - Jukes Namm
- Loma Linda University Cancer Center, Loma Linda, California
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Fish R, Renehan AG, Punnett G, Aziz O, Fulford P, Selvasekar C, Wilson M, Halstead R, O'Dwyer ST. Referral and treatment pathways for pseudomyxoma peritonei of appendiceal origin within a national treatment programme. Colorectal Dis 2018; 20:888-896. [PMID: 29920919 DOI: 10.1111/codi.14310] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/06/2018] [Indexed: 02/08/2023]
Abstract
AIM Pseudomyxoma peritonei (PMP) is a rare neoplasm of the appendix, which if untreated disseminates throughout the abdominal cavity and generates considerable morbidity. Since 2002 in the UK, patients with PMP have been managed via two nationally commissioned centres. We evaluated referrals and treatment pathways over time at the Manchester centre. METHOD Data from all patients referred with suspected PMP were prospectively collected (2002-2015). Definitive treatment was cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy. Disease burden was quantified using the Peritoneal Cancer Index (PCI) (score 0-39) and complete cytoreduction (CC) defined by scores of 0/1. Novel treatment algorithms were developed for patients with low grade appendiceal mucinous neoplasm (LAMN) localized to the peri-appendiceal tissue. RESULTS In all, 817 patients with confirmed PMP were referred increasing from 11 in 2002 to 103 in 2015. Disease burden was high with a mean PCI of 31 in the first quartile (Q1), levelling off to 15, 15, 17 thereafter (P = 0.002). The proportion of CC0/1 increased from 67% in Q1 to 77% Q2 and 74% Q3/4. Where complete cytoreduction was achieved, 5- and 10-year overall survival was 77% and 66%. The proportion of patients referred with localized LAMN increased over time reaching 25% each year since 2010 (Ptrend < 0.0001). Two-thirds of localized LAMN now undergo laparoscopically assisted risk-reducing CRS. CONCLUSION The establishment of a national treatment centre was associated with an initial presentation of patients with advanced disease. The programme has demonstrated a clear trend over time towards earlier referral and adoption of minimally invasive techniques for localized disease.
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Affiliation(s)
- R Fish
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - A G Renehan
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Manchester Cancer Research Centre, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
| | - G Punnett
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK
| | - O Aziz
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - P Fulford
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK
| | - C Selvasekar
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK
| | - M Wilson
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK
| | - R Halstead
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK
| | - S T O'Dwyer
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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Sugarbaker PH. Update on the management of malignant peritoneal mesothelioma. Transl Lung Cancer Res 2018; 7:599-608. [PMID: 30450299 PMCID: PMC6204413 DOI: 10.21037/tlcr.2018.08.03] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 08/01/2018] [Indexed: 12/20/2022]
Abstract
Malignant peritoneal mesothelioma (MPM) is a rare disease whose natural history is confined to the peritoneal space. Systemic chemotherapy has little impact on survival of patients with MPM. A surgical procedure with a goal of resection of all visible evidence of disease, called cytoreductive surgery (CRS) has been utilized in MPM patients. Also, regional chemotherapy with hyperthermic intraperitoneal chemotherapy (HIPEC) and normothermic intraperitoneal chemotherapy long-term (NIPEC-LT) have been effectively utilized in MPM patients. In the absence of CRS and HIPEC the median survival of MPM patients is approximately 1 year. The aggressive surgical approach plus regional chemotherapy has increased the median survival to more than 5 years. With NIPEC-LT added on, 70% 5-year survival has been reported. Knowledgeable patient selection for treatment is mandatory. The use of CRS, HIPEC and NIPEC-LT has greatly benefited patients with MPM. Global application of these treatments is indicated.
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Affiliation(s)
- Paul H Sugarbaker
- Center for Gastrointestinal Malignancies, MedStar Washington Hospital Center, Washington, DC, USA
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Kim DW, Park DG, Song S, Jee YS. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy as Treatment Options for Peritoneal Metastasis of Advanced Gastric Cancer. J Gastric Cancer 2018; 18:296-304. [PMID: 30276006 PMCID: PMC6160528 DOI: 10.5230/jgc.2018.18.e32] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 12/12/2022] Open
Abstract
Purpose This study aimed to examine the outcomes of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with peritoneal metastasis (PM) of advanced gastric cancer (AGC). Materials and Methods Between May 2015 and June 2017, 38 CRS and HIPEC procedures were performed in patients with PM of AGC at the Dankook University Hospital. We prospectively collected and analyzed data regarding PM grade, morbidity and mortality rates, and short-term follow-up results (median, 13.5 months). Results The mean peritoneal cancer index was 15 (range, 0-39). Complete cytoreduction was achieved in 21 patients (55.2%), whereas complications occurred in 16 (42.1%) and 2 (5.7%) patients died. The overall median patient survival time was 19 months. The patients who underwent complete cytoreduction had a median survival time of 26 months, which was significantly longer than the median survival time of 16 months in the patients who did not undergo complete cytoreduction (P=0.006). Conclusions CRS with HIPEC may have a beneficial effect in patients with PM of AGC. However, the rates of complications and mortality associated with this combined therapeutic approach are high. Therefore, this treatment should be performed only in selected patients by surgeons experienced in the field of gastric cancer with PM.
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Affiliation(s)
- Dong-Wook Kim
- Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Dong-Guk Park
- Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Sanghyun Song
- Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Ye Seob Jee
- Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
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Abstract
Appendiceal neoplasms are identified in 0.9 to 1.4% of appendiceal specimens, and the incidence is increasing. It has long been professed that neuroendocrine tumors (formerly carcinoids) are the most common neoplastic process of the appendix; recent data, however, has suggested a shift in epidemiology. Our intent is to distill the complex into an algorithm, and, in doing so, enable the surgeon to seamlessly maneuver through operative decisions, treatment strategies, and patient counseling. The algorithm for evaluation and treatment is complex, often starts from the nonspecific presenting complaint of appendicitis, and relies heavily on often subtle histopathologic differences.
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Affiliation(s)
- Quinton M Hatch
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Erin W Gilbert
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon
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Van Poucke S, Huskens D, Van der Speeten K, Roest M, Lauwereins B, Zheng MH, Dehaene S, Penders J, Marcus A, Lancé M. Thrombin generation and platelet activation in cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy - A prospective cohort study. PLoS One 2018; 13:e0193657. [PMID: 29927924 PMCID: PMC6013150 DOI: 10.1371/journal.pone.0193657] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 02/15/2018] [Indexed: 12/20/2022] Open
Abstract
Background and objectives Cytoreductive surgery (CRS) with hyperthermic intraperitoneal peroperative chemotherapy (HIPEC), indicated for patients with peritoneal metastases from digestive or gynecological malignancies alike, demonstrates a considerable impact on hemostatic metabolism, both on platelet and on coagulation level. The potential hemostatic interference in CRS and HIPEC is phase dependent. The hypothesis of this prospective cohort study is that the procedure exposed an increased thrombotic risk, resulting in a faster and increased thrombin generation and hyper platelet function. Methods This study explores the combined use of ROTEM (rotational thromboelastometry), PACT (platelet activation test) and CAT (thrombin generation test) assays during CRS and HIPEC with a follow-up of 7 days postoperative in 27 patients with confirmed histological diagnosis of peritoneal disease. Results Platelet reactivity (relative to before incision values) to CRP (collagen-related peptide) (p value 0.02) and TRAP (thrombin receptor activator peptide) (p value 0.048) seems to be slightly reduced during CRS and HIPEC with regard to αIIbβ3 activation, while P-selectin expression is not affected. During surgery, CAT demonstrates that, the LT (lagtime) (p value 0.0003) and TTP (time-to-thrombin peak) values (p value 0.002) decrease while and the TP (thrombin peak) (p value 0.004) and ETP (endogenous thrombin potential) (p value 0.02) increase. Subsequently, after surgery, the LT and TTP increase and ETP and TP decrease in time. ROTEM EXTEM (extrinsic) MCF (maximum clot firmness) (p value 0.005), INTEM (intrinsic) MCF (p value 0.003) and FIBTEM (fibrinogen) MCF (p value <0.001) decreased during CRS. At day 7 INTEM and FIBTEM MCF values (p values of 0.004 and <0.001) were significantly higher than before surgery. No considerable changes in platelet count and hemoglobin concentration and absence of leukopenia are noticed. Conclusion This approach detects changes in coagulation much earlier than noticed by standard coagulation tests.
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Affiliation(s)
- Sven Van Poucke
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, ZOL, Genk, Belgium
- * E-mail:
| | - Dana Huskens
- Synapse Research Institute, Maastricht, The Netherlands
| | | | - Mark Roest
- Synapse Research Institute, Maastricht, The Netherlands
| | - Bart Lauwereins
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, ZOL, Genk, Belgium
| | - Ming-Hua Zheng
- Department of Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Seppe Dehaene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, ZOL, Genk, Belgium
| | | | - Abraham Marcus
- Department of Anesthesiology, ICU and Perioperative Medicine,HMC, Doha,Qatar
| | - Marcus Lancé
- Department of Anesthesiology & Pain Treatment, Maastricht University Medical Centre, Maastricht, The Netherlands
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Stiles ZE, Hinkle NM, Munene G, Dickson PV, Davidoff AM, Deneve JL. The Impact of Ostomy Creation after Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy in a Newly Established Peritoneal Malignancy Program. Am Surg 2018. [DOI: 10.1177/000313481808400618] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has improved outcomes for selected patients with peritoneal carcinomatosis and often requires ostomy creation. We examined the impact of ostomy creation in a newly established peritoneal malignancy program. A retrospective review was performed of CRS-HIPEC procedures from 2011 to 2016. Those who did and did not receive an ostomy were compared. Fifty-eight patients underwent CRS-HIPEC and an ostomy was created in 25.9 per cent. Median peritoneal cancer index (14 vs 16, P = 0.63) and multivisceral resection rates (87.9 vs 100.0%, P = 0.17) were similar between groups. Multivariable analysis revealed that bowel resection (OR 210.65, P = 0.02) was significantly associated with ostomy creation. Advanced age was noted to be inversely associated with stoma formation (OR 0.04, P = 0.04). Progression-free survival was significantly lower in the ostomy group (18 vs 23 months, P = 0.03). Those with an ostomy experienced prolonged length of stay (13.3 ± 7.4 vs 9.5 ± 3.7, P = 0.01). At follow-up, 6/10 temporary ostomies had undergone reversal and three patients experienced morbidity after reversal. Ostomy creation may occur during CRS-HIPEC and carries potential for morbidity. Ostomy creation may contribute to postoperative length of stay. Patients should be counseled preoperatively on the potential impact of ostomy placement during CRS-HIPEC.
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Affiliation(s)
- Zachary E. Stiles
- Department of Surgery, University of Tennessee Health Science Center (UTHSC), Memphis, Tennessee
| | - Nathan M. Hinkle
- Department of Surgery, University of Tennessee Health Science Center (UTHSC), Memphis, Tennessee
| | - Gitonga Munene
- Western Michigan University Homer Stryker School of Medicine, West Michigan Cancer Center, Kalamazoo, Michigan
| | - Paxton V. Dickson
- Department of Surgery, University of Tennessee Health Science Center (UTHSC), Memphis, Tennessee
| | - Andrew M. Davidoff
- Western Michigan University Homer Stryker School of Medicine, West Michigan Cancer Center, Kalamazoo, Michigan
| | - Jeremiah L. Deneve
- Department of Surgery, University of Tennessee Health Science Center (UTHSC), Memphis, Tennessee
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Bhatt A, Mishra S, Prabhu R, Ramaswamy V, George A, Bhandare S, Shah M, Mehta S. Can low grade PMP be divided into prognostically distinct subgroups based on histological features? A retrospective study and the importance of using the appropriate classification. Eur J Surg Oncol 2018; 44:1105-1111. [PMID: 29685759 DOI: 10.1016/j.ejso.2018.03.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/14/2018] [Accepted: 03/31/2018] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The pathological classification of PMP of appendiceal origin has prognostic and treatment implications. Our goals were to • Classify low grade mucinous carcinoma peritonei (LGMCP) into prognostically distinct subgroups based on histological features. • Compare the reproducibility of the WHO and the PSOGI classifications for both PMP and the appendiceal primary tumor. PATIENTS AND METHODS A retrospective analysis of patients undergoing CRS and HIPEC or debulking surgery was done. All the tumors were re-classified according to the PSOGI classification. LGMCP was further classified into three histological subgroups and the impact on survival was evaluated. RESULTS From Jun 2011 to June 2016, 101 patients underwent CRS with HIPEC (n = 89) or debulking surgery (n=12). The median PCI was 28 (3-39) and 74.1% patients had CC-0/1 resections. Of the 76.2% patients who had LGMCP, 4 patients (5.1%) were classified as group 1, 54 (70.1%) as group 2 and 19 patients (24.6%) as group 3. At a median follow up of 21 months, the disease free survival was not reached, 30 months and 14 months for groups 1, 2 and 3 respectively (p = 0.09). There was no difference in overall survival. Using the WHO classification, there was a discordance in the grade of the primary tumor and the peritoneal lesions in 19.8% and conflicting terminology was used in 62% of patients. CONCLUSIONS The subgroups of LGMCP described here are prognostically different though this needs further prospective evaluation in larger series. The PSOGI classification is more uniformly reproducible and should be preferred to the WHO classification.
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Affiliation(s)
- Aditi Bhatt
- Department of Surgical Oncology, Fortis Hospital, Bangalore, India.
| | - Suniti Mishra
- Department of Pathology, Fortis Hospital, Bangalore, India
| | - Robin Prabhu
- Department of Surgical Oncology, Fortis Hospital, Bangalore, India
| | | | - Antony George
- Department of Anesthesiology, Fortis Hospital, Bangalore, India
| | | | - Mita Shah
- Department of Pathology, Saifee Hospital, Mumbai, India
| | - Sanket Mehta
- Department of Peritoneal Surface Oncology, Saifeee Hospital, Mumbai, India
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Guerrero WL, Munene G, Dickson PV, Darby D, Davidoff AM, Martin MG, Glazer ES, Shibata D, Deneve JL. Early experience with cytoreduction and hyperthermic intraperitoneal chemotherapy at a newly developed center for peritoneal malignancy. J Gastrointest Oncol 2018; 9:338-347. [PMID: 29755773 DOI: 10.21037/jgo.2018.01.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has improved outcomes for patients with peritoneal carcinomatosis (PC). We present our experience from a newly developed peritoneal surface malignancy program. Methods An IRB approved retrospective review was performed for the first 50 patients treated with CRS/HIPEC with clinicopathologic data described. Results Patients treated with CRS/HIPEC were Caucasian (64%), female (66%) with a median age of 53 years (range, 11-73 years). Primary pathology included: appendix (40%, n=20), ovary (20%, n=10), colon (14%, n=7), desmoplastic small round cell tumor (14%, n=7) or other (12%, n=6). The median peritoneal cancer index (PCI) score was 15.5 (range, 1-39) and 92% underwent complete cytoreduction (CCR 0/1). Median hospital length of stay was 9.0 days (range, 6-35 days). Eight patients (16%) suffered major morbidity with 2 (4%) 30-day mortalities. Conclusions Short-term outcomes observed after CRS/HIPEC in a newly developed center for PC are consistent with published higher volume center experiences.
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Affiliation(s)
- Whitney L Guerrero
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Gitonga Munene
- Western Michigan University, Homer Stryker School of Medicine, West Michigan Cancer Center, Kalamazoo, MI, USA
| | - Paxton V Dickson
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dina Darby
- University of Tennessee Medical Practice, Surgical Oncology, Methodist Healthcare, Memphis, TN, USA
| | - Andrew M Davidoff
- Department of Pediatric Surgery, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Evan S Glazer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David Shibata
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Nizri E, Baratti D, Guaglio M, Sinukumar S, Cabras A, Kusamura S, Deraco M. Multicystic mesothelioma: Operative and long-term outcomes with cytoreductive surgery and hyperthermic intra peritoneal chemotherapy. Eur J Surg Oncol 2018; 44:1100-1104. [PMID: 29703622 DOI: 10.1016/j.ejso.2018.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/01/2018] [Accepted: 03/06/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Multicystic peritoneal mesothelioma (MCPM) is an extremely rare disease with 40-50% rate of recurrence after surgical debulking. Due to the recurrent nature of the disease, the option of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) was offered for this condition. In the present study we aimed to describe the outcomes of this strategy in a single center cohort. METHODS We retrospectively reviewed a prospectively collected database of all patients with MCPM that underwent the combined procedure in our center. Clinical presentation, operative procedures and outcomes were reviewed. RESULTS Between August 1997 and October 2017, 19 patients with MCPM underwent 20 cytoreduction and HIPEC procedures in our center. The majority of the patients were females (n = 17, 89%), and mean age was 42, as reported in other series. Disease extent, as measured by mean peritoneal carcinomatosis index (PCI) was 15.5 ± 9.9 and total number of procedures performed 6.7 ± 2.6. Major complications occurred in 3 (15%) patients, with no perioperative mortality. After a median of follow-up of 69 months (range 4-220) all patients were alive and 4 patients had recurrence (21%). Patients with high PCI (defined by median PCI) had shorter recurrence free survival (RFS) than patient with low PCI (mean RFS = 106.4 ± 6.6 for high PCI vs. 125.6 ± 34.1 for low PCI, p = 0.03). CONCLUSION Cytoreduction and HIPEC offer low recurrence rate and prolonged mean RFS for patients with MCPM. The combined procedure can be offered with acceptable morbidity in specialized centers.
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Affiliation(s)
- Eran Nizri
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy; Department of Surgery A, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Dario Baratti
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marcello Guaglio
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Snita Sinukumar
- Department of Oncology, Jehangir Hospital, Pune, Maharashtra, India
| | - Antonello Cabras
- Department of Pathology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Shigeki Kusamura
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.
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Sideris M, Hanrahan J, Tsoulfas G, Theodoulou I, Dhaif F, Papalois V, Papagrigoriadis S, Velmahos G, Turner P, Papalois A. Developing a novel international undergraduate surgical masterclass during a financial crisis: our 4-year experience. Postgrad Med J 2018. [PMID: 29519810 DOI: 10.1136/postgradmedj-2017-135479] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Essential Skills in the Management of Surgical Cases (ESMSC) is a novel 3-day international undergraduate surgical masterclass. Its current curriculum (Cores integrated for Research-Ci4R) is built on a tetracore, multiclustered architecture combining high-fidelity and low-fidelity simulation-based learning (SBL), with applied and basic science case-based workshops, and non-technical skills modules. We aimed to report our experience in setting up ESMSC during the global financial crisis. METHODS We report the evolution of our curriculum's methodology and summarised the research outcomes related to the objective performance improvement of delegates, the educational environment of the course and the use of mixed-fidelity SBL. Feedback from the last three series of the course was prospectively collected and analysed using univariate statistics on IBM SPSS V.23. RESULTS 311 medical students across the European Union (EU) were selected from a competitive pool of 1280 applicants during seven series of the course between 2014 and 2017. During this period, curriculum 14 s evolved to the final Ci4R version, which integrates a tetracore structure combining 32 stations of in vivo, ex vivo and dry lab SBL with small group teaching workshops. Ci4R was positively perceived across different educational background students (p>0.05 for any comparison). CONCLUSIONS ESMSC is considered an innovative and effective multidisciplinary teaching model by delegates, where it improves delegates objective performance in basic surgical skills. Our experience demonstrates provision of high-quality and free surgical education during a financial crisis, which evolved through a dynamic feedback mechanism. The prospective recording and subsequent analysis of curriculum evolution provides a blueprint to direct development of effective surgical education courses that can be adapted to local needs.
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Affiliation(s)
- Michail Sideris
- Women's Health Research Unit, Queen Mary University of London, London, UK
| | - John Hanrahan
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Georgios Tsoulfas
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Iakovos Theodoulou
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Fatema Dhaif
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | | | - George Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Boston, Maryland, USA
| | - Patricia Turner
- American College of Surgeons, Chicago, Illinois, USA.,Department of Surgery, Section of General Surgery, The University of Chicago, Chicago, Illinois, USA
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Sugarbaker PH, Turaga KK, Alexander HR, Deraco M, Hesdorffer M. Management of Malignant Peritoneal Mesothelioma Using Cytoreductive Surgery and Perioperative Chemotherapy. J Oncol Pract 2017; 12:928-935. [PMID: 27858561 DOI: 10.1200/jop.2016.011908] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Malignant peritoneal mesothelioma is a rare disease, with approximately 800 new patients per year in the United States. Its natural history is defined by progression restricted to the peritoneal space. In the past, patients with this disease had a limited lifespan of approximately 1 year. Numerous single-institution studies as well as a systematic review have reported median survival of 3 to 5 years with a combination of cytoreductive surgery and hyperthermic perioperative chemotherapy. These markedly improved survival statistics were achieved in experienced centers with 1% mortality and 20% morbidity rates. Data have shown that knowledgeable patient selection is required to prevent patients unlikely to benefit from undergoing these interventions. The conclusion is that patients with peritoneal mesothelioma can experience long-term progression-free survival or significant palliation with cytoreductive surgery plus hyperthermic perioperative chemotherapy. This management plan should be considered the standard of care for properly selected patients with malignant peritoneal mesothelioma at experienced centers around the world.
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Affiliation(s)
- Paul H Sugarbaker
- MedStar Washington Hospital Center, Washington, DC; University of Chicago, Chicago, IL; University of Maryland School of Medicine, Baltimore, MD; Mesothelioma Applied Research Foundation, Alexandria, VA; and Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Kiran K Turaga
- MedStar Washington Hospital Center, Washington, DC; University of Chicago, Chicago, IL; University of Maryland School of Medicine, Baltimore, MD; Mesothelioma Applied Research Foundation, Alexandria, VA; and Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - H Richard Alexander
- MedStar Washington Hospital Center, Washington, DC; University of Chicago, Chicago, IL; University of Maryland School of Medicine, Baltimore, MD; Mesothelioma Applied Research Foundation, Alexandria, VA; and Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Marcello Deraco
- MedStar Washington Hospital Center, Washington, DC; University of Chicago, Chicago, IL; University of Maryland School of Medicine, Baltimore, MD; Mesothelioma Applied Research Foundation, Alexandria, VA; and Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Mary Hesdorffer
- MedStar Washington Hospital Center, Washington, DC; University of Chicago, Chicago, IL; University of Maryland School of Medicine, Baltimore, MD; Mesothelioma Applied Research Foundation, Alexandria, VA; and Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori di Milano, Milan, Italy
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CRS and HIPEC for PMP-Use of the LC-CUSUM to Determine the Number of Procedures Required to Attain a Minimal Level of Proficiency in Delivering the Combined Modality Treatment. Indian J Surg Oncol 2017; 8:533-539. [PMID: 29203986 DOI: 10.1007/s13193-017-0692-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 08/07/2017] [Indexed: 01/02/2023] Open
Abstract
The learning curve for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for pseudomyxoma peritonei (PMP) which peaks at 90 procedures for the surgeon may take several years to reach. The cumulative summation (CUSUM) test of the learning curve (LC-CUSUM) was used to assess the safety of the procedure (minimal level of proficiency for the surgeon) in terms of morbidity, mortality, and completeness of cytoreduction and early oncological failure before the peak of the learning curve had been reached. The limits for h0 and h1 were set based on the results of large series of such cases published before. From 2011 to 2016, 77 patients with PMP underwent CRS and HIPEC. The mean peritoneal cancer index (PCI) was 28 and 75% of the patients had a CC-0/1 resection. The grade 3-4 morbidity was 42.6% and the mortality was 5.2%. The 5-year overall survival (OS) was 62.3% and the 3-year disease-free survival (DFS) was 71%. The LC-CUSUM analysis showed that for in-hospital mortality, acceptable limits are reached after the 57th case, after the 38th case for the grade 3-4 morbidity and CC-2/3 resections both and after the 70th case for early oncological failure. The number of cases required to attain a minimal level of proficiency for each prognostic variable is different. Using the CUSUM test, surgeons can analyze their performance and determine the areas in which they need to improve before the peak of the learning curve is reached. These outcomes reflect the performance of the multidisciplinary team and not the surgeon alone.
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