Tumor volume as a prognostic factor for sarcomatosis

Cytoreductive Surgery with Bidirectional Intraoperative Chemotherapy (BDIC) Using Intravenous Ifosfamide Plus Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Patients with Peritoneal Sarcomatosis: A Retrospective Cohort Study

BACKGROUND

Peritoneal sarcomatosis (PS) is a rare tumor with limited therapeutic options. Bidirectional intraoperative chemotherapy (BDIC) using intravenous ifosfamide and doxorubicin-based hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery (CRS) is an emerging treatment for peritoneal malignancies.

PATIENTS AND METHODS

Patients with PS who underwent CRS/BDIC using intravenous ifosfamide and HIPEC from January 2017 to July 2021 were retrospectively analyzed. The last follow-up date was May 2022.

RESULTS

A total of 29 patients were included. Overall survival (OS) rates at 6, 12, 24, and 48 months after CRS/BDIC were 93.1%, 89.2%, 81.4%, and 73.3%, respectively. As of May 2022, 6 patients (20.6%) had died, including four (13.8%) with a proven recurrent tumor and two with incomplete tumor resection [completeness of cytoreduction (CC)-2 or CC-3]. Of the 20 patients (68.9%) with CC-0 or CC-1, 7 had locoregional tumor recurrence without distant metastasis, whereas the other 13 were alive with no evidence of recurrent tumor in May 2022. Disease recurrence rates were 15% at 6 months and 35% at 12, 24, and 48 months after CRS/BDIC. Clavien-Dindo class ≥ IIIa complications developed in 9 patients (31.0%) with no deaths. Leukopenia occurred in 5 patients (17.2%) and thrombocytopenia in 12 patients (41.3%); these hematologic abnormalities resolved. A total of 9 (31.0%) patients developed nephrotoxicity; all recovered except one, who progressed to chronic kidney disease.

CONCLUSIONS

CRS/BDIC using intravenous ifosfamide and doxorubicin-based HIPEC is a potentially effective treatment for PS and has an acceptable rate of complications.

Unravelling Peritoneal Carcinomatosis Using Cross-Sectional Imaging Modalities

Peritoneal carcinomatosis (PC) refers to malignant epithelial cells that spread to the peritoneum, principally from abdominal malignancies. Until recently, PC prognosis has been considered ill-fated, with palliative therapies serving as the only treatment option. New locoregional treatments are changing the outcome of PC, and imaging modalities have a critical role in early diagnosis and disease staging, determining treatment decision making strategies. The aim of this review is to provide a practical approach for detecting and characterizing peritoneal deposits in cross-sectional imaging modalities, taking into account their appearances, including the secondary complications, the anatomical characteristics of the peritoneal cavity, together with the differential diagnosis with other benign and malignant peritoneal conditions. Among the cross-sectional imaging modalities, computed tomography (CT) is widely available and fast; however, magnetic resonance (MR) performs better in terms of sensitivity (92% vs. 68%), due to its higher contrast resolution. The appearance of peritoneal deposits on CT and MR mainly depends on the primary tumour histology; in case of unknown primary tumour (3-5% of cases), their behaviour at imaging may provide insights into the tumour origin. The timepoint of tumour evolution, previous or ongoing treatments, and the peritoneal spaces in which they occur also play an important role in determining the appearance of peritoneal deposits. Thus, knowledge of peritoneal anatomy and fluid circulation is essential in the detection and characterisation of peritoneal deposits. Several benign and malignant conditions show similar imaging features that overlap those of PC, making differential diagnosis challenging. Knowledge of peritoneal anatomy and primary tumour histology is crucial, but one must also consider clinical history, laboratory findings, and previous imaging examinations to achieve a correct diagnosis. In conclusion, to correctly diagnose PC in cross-sectional imaging modalities, knowledge of peritoneal anatomy and peritoneal fluid flow characteristics are mandatory. Peritoneal deposit features reflect the primary tumour characteristics, and this specificity may be helpful in its identification when it is unknown. Moreover, several benign and malignant peritoneal conditions may mimic PC, which need to be considered even in oncologic patients.

HIPEC for gynaecological malignancies: A last update (Review)

Advanced-stage gynaecological cancer represents a clinical entity with challenging surgical treatment in an effort to optimize prognosis. Hyperthermic intraperitoneal chemotherapy (HIPEC) following cytoreductive surgery (CRS) has been reported as a method potentially eligible to improve prognosis. However, no definitive conclusions have yet been made on which types of cancer and which context HIPEC may actually have a beneficial impact. The present review discusses the efficacy and safety of HIPEC as a treatment option for patients with primary/recurrent ovarian, endometrial and cervix cancer, as well as peritoneal sarcomatosis. A literature search was conducted using MeSH terms for each topic in the PubMed database and supplemented with a manual search to retrieve additional articles eligible for inclusion/fulfilling the inclusion criteria. The implementation of HIPEC appears to be beneficial in terms of survival in patients with epithelial ovarian carcinoma (EOC) following neoadjuvant chemotherapy, as well as in patients with recurrent EOC. Statistical superiority is not justified by current studies regarding other gynaecological malignancies with peritoneal dissemination. Furthermore, as regards safety, HIPEC following CRS does not appear to significantly increase the mortality and morbidity rates compared to the use of CRS alone. The rationale for using HIPEC and CRS in the treatment of ovarian cancer, particularly in the neoadjuvant setting, as well as for recurrences, is adequately evidenced, with acceptable safety and post-operative complication rate profiles. Its current place in the multimodal strategy for patients with peritoneal metastases remains uncertain, however. Randomized clinical trials are warranted to further examine the use of HIPEC and establish the optimal regimen and temperature settings. The role of optimal cytoreduction and no residual disease, as well as the proper patient selection remain basic parameters for maximizing survival parameters.

Multidimensional characteristics, prognostic role, and preoperative prediction of peritoneal sarcomatosis in retroperitoneal sarcoma

Background

Peritoneal sarcomatosis (PS) could occur in patients with retroperitoneal sarcomas (RPS). This study aimed to expand the understanding of PS on its characteristics and prognostic role, and develop a nomogram to predict its occurrence preoperatively.

Methods

Data of 211 consecutive patients with RPS who underwent surgical treatment between 2011 and 2019 was retrospectively reviewed. First, the clinicopathological characteristics of PS were summarized and analyzed. Second, the disease-specific survival (DSS) and recurrence-free survival (RFS) of patients were analyzed to evaluate the prognostic role of PS. Third, preoperative imaging, nearly the only way to detect PS preoperatively, was combined with other screened risk factors to develop a nomogram. The performance of the nomogram was assessed.

Results

Among the 211 patients, 49 (23.2%) patients had PS with an incidence of 13.0% in the primary patients and 35.4% in the recurrent patients. The highest incidence of PS occurred in dedifferentiated liposarcoma (25.3%) and undifferentiated pleomorphic sarcoma (25.0%). The diagnostic sensitivity of the preoperative imaging was 71.4% and its specificity was 92.6%. The maximum standardized uptake value (SUVmax) was elevated in patients with PS (P<0.001). IHC staining for liposarcoma revealed that the expression of VEGFR-2 was significantly higher in the PS group than that in the non-PS group (P = 0.008). Survival analysis (n =196) showed significantly worse DSS in the PS group than in non-PS group (median: 16.0 months vs. not reached, P < 0.001). In addition, PS was proven as one of the most significant prognostic predictors of both DSS and RFS by random survival forest algorithm. A nomogram to predict PS status was developed based on preoperative imaging combined with four risk factors including the presentation status (primary vs. recurrent), ascites, SUVmax, and tumor size. The nomogram significantly improved the diagnostic sensitivity compared to preoperative imaging alone (44/49, 89.8% vs. 35/49, 71.4%). The C-statistics of the nomogram was 0.932, and similar C-statistics (0.886) was achieved at internal cross-validation.

Conclusion

PS is a significant prognostic indicator for RPS, and it occurs more often in recurrent RPS and in RPS with higher malignant tendency. The proposed nomogram is effective to predict PS preoperatively.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal sarcomatosis-A systematic review and meta-analysis

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) play an important role in the treatment of various peritoneal surface malignancies, but its efficacy in peritoneal sarcomatosis (PS) remains unknown. Hence, we performed a systematic review and meta-analysis to investigate outcomes of CRS-HIPEC in PS, in accordance with PRISMA guidelines. 16 studies with a total of 320 patients were included in the meta-analysis. Pooled mean length of hospital stay after CRS-HIPEC was 16.0 days (95% CI: 12.2-19.8) and rate of serious complications was 17.4% (95% CI: 9.8-26.3). The median DFS was 12.0 months (95% CI: 8.0-16.0) and the 5-year DFS was 21.8% (95% CI: 13.2-31.7). Overall pooled median OS was 29.3 months (95% CI: 23.8-34.8), with a 5-year OS of 35.3% (95% CI: 26.3-44.8). Subgroup analysis showed that patients with CC-0 cytoreduction had a higher median OS of 34.6 months (95% CI: 23.2-45.9). Median OS for patients with a primary tumour histology of leiomyosarcoma and liposarcoma was 33.5 months (95% CI: 15.9-51.1) and 39.1 months (95% CI: 20.8-57.5) respectively. The site of recurrence was locoregional in 57.3% (95% CI: 38.9-74.8), distant in 17.3% (95% CI: 3.9-35.6), and both in 17.4% (95% CI: 5.8-32.2). In conclusion, our results suggest that CRS-HIPEC may improve outcomes in a select group of PS patients.

Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy in Peritoneal Sarcomatosis

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the treatment most likely to achieve prolonged survival for peritoneal surface disease from various primaries, yet management of peritoneal sarcomatosis is controversial as a result of the propensity of sarcomas for hematogenous spread and the paucity of effective chemotherapy. Therefore, we reviewed our experience in patients with sarcomatosis. A retrospective analysis of a prospective database of 990 procedures was performed. Eastern Cooperative Oncology Group, age, type of primary, resection status, morbidity, mortality, and outcomes were reviewed. Over 20 years, 17 cytoreductions for sarcomatosis were performed. After excluding patients with gastrointestinal stromal tumor or uterine leiomyosarcoma, 10 procedures performed in seven patients remained. Median follow-up was 84.8 months. R0/1 resection was achieved in 60 per cent. The 30-day morbidity was 50 per cent; no operative mortality rate was observed. R2 resection had no long-term survivors. The reason for death was peritoneal recurrence in 57 per cent. Median survival was 21.6 months and five-year survival was 43 per cent. Median survival for patients with peritoneal sarcomatosis treated with CRS-HIPEC is similar with the historical reported survival before introducing chemoperfusion. Although a complete cytoreduction is related to improved survival, the role of HIPEC in these patients is unknown. A multi-institutional review will help define the role of CRS-HIPEC in this population.

Fibrosarcoma with sarcomatosis and metastasis in a FeLV-negative cat

A 6-year-old, spayed female, mixed shorthair cat presented to the emergency service at The Ohio State University Veterinary Medical Center for evaluation of hypercalcemia, a right eye mass, and multiple intrathoracic and intra-abdominal masses. Cytologic evaluation of one of the abdominal masses revealed a uniform population of large, anaplastic mesenchymal cells found individually, in loose aggregates, and occasionally associated with pink, extracellular matrix. The cytology was consistent with a malignant mesenchymal neoplasm, with primary consideration given to fibrosarcoma and hemangiosarcoma. The cat was euthanized and histopathology confirmed disseminated fibrosarcoma. Fibrosarcoma comprises 12%-41% of feline cutaneous tumors and affects cats at a mean age of 9.6 years. Three manifestations of fibrosarcoma predominate in cats: spontaneous solitary fibrosarcoma, vaccine-induced/injection site fibrosarcoma, and oncogene-induced (FSV) fibrosarcoma. The history, signalment, and results from diagnostics performed did not support solitary fibrosarcoma or injection-induced sarcoma. Although some criteria fit with virally induced fibrosarcoma, such as age and the presence of multiple fibrosarcomas, the neoplastic population was negative for FeLV IHC. The presence of fibrosarcomas throughout the pleural and peritoneal cavity was most compatible with sarcomatosis and the distant metastasis of an unidentified primary neoplasm. To the authors' knowledge, this is the first reported case of sarcomatosis in a FeLV-negative cat.

A Simplified Peritoneal Sarcomatosis Score for patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Background

With the introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), long-term survival can be achieved in selected patients with peritoneal surface malignancy. In patients with peritoneal sarcomatosis (PS), CRS/HIPEC remains a topic of debate. It is important that patient selection and outcome be improved with a tool that better predicts survival in such patients. To this end, we devised a Simplified Peritoneal Sarcomatosis Score (SPSS) adopted from the previously-described peritoneal surface disease severity score (PSDSS).

Methods

Patients were included if they were diagnosed with PS and underwent CRS/HIPEC with intended complete cytoreduction between 2007 and 2017. To calculate SPSS, we recorded symptoms (none =0, present =1), peritoneal carcinomatosis index (PCI) (≤10=0, >10=1), and grade of tumor (low =0, high =1). Thus, SPSS ranged from 0 to 3. SPSS-L (low) included patients with score of 0-1; SPSS-H (high) included patients with scores 2-3. Survival curves were generated using Kaplan-Meier method according to the two tiers of SPSS.

Results

Twenty-five patients were included. Mean age was 51.84±10.75 years. Median follow-up was 18 months. Compared to SPSS-H, SPSS-L patients had a longer median overall survival (OS) (36±16 vs. 16±6 months, respectively; P=0.021) and a longer median disease-free survival (DFS) (36±16 vs. 16±6 months, respectively; P<0.001). On multivariate analysis, advanced disease (SPSS-H) was an independent predictor of OS (P=0.020) and DFS (P=0.018).

Conclusions

SPSS can be used as a tool for patient selection for surgery, prognosis prediction, and stratification into clinical trials of PS patients.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in seven patients with peritoneal sarcomatosis from uterine sarcoma

Peritoneal sarcomatosis from uterine sarcoma is a rare disease with no effective treatment and poor prognosis. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has successful results in peritoneal carcinomatosis from gastrointestinal/gynecological origins. We show that CRS/HIPEC is safe, feasible, and may benefit selected patients with peritoneal sarcomatosis from uterine sarcoma.

Cytoreductive Surgery in Combination with HIPEC in the Treatment of Peritoneal Sarcomatosis

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an effective treatment for peritoneal carcinomatosis, but it has been debated for peritoneal sarcomatosis. The purpose of the study is the presentation of perioperative and long-term results of CRS and hyperthermic intraoperative intraperitoneal chemotherapy in patients with peritoneal sarcomatosis. Retrospective study in a prospectively maintained database of 20 patients that underwent 29 CRS + HIPEC for peritoneal sarcomatosis. Clinical and histopathologic variables were correlated to survival. Complete cytoreduction was possible in 86.2% of the cases. The hospital mortality and morbidity rate were 0 and 20.7%, respectively. The median follow-up was 26 months, and recurrence was recorded in 20 cases (69%). The median and 5-year survival was 55 ± 13 (34-58) months and 43%, respectively. Prior surgical score (PSS) was the single variable related to survival (p = 0.018). The histologic subtype of the tumor was related to recurrence (p < 0.001). CRS and HIPEC in peritoneal sarcomatosis may offer a survival benefit in selected patients with low hospital mortality. The variety of histologic types of sarcomatosis has not made possible the identification of subgroups of patients that may be offered significant benefit by CRS and HIPEC. Further studies are required.

Cytoreductive surgery and HIPEC in the treatment of peritoneal metastases of sarcomas and other rare malignancies

.................................... Cytoreductive surgery and HIPEC in the treatment of peritoneal metastases of sarcomas and other rare malignancies.

Multi-institutional study of peritoneal sarcomatosis from uterine sarcoma treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

OBJECTIVE

Uterine sarcoma (US) is a rare tumor representing 1% of female genital tract malignancies. Peritoneal sarcomatosis (PS) after US, diminishes median overall survival (OS) and progression-free survival (PFS) with cytoreductive surgery (CRS) alone, with or without systemic chemotherapy is <1 year and 6 months, respectively. A multi-institutional review of PS from US was conducted to evaluate CRS and hyperthermic intraperitoneal chemotherapy (HIPEC) and effects on survival outcomes.

METHODS

A retrospective review of 36 patients from 7 specialized international centers was performed. Selection criteria included PS of uterine origin with CRS/HIPEC treatment. Clinical data were analyzed. OS and PFS were estimated with Kaplan-Meier method.

RESULTS

Thirty-six patients underwent a total 38 HIPEC procedures performed from 2005 to 2014; 35 previous treatment and 1 primary treatment. Twenty-nine (81%) LMS patients, 3 (8%) endometrial stromal sarcoma (ESS), 3 (8%) adeneosarcoma (AS), and 1 (3%) categorized as other. Median PCI was 16 (range: 2-39), 10 patients had PCI ≥20. Thirty-four patients (94%) had complete cytoreduction (CC 0-1), 19 patients recurred. CRS/HIPEC OS at 1, 3, and 5-years was 75%, 53%, and 32% respectively, with median OS of 37 months (CI 95%: 20-54). PFS in 32 patients with CC at 1, 3, and 5-years was 67%, 32% and 32%, respectively with median PFS of 18.9 months (CI 95%: 6.7-31).

CONCLUSIONS

CRS/HIPEC is a promising treatment modality for patients with PS. Histological subtype may influence survival. A global prospective registry of patients to further assess the efficacy of CRS/HIPEC is needed.

Peritoneal metastases of rare carcinomas treated with cytoreductive surgery and HIPEC - A single center case series

Introduction

In selected cases, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an established treatment for patients suffering from peritoneal metastases from colorectal, ovarian, gastric or appendiceal origin. The effectiveness of this extensive has not been elucidated within other rare diseases by now.

Methods

We conducted a retrospective analysis of patients treated with CRS for peritoneal carcinomatosis during the period between July 2010 and September 2015. Exclusion criteria were adenocarcinomas of the stomach, colon, neoplasms of the appendix, mesothelioma and ovarian cancers. Aim of this study was to examine the feasibility, complication rate and survival of patients with rare diseases.

Results

A total of 14 Patients were included: Four rare gynecological tumors, three adenocarcinomas of the small intestine, three retroperitoneal sarcomas, one cholangiocellular carcinoma, one neuroendocrine gastric tumor, one malignant peripheral nerve sheath tumor and one cancer of unknown primary syndrome. In 12 of 14 patients a macroscopically complete tumorresection could be achieved. No patient died during hospitalization. Seven of 14 patients experienced general complication of grade III according to NCI CTCAE V4.0, while two experienced complications of grade IV. Median follow-up and one year overall survival were 15.5 months and 46.8%, respectively.

Conclusion

For patients with rare tumors, CRS and HIPEC is feasible with an acceptable perioperative morbidity and mortality. To improve knowledge in patient selection and outcome, rare tumors treated with CRS and HIPEC should be documented in central databases (as for example BIG RENAPE, Pierre-Benite, France).

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The difficulties in deciding of whether to perform CRS and HIPEC for PSM arising from unusual malignancies are remaining.

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Perioperative morbidity for extensive surgical treatment and HIPEC is acceptable in specialized PSM centers.

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The prospective registration in tumor registries could help to better define the indications for CRS and HIPEC in rare PSM.

Cytoreductive Surgery plus Hyperthermic Intraperitoneal Chemotherapy for Management of Peritoneal Sarcomatosis: A Preliminary Single-Center Experience from Saudi Arabia

Aim. To report our preliminary single-center experience with cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for management of peritoneal sarcomatosis (PS). Methods. Eleven patients were retrospectively analyzed for perioperative details. Results. Cytoreduction completeness (CC-0/1) was achieved in all patients with median peritoneal cancer index (PCI) of 14 ± 8.9 (range: 3-29). Combination cisplatin + doxorubicin HIPEC chemotherapy was used in 6 patients. Five patients received intraoperative radiation therapy (IORT). The median operative time, estimated blood loss, and hospital stay were 8 ± 1.4 hours (range: 6-10), 1000 ± 250 mL (range: 700-3850), and 11 ± 2.4 days (range: 7-15), respectively. Major postoperative Clavien-Dindo grade III/IV complications occurred in 1 patient and none developed HIPEC chemotherapy-related toxicities. The median overall survival (OS) and disease-free survival (DFS) after CRS + HIPEC were 28.3 ± 3.2 and 18.0 ± 4.0 months, respectively. The median follow-up time was 12 months (range: 6-33). Univariate analysis of several prognostic factors (age, gender, PS presentation/pathology, CC, PCI, HIPEC chemotherapy, and IORT) did not demonstrate statistically significant differences of OS and DFS. Conclusion. CRS + HIPEC appear to be feasible, safe, and offer survival oncological benefits. However, definitive conclusions cannot be deduced.

Cytoreduction and HIPEC in the treatment of "unconventional" secondary peritoneal carcinomatosis

BACKGROUND

Peritoneal metastasis (PM) is considered a terminal and incurable disease. In the last 30 years, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) radically changed the therapeutic approach for these patients and is regarded as the standard of care for pseudomyxoma peritonei from appendiceal cancer and peritoneal mesotheliomas. Improved survival has also been reported in treating PM from ovarian, gastric, and colorectal cancers. However, PM often seriously complicates the clinical course of patients with other primary digestive and non-digestive cancers. There is increasing literature evidence that helped to identify not only the primary tumors for which CRS and HIPEC showed a survival advantage but also the patients who may benefit form this treatment modality for the potential lethal complications. Our goal is to report our experience with cytoreduction and HIPEC in patients with PM from rare or unusual primary tumors, discussing possible "unconventional" indications, outcome, and the peculiar issues related to each tumor.

METHODS

From a series of 253 consecutive patients with a diagnosis of peritoneal carcinomatosis and treated by CRS and HIPEC, we selected only those with secondary peritoneal carcinomatosis from rare or unusual primary tumors, excluding pseudomyxoma peritonei, peritoneal mesotheliomas, ovarian, gastric, and colorectal cancers. Complications and adverse effects were graded from 0 to 5 according to the WHO Common Toxicity Criteria for Adverse Events (CTCAE). Survival was expressed as mean and median.

RESULTS

We admitted and treated by CRS and HIPEC 28 patients with secondary peritoneal carcinomatosis from rare or unusual primary tumors. Morbidity and mortality rates were in line with those reported for similar procedures. Median survival for the study group was 56 months, and 5-year overall survival reached 40.3 %, with a difference between patients with no (CC0) and minimal (CC1) residual disease (52.3 vs. 25.7), not reaching statistical significance. Ten patients are alive disease-free, and eight are alive with disease.

CONCLUSIONS

Cytoreduction and HIPEC should not be excluded "a priori" for the treatment of peritoneal metastases from unconventional primary tumors. This combined therapeutic approach, performed in an experienced center, is safe and can provide a survival benefit over conventional palliative treatments.

The role of hyperthermic intraperitoneal chemotherapy (HIPEC) and isolated perfusion (ILP) interventions in sarcoma

Locally advanced sarcomas in the extremity and in the retroperitoneum/abdominal cavity (peritoneal sarcomatosis, PS) can be managed administering chemotherapy locally using isolated limb perfusion (ILP) and hyperthermic intraperitoneal chemotherapy (HIPEC), respectively. In this review, the authors discuss the pros and cons of the use of these locoregional therapies in locally advanced soft tissue sarcoma, with a view to establishing their role in the multidisciplinary approach to these difficult diseases.

Favorable outcomes after whole abdominopelvic radiation therapy for pediatric and young adult sarcoma

BACKGROUND

Current Children's Oncology Group (COG) guidelines recommend 24 Gy whole abdominopelvic radiation therapy (WAP-RT) for pediatric patients with sarcoma with peritoneal dissemination and/or malignant ascites. However, WAP-RT has never been described for pediatric sarcoma excluding desmoplastic small round-cell tumor (DSRCT). The objective of this study was to evaluate feasibility, outcomes, and toxicity of WAP-RT in children with sarcoma and peritoneal dissemination.

PROCEDURE

Detailed records of all 10 pediatric patients with sarcoma (excluding DSRCT) treated with WAP-RT from 2001 to 2013 were reviewed.

RESULTS

Median age was 9.9 years (range, 1.7-33.8). Seven patients had rhabdomyosarcoma, 2 embryonal undifferentiated sarcoma of the liver, and 1 Ewing sarcoma. Patients received a median dose of 24 Gy with intensity-modulated radiation therapy (IMRT) to the whole abdomen and pelvis. Two patients did not complete treatment, one due to transfusion-resistant pancytopenia and one due to moderate acute gastrointestinal toxicity. At a median follow-up of 4.0 years, both relapse-free survival and overall survival were 100%. Acute hematologic toxicities were common, with 40% of patients developing a grade 4 hematologic toxicity. Most acute gastrointestinal toxicities were grade 1 and managed appropriately with anti-diarrheals and anti-emetics. Late effects varied, and half of patients are without long-term sequelae.

CONCLUSIONS

All patients remain free of disease, both locally and distantly. Although WAP-RT was associated with acute and late toxicity, treatment was feasible with supportive care. Given the excellent rates of tumor control, we recommend that all providers give WAP-RT with IMRT to patients with pediatric sarcoma and peritoneal dissemination and/or malignant ascites.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of recurrent high-grade uterine sarcoma with peritoneal dissemination

OBJECTIVE

Peritoneal sarcomatosis from primary uterine sarcoma (US) is a rare condition. Conventional therapeutic modalities have failed to improve survival and outcomes among patients with high-grade US with extrapelvic spread. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has shown improved outcomes for peritoneal carcinomatosis from other epithelial primaries with similar clinical presentation. We report our experience applying this treatment in 3 patients with recurrent high-grade US with peritoneal dissemination.

STUDY DESIGN

This retrospective review of a prospective database of 378 patients with peritoneal dissemination of cancer treated with CRS/HIPEC identified 3 patients with recurrent high-grade US. Follow-up for disease progression was carried out by physical examination and computed tomography scan of the chest, abdomen, and pelvis.

RESULTS

Two leiomyosarcomas and 1 adenosarcoma with sarcomatous overgrowth were identified. Two of the 3 had failed standard treatment with surgery and systemic chemotherapy before CRS/HIPEC was performed. Follow-up ranged from 34 to 140 months. All 3 patients are alive, 2 with no evidence of disease (NED), and 1 alive with disease. Adramycin/cisplatin was used for HIPEC in 1 case (140 months with NED), whereas melphalan was used in the other 2 cases (53 months alive with disease, 34 months with NED). Two patients underwent 1 CRS/HIPEC, whereas 1 required 3 CRS/HIPEC due to disease recurrence.

CONCLUSION

CRS/HIPEC shows promise as a treatment modality for the management of selected patients with recurrent high-grade US with peritoneal dissemination. Further studies are warranted.

Peritoneal sarcomatosis in pediatric malignancies

Peritoneal sarcomatosis (PSC) is defined as peritoneal involvement of multiple sarcomatous tumors. Desmoplastic small round cell tumors (DSRCT) and rhabdomyosarcomas are the most common pediatric PSC cases. PSC has been treated with chemotherapy and mainly palliative surgery, but long-term outcome has been poor. New imaging technologies have improved the evaluation of disease extent and patterns of peritoneal dissemination, and cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is being evaluated as a treatment option to prolong remission in pediatric patients. We will review the clinical characteristics, potential biologic mechanisms, radiographic characteristics, and potential therapies for pediatric PSC patients.

Indikationen und Resultate der Peritonektomie bei nichtkolorektaler Peritonealkarzinose

<b><i>Hintergund:</i></b> In dieser Übersichtsarbeit soil der Stellenwert der zytoreduktiven chirurgischen Therapie (CRS) in Kombination mit einer hyperthermen intraperitonealen Chemotherapie (HIPEC) der Peritonealkarzinose bei nichtkolorektalen Karzinomen dargestellt werden. Hierzu zählen als primäre Tumoren des Peritoneums das Mesotheliom und das Pseudomyxoma peritonei. Zu den wichtigsten sekundären malignen Erkrankungen des Peritoneums zählen die Peritonealkarzinose des Magenkarzinoms, des Pankreaskarzinoms und des Ovarialkarzinoms sowie die Sarkomatose. <b><i>Methode:</i></b> Pathologische Besonderheiten der einzelnen Entitäten und Therapieempfehlungen anhand der aktuellen Literatur werden im Einzelnen beschrieben. <b><i>Ergebnisse:</i></b> Prinzipiell ist die chirurgische Behandlung der Peritonealkarzinose im Sinne einer CRS in Kombination mit einer HIPEC ein sinnvolles Therapiekonzept - vorausgesetzt, dass eine nahezu komplette Tumorentfernung erzielt werden kann. <b><i>Schlussfolgerung: </i></b>Aufgrund der erhöhten Morbidität sollte ein chirurgischer Eingriff gut indiziert sein. Bei ausgewählten Patienten ist eine CRS der Peritonealkarzinose in Kombination mit einer HIPEC ein sinnvolles und lebensverlängerndes Verfahren.

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

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

Gastrointestinal stromal tumours treated before and after the advent of c-kit immunostaining

BACKGROUND

Recently developed immunohistochemical markers have revolutionised the classification of gastrointestinal stromal tumours (GISTs) whilst tyrosine kinase inhibitors (imatinib) have had a significant impact on the treatment of advanced tumours. We review the clinicopathological features of previously resected mesenchymal tumours of the gastrointestinal tract in our institution to 1) reclassify the histological diagnosis of those stained prior to c-kit availability; 2) perform survival analysis to identify prognostic factors, and 3) to consider the implications for patients.

METHODS

Clinicopathological records of patients with a diagnosis of mesenchymal tumours treated between May 1992 and April 2007 were reviewed.

RESULTS

82 patients were reviewed. 26 (32%) were reclassified as GISTs following c-kit immunostaining and a further 14 patients were treated for GIST up to April 2007 (Total: 40 patients; 21 males and 19 females, mean age 67, range 30-92 years). 36 (90%) underwent complete resection. 5-year survival of patients with GIST alone was 80%. Females had a better median survival (M: F 43 months: 73 months).

CONCLUSIONS

The availability of c-kit staining allowed 32% of previously diagnosed mesenchymal tumours to be reclassified as GISTs. This may have implications for the follow-up of patients diagnosed prior to the availability of this method.

Gastrointestinal stromal tumors and shock

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumor of the gastrointestinal tract. Clinically, they are associated with nonspecific symptoms, but some patients can present gastrointestinal bleeding with shock. We report two cases of GIST of the small bowel, revelated by hemorrhagic shock secondary to acute bleeding, succesfully treated by emergency surgery.

Toxicity and Outcomes Associated with Surgical Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Patients with Sarcomatosis

BACKGROUND

Treatment of peritoneal recurrence following surgical resection of intra-abdominal sarcomas presents a significant challenge to clinicians. Historically, treatment with systemic chemotherapy has been ineffective and surgical resection alone has not been durable. We prospectively evaluated the feasibility of cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin (CDDP) alone or in combination with mitoxantrone (MITOX) for the treatment of sarcomatosis.

METHODS

Two phase I trials of HIPEC were conducted (1998-2003). Eligible patients with evidence of sarcomatosis underwent cytoreductive surgery followed by HIPEC. In the first trial, CDDP dosing was established as 90 mg/m2 with a perfusate time of 90 minutes and temperature of 41 degrees C. In the second trial, MITOX (20 mg/m2) was instilled following perfusion with CDDP. Toxicity, efficacy, and quality of life (QOL) were evaluated.

RESULTS

A total of 28 patients were enrolled in the two trials. We noted a higher overall toxicity score and complication rate with combination CDDP/MITOX versus CDDP alone and shorter overall survival duration (5.5 months vs 16.9 months, respectively). In addition, local recurrence rates were similar in both groups (CDDP 79% vs CDDP/MITOX 68%). As expected, QOL scores at 6-8 weeks following HIPEC were 15-25% lower than the baseline scores; however, they returned to baseline at 3-6 months.

CONCLUSIONS

Although the HIPEC technique is feasible for patients with sarcomatosis, it is associated with significant toxicity and limited clinical benefit. Combination CDDP/MITOX failed to demonstrate any benefit over CDDP alone; moreover, there was an increase in toxicity.

Surgical resection for gastrointestinal stromal tumors (GIST): experience on 25 patients

BACKGROUND

Gastrointestinal stromal tumors (GIST) are infrequent and diagnosis and prognosis could be troublesome. We present short and long term results of surgical resection for GIST at the Department of Surgery, University of Insubria, during a period of 17 years.

MATERIALS AND METHODS

All patients' data, tumor characteristics, surgical procedure and survival data were analyzed retrospectively. Tumors were divided in risk classes using the classification proposed by Fletcher, based on tumor size and number of mitosis.

RESULTS

Between 1987 and 2004, 25 patients underwent surgical resection for GIST. Stomach was the most common site of localization. Complete resection was achieved in 88% cases, while in 12% radical resection was not possible. The mean tumor size was 9.2 cm (1.2-30 cm): <5 cm diameter in 14/25 cases (56%), 5-10 cm in 5/25 (20%) and >10 cm in 6/25 (24%). Mitotic count was <10/50 HPF in 68% (17/25) and >10/50 in 32% (8/25). Using Fletcher's classification, tumors were divided in very low (11/25, 44%), low (4/25, 16%), intermediate (6/25, 24%) and high-risk (4/25, 16%) groups. The 5-year overall survival was 65% and 34% respectively with a statistically significant difference between tumors <5 cm and >10 cm in diameter and between complete and incomplete resection. High-risk tumors had a significantly shorter survival than low or very low risk.

CONCLUSION

Our experience confirms that GIST's are uncommon and aggressive cancers. The prognosis is strictly related to tumor size and number of mitosis. Although significant advances on new chemotherapeutic regimes have been made, to date, only radical surgery offers the chance of long-term survival.

Randomized trial of cytoreduction followed by intraperitoneal chemotherapy versus cytoreduction alone in patients with peritoneal sarcomatosis

PURPOSE

In order to decrease loco-regional relapse after complete resection of peritoneal sarcomatosis (PS), the role of intraperitoneal chemotherapy (IPEC) was prospectively evaluated.

METHODS

Patients (pts) with completely resected PS were randomized between adjunction of IPEC or not. IPEC consisted of doxorubicin, 0.1mg/kg and cisplatin, 15 mg/m(2) per day for 5 consecutive days. Primary endpoint was survival, measured as time from randomization to death. The scheduled number of patients needed was 40 in order to detect a minimal increase of 40% overall survival with the adjunction of IPEC with a power of 80%.

RESULTS

Thirty-eight consecutive pts have been randomized, 19 in each group. Ratio of retroperitoneal (RPS) and visceral (VS) sarcomatosis were 9/10 and 6/13 in IPEC- and IPEC+ group, respectively. Histoprognostic grade, Sugarbaker's score and mean number of resected organs were similar in both groups. There were no toxic deaths and morbidity was similar in both groups (four pts in each group). The median follow-up is 60 months. The median local relapse-free, metastatic relapse-free survival and overall survival were identical in both groups (12.5, 18 and 29 months, respectively), with no difference between RPS and VS sarcomatosis.

CONCLUSION

Administration of IPEC after a macroscopically complete surgery did not allow to increase greatly the outcome of pts. Complete surgery remains the cornerstone of the treatment of patients with sarcomatosis with best results for low grade sarcomatosis.

Update on the biology and therapy of gastrointestinal stromal tumors

BACKGROUND

Gastrointestinal stromal tumors (GISTs), the most common mesenchymal tumors of the gastrointestinal tract, are an example of a disease with an effective, molecularly targeted therapy.

METHODS

Published articles and author experience were used to comprehensively define the clinical features, biology, and state-of-the-art therapy of GISTs.

RESULTS

GISTs are thought to originate from the neoplastic transformation of the interstitial cells of Cajal, the intestinal pacemaker cells. GISTs commonly have mutations in the kit gene, resulting in a gain-of-function mutation and ligand-independent constitutive activation of the KIT receptor tyrosine kinase. Successful tyrosine kinase inhibitors target the aberrant pathways that are critical for tumor cell viability. The development of imatinib mesylate (formerly STI 571) in the treatment of metastatic GISTs represents a therapeutic breakthrough.

CONCLUSIONS

Progress in the clinical diagnosis has led to an increased recognition of this disease as a distinct clinical entity. Treatment of metastatic GIST with imatinib has led to unprecedented improvements in progression-free and overall survival. The use of imatinib in the preoperative and postoperative treatment of GISTs is an area of intense investigation.

Sarcomes du grêle

Sarcomas of the small intestine are rare, clearly differentiated, malignant, mesenchymatous tumours that can be of smooth muscle, Schwann cell or fibroblastic origin. From a clinical point of view, the pain and abdominal mass are the 2 types of symptoms that frequently reveal the disease. In rare cases, sarcomas of the small intestine are manifested by an acute complication. No imaging method can clearly confirm the diagnosis. Before immunohistochemistry, differential diagnosis was made on undifferentiated mesenchymatous "stromal" tumours, which are also rare. Exeresis must be complete and without perforation of the tumour because of the risk of locoregional relapse. The benefits provided by chemotherapy and radiotherapy are limited because of the low mitotic activity of the tumour cells and its weak vascularisation. Long-term survival is limited by poor prognosis criteria: high grade malignancy, size greater than 5 cm, tumour extension, perforation of the tumour, quality of surgical resection and histological type.

Giant malignant gastrointestinal stromal tumors: Recurrence and effects of treatment with STI-571

AIM: Malignant gastrointestinal stromal tumors (GISTs) are rare. Tumors larger than 10 cm tend to recur earlier: the larger the volume of the tumor, the worse the prognosis. We hypothesized that treatment with imatinib mesylate (Gleevec; STI-571), a c-kit tyrosine kinase inhibitor, as palliative therapy would prolong the survival of patients with recurrent giant malignant GISTs after resection.

METHODS: We performed a retrospective analysis of the effects of resection on patients with giant GISTs (>10 cm in diameter) to determine the overall survival and recurrence rates. Twenty-three patients diagnosed with giant GISTs were included from June 1996 to December 2003. STI-571 was not available until January 2000. After that time, 9 patients received this drug. The factors of age, sex, tumor location, histological surgical margin, and STI-571, tumor size changes and drug side effects were reviewed. We compared the survival rate to determine the prognostic factors and the effects of STI-571 on patients with recurrent malignant gastrointestinal stromal tumor.

RESULTS: The positive surgical margin group had a significantly higher recurrence rate than the negative margin group (P = 0.012). A negative surgical margin and palliative treatment with STI-571 were significant prognostic variables (Log-rank test, P<0.05). Age, sex and tumor location were not significant prognostic variables. The 5-year survival rate of the surgical margin free patients was 80% and the 2-year survival rate of the surgical margin positive patients was 28%. The 5-year survival rate was 80% for the patients given STI-571 and 30% for the patients not given STI-571. The use of STI-571 gave a significant tumor shrinkage (6/9) rate in patients with giant GIST recurrence after resection.

CONCLUSION: A negative surgical margin and the use of STI-571 after surgical resection were good prognostic indicators. Achieving a tumor-free surgical margin is still the best primary treatment for patients with such tumors. If STI-571 is used immediately when the surgical margin is positive and the tumor recurs after resection, then the prognosis of patients with giant GISTs can be improved.

CT-based analysis of malignant tumor volume and localization: a preliminary study

The purpose of this study was to correlate 3D-CT (3D computed tomography) volume measurements of malignant tumors with the response to treatment, and to observe bone invasion in these lesions applying a specific imaging protocol. We analyzed 17 individuals with maxillofacial malignant lesions who were submitted to spiral CT (2D-CT). The original data were transferred to an independent workstation using a 3D volume rendering package software, which was used by two examiners to obtain area and volume measurements of the lesions, independently, three times each, prior to and after treatment. The segmentation protocol was applied for the assessment of bone involvement. The difference between imaging and gold standard values was not considered significant (p > 0.05). Regarding bone invasion, three false-negatives were obtained using MPR-CT (multiplanar reconstruction) and no false-negatives were obtained using the 3D segmentation protocol. The use of 3D-CT may be a differential and important factor for expanding options regarding the localization, dimension, and clarification of lesion components.

Outcome and long term results of surgical resection for gastrointestinal stromal tumors (GIST)

BACKGROUND AND AIMS

Gastrointestinal Stromal Tumors (GIST) are rare; diagnosis and prognosis of these tumors are often complex. We present short and long term results of surgical resection for GIST at the Department of Surgery, University of Insubria, during a period of 14 years.

MATERIAL AND METHODS

All patients' data, tumor characteristics, surgical procedure and survival data were analyzed retrospectively. Tumors were divided in risk classes using a new classification proposed by Fletcher, based on tumor size and number of mitosis.

RESULTS

From 1987 to 2001 19 patients underwent surgical resection for GIST. Stomach was the most common site of localization. Complete resection was achieved in 78.9 % cases, while in 21.1% radical resection was not possible. The mean tumor size was 8.4 cm (1.2-30 cm): < 5 cm diameter in 11/19 cases (58%), 5-10 cm in 4/19 (21%) and > 10 cm in 4/19 (21%). Mitotic count was < 10/50 HPF in 68.5 % (13/19) and > 10/50 in 31.5 % (6/19). Using Fletcher's classification, tumors were divided in very low (8/19, 42.2 %), low (3/19, 15.8 %), intermediate (4/19, 21%) and high risk (4/19, 21%). The 5 years overall survival was 63 % and 34 % respectively with a statistically significant difference between tumors < 5cm and > 10 cm in diameter and between complete and incomplete resection. High risk tumors have a significantly shorter survival than low or very low risk.

CONCLUSIONS

Our experience confirms that GIST are uncommon and aggressive cancers which prognosis is strictly related to tumor size and number of mitosis. Although significant advances on new chemotherapic regimes have been made, to date, radical surgical removal is the only chance of long term survival.

Hyperthermic intraperitoneal intraoperative chemotherapy after cytoreductive surgery for the treatment of abdominal sarcomatosis: clinical outcome and prognostic factors in 60 consecutive patients

BACKGROUND

Abdominal sarcomatosis is a rare nosologic entity with a poor prognosis. After a Phase I study on cytoreductive surgery combined with hyperthermic intraperitoneal intraoperative chemotherapy (HIIC), the authors reported the results of the treatment of 60 patients using this novel multimodal approach.

METHODS

Twenty-nine patients had multifocal primary disease and 31 patients had recurrent abdominal sarcoma. Tumor histology was represented by visceral (n = 26 [43%]) and retroperitoneal (n = 34 [57%]) sarcoma. All patients underwent cytoreductive surgery (with no or minimal residual disease) and 90-minute HIIC with doxorubicin (15.25 mg/L of perfusate) and cisplatin (43 mg/L). The clinical outcome and the prognostic value of 11 clinicopathologic variables were analyzed.

RESULTS

No postoperative deaths occurred. The morbidity rate was 33% and the moderate to severe locoregional toxicity rate was 15%. The median time to local disease progression and the median overall survival were 22 months and 34 months, respectively. Using multivariate analysis, histologic grading and completeness of surgical cytoreduction predicted patient prognosis, indicating that both local progression-free and overall survival were affected significantly by tumor aggressiveness and local disease control.

CONCLUSIONS

Although these results were encouraging, there was no definitive conclusion reached regarding the therapeutic activity of this locoregional treatment. In addition, the toxicity rate was substantial. In the absence of effective systemic agents, the therapeutic potential of cytoreductive surgery plus HIIC should be explored further in comparative trials.

Is there a role for surgery in patients with “unresectable” cKIT+ gastrointestinal stromal tumors treated with imatinib mesylate?

BACKGROUND

Imatinib mesylate (Gleevec) is being studied as adjuvant chemotherapy for the treatment of cKIT+ gastrointestinal stromal tumors (GISTs). Early reports using Gleevec for the treatment of unresectable GISTs have shown 50% to 60% partial response rates based on radiographic evaluation alone. No study has yet correlated radiographic response with pathologic findings. This retrospective review of patients with cKIT+ GISTs who received Gleevec prior to surgical resection examines the pathologic response to therapy and the feasibility of surgical resection after treatment.

METHODS

Patients with cKIT+ GISTs were identified from the institutional sarcoma database. Patients were included if they had pathologic confirmation of cKIT mutation and therapy with Gleevec. The pretreatment and preoperative radiographs, surgeons' operative notes, and pathology reports were reviewed for documentation of the extent of disease.

RESULTS

Between January 2001 and Octorber 2002, 126 patients with unresectable cKIT + GISTs treated with Gleevec were identified. Of these 126 patients, 17 have subsequently undergone surgical resection after a median of 10 months (range 2 to 16) of treatment with Gleevec. Based on computed tomographic (CT) scanning, 1 (6%) patient had evidence of a complete tumor response, 12 (70%) patients had a partial response, 3 (24%) patients had stable disease, and 1 (6%) patient had progressive disease. Posttreatment/preoperative CT imaging documented an overall response rate of 76%. The pathologic review of the operative specimens showed that 2 (12%) patients had a complete response to therapy, 11 (65%) had a partial response to therapy, 3 (18%) patients had no evidence of treatment effect on the excised tumor, 1 patient had progressive disease. Sixteen patients (94%) underwent complete surgical resection of disease, including 3 patients with no pathologic evidence of response to therapy. One patient had progression of disease and was unresectable at surgical exploration.

CONCLUSIONS

This series is the first to present pathologic data after the treatment of cKIT+ GISTs with Gleevec. In this series, the majority of responses were limited to partial responses, indicating that surgical resection remains a vital component of the treatment plan for patients with cKIT+ GISTs. This series is consistent with previous reports indicating that complete responses are extremely rare in response to treatment with Gleevec. Patients with advanced disease may benefit from a course of neoadjuvant therapy with Gleevec followed by resection, even when there is evidence of multifocal disease. A prospective evaluation of neoadjuvant Gleevec therapy for advanced cKIT+ GISTs is warranted.