Impact of the extent and duration of cytoreductive surgery on postoperative hematological toxicity after intraperitoneal chemohyperthermia for peritoneal carcinomatosis

Prophylactic Hyperthermic Intraperitoneal Chemotherapy for Patients at High Risk of Developing Gallbladder Cancer Peritoneal Metastases: Case Report and Rationale for a Prospective Clinical Trial

Gallbladder cancer is a devastating disease with a 5-year survival of only 18%. The majority of gallbladder cancers are discovered incidentally in patients undergoing cholecystectomy. During non-oncologic laparoscopic cholecystectomy for gallbladder disease, gallbladder perforation occurs in 29% of cases and spillage of gallstones occurs in 9% of cases. Patients with gallbladder cancer frequently develop peritoneal recurrence, particularly after intra-operative bile spillage during cholecystectomy for incidental gallbladder cancer. The high likelihood of spillage and peritoneal seeding during cholecystectomy for incidental gallbladder cancer suggests the need for prophylactic strategies to prevent peritoneal carcinomatosis. Hyperthermic intraperitoneal chemotherapy (HIPEC) has efficacy in gallbladder cancer patients with macroscopic peritoneal disease undergoing cytoreductive surgery and has been associated with a survival advantage in a multi-institutional retrospective case series. However, the utilization of HIPEC with a prophylactic intent against the development of peritoneal disease following resection of gallbladder cancer has not yet been prospectively studied. Here, we review the literature surrounding gallbladder cancer and HIPEC, report an institutional experience utilizing prophylactic HIPEC, and discuss a recently proposed prospective clinical trial evaluating the efficacy of prophylactic HIPEC in the prevention of gallbladder peritoneal metastasis.

Analysis of Intraoperative Variables Responsible for the Increase in Lactic Acid in Patients Undergoing Debulking Surgery

Background: Cytoreductive surgery (CRS) is a complex procedure with a high incidence of perioperative complications. Elevated lactacidaemia levels have been associated with complications and perioperative morbidity and mortality. This study aims to analyse the intraoperative variables of patients undergoing CRS and their relationship with lactacidaemia levels. Methods: This retrospective, observational study included 51 patients with peritoneal carcinomatosis who underwent CRS between 2014 and 2016 at the Abdomino-Pelvic Oncological Surgery Reference Unit (URCOAP) of the General University Hospital of Castellón (HGUCS). The main variable of interest was the level of lactic acid at the end of surgery. Intraoperative variables, including preoperative haemoglobin, duration of surgery, intraoperative bleeding, fluid therapy administered, administration of blood products, and intraoperative peritoneal cancer index (PCI), were analysed. Results: Positive correlations were found between lactic acid levels and PCI, duration of intervention, fluid therapy, intraoperative bleeding, and transfusion of blood products. Additionally, a negative correlation was observed between haemoglobin levels and lactic acid levels. Notably, the strongest correlations were found with operative PCI (ρ = 0.532; p-value < 0.001) and duration of surgery (ρ = 0.518; p-value < 0.001). Conclusions: PCI and duration of surgery are decisive variables in determining the prognosis of patients undergoing debulking surgery. This study suggests that, for each minute of surgery, lactic acid levels increase by 0.005 mmol/L, and for each unit increase in PCI, lactic acid levels increase by 0.060 mmol/L.

Cytoreductive Thoracic Surgery Combined with Hyperthermic Chemoperfusion for Pleural Malignancies: A Single-Center Experience

BACKGROUND

Lung-sparing cytoreductive surgery by extended pleurectomy and decortication (EPD) in combination with hyperthermic intrathoracic chemoperfusion (HITOC) forms a promising treatment strategy for malignant pleural mesothelioma and recurrent pleural thymic malignancies.

OBJECTIVES

The objective of this study was to scrutinize the surgical procedure and perioperative patient management with emphasis on perioperative morbidity and local tumor control.

METHODS

In 2014, a standardized EPD and HITOC procedure was implemented at the Thoraxklinik Heidelberg. This retrospective analysis included clinical data of consecutive patients with pleural mesothelioma and pleural metastasized malignancies treated by EPD and HITOC. The surgical procedure, perioperative management, lung function data, and progression-free survival (PFS) were analyzed.

RESULTS

In the time range between April 2, 2014 and July 2018, 76 patients with pleural malignancies have been treated with EPD and HITOC, and were analyzed retrospectively. It included 61 patients with pleural mesothelioma and 15 patients with pleural metastases of thymic malignancies (12), non-small cell lung cancer (1), colorectal carcinoma (1), and sarcoma (1). Perioperative morbidity following EPD and HITOC treatments represented 23.7% of overall malignancies, while 30- and 90-day mortality were 0 and 1.3%, respectively. Median PFS lasted 18.4 months for mesothelioma and 72.2 months for thymic malignancies.

CONCLUSION

Combining EPD with HITOC can be performed in patients with either pleural mesothelioma or pleural metastases resulting in low perioperative morbidity and mortality as well as remarkable local tumor control.

A precise temperature control during hyperthermic intraperitoneal chemotherapy promises an early return of bowel function

Introduction

The hyperthermic intraperitoneal chemotherapy (HIPEC) has been widely applied in clinical practice for peritoneal carcinomatosis (PC). The temperature is one of the important elements affecting the efficacy of HIPEC, and it can become fluctuant by several factors. This study is aimed to explore the role of a stable perfusion temperature in promoting bowel recovery of PC patients due to gastrointestinal malignancies.

Methods

Between January 2012 and July 2013, 59 PC patients undergoing cytoreductive surgery and three-cycle HIPEC were included. Patients having stable perfusion temperature for all cycles were assigned into the study group, with the rest having unstable temperature into the control group. Time of flatus and defecation passage and initiation time of enteral nutrition were compared between both groups to detect the significance in bowel function recovery, with visual analogue scale (VAS) pain intensity and overall survival (OS) compared meanwhile.

Results

In sum, 33 (55.9%) patients obtained stable temperature during HIPEC, and the rest of 26 (44.1%) developed fluctuant perfusion temperature. Average time of flatus (2.3 ± 1.2 vs 3.9 ± 2.2 days, P =.002), defecation passage (5.2 ± 2.1 vs 7.1 ± 2.9 days, P =.004) and enteral nutrition initiation (4.3 ± 1.5 vs 6.7 ± 2.3 days, P <.001) were much shorter in the study group than the control group. Additionally, the VAS score (4.5 ± 2.3 vs 6.3 ± 1.3, P <.001) and 5-year OS rate (17.8% vs 11.1%, P=.135) were both improved, with significance observed in postoperative pain control.

Conclusions

During HIPEC, a precise temperature control could promise an early recovery of bowel function and reduce postoperative pain, without survival significance found based on the current cohort.

Guidelines on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy arising from colorectal or appendiceal neoplasms

To meet the needs of patients, Canadian surgical and medical oncology leaders in the treatment of peritoneal surface malignancies (psms), together with patient representatives, formed the Canadian HIPEC Collaborative Group (chicg). The group is dedicated to standardizing and improving the treatment of psm in Canada so that access to treatment and, ultimately, the prognosis of Canadian patients with psm are improved. Patients with resectable psm arising from colorectal or appendiceal neoplasms should be reviewed by a multidisciplinary team including surgeons and medical oncologists with experience in treating patients with psm. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy should be offered to appropriately selected patients and performed at experienced centres. The aim of this publication is to present guidelines that we recommend be applied across the country for the treatment of psm.

Hyperthermic intraperitoneal chemotherapy after cytoreductive surgery for the treatment of peritoneal carcinomatosis in pediatric solid malignancies: a single institution experience

BACKGROUND

Peritoneal carcinomatosis from abdominal tumors is an uncommon condition in children usually associated with dismal prognosis. Hyperthermic intraperitoneal chemotherapy (HIPEC) following complete macroscopic surgery has been demonstrated to be safe and of benefit in selected cases. Experience in pediatrics is scarce.

METHODS

We retrospectively reviewed the medical files of patients under the age of 18years with an abdominal malignancy and peritoneal carcinomatosis who had been treated with HIPEC in our institution between March 2001 and April 2012. HIPEC had been administered using the open technique with oxaliplatin (300mg/m(2)) and irinotecan (200mg/m(2)) or oxaliplatin alone (460mg/m(2)) in the peritoneal cavity for 30minutes at 43°C and an intravenous perfusion of leucovorin (20mg/m(2)) and 5-fluorouracil (400mg/m(2)).

RESULTS

Nine patients had undergone HIPEC. Grade 3-4 complications had occurred in seven patients and were intraabdominal (n=3) or extraabdominal (n=8). No procedure-related deaths had occurred. Four patients are alive and in complete remission after a median follow-up of 4.9years (1.7-9.6). However one relapsed after HIPEC and required additional salvage therapy.

CONCLUSIONS

HIPEC could be considered in patients with peritoneal carcinomatosis from primary abdominal tumors. Its complications are manageable by an experienced multidisciplinary team. There are four long-term survivors, one after a relapse.

Morbidity and mortality outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with primary and recurrent advanced ovarian cancer

BACKGROUND

The aim of this study is to report the perioperative outcomes of CRS and HIPEC from a single institution and review those factors that are associated with a poor perioperative outcome in patients with peritoneal dissemination from primary or recurrent ovarian cancer.

PATIENTS AND METHOD

A retrospective cohort study setting was conducted in a third level hospital peritoneal surface malignancy program. Ninety one patients diagnosed with ovarian peritoneal carcinomatosis, primary and recurrent without extraperitoneal metastasis were included for cytoreductive surgery and HIPEC with paclitaxel. We analyzed the postoperative morbidity rates and a univariate and multivariate analysis of factors associated with overall (grade I-IV) and major (grade III-IV) postoperative morbidity were performed.

RESULTS

Peritoneal Cancer Index (PCI) upper than 12 (OR = 2.942 95%: 1.892-9.594 p = 0.044) was an independent factor associated with the occurrence of I-IV postoperative morbidity. Regarding major complications (grade III-IV), on multivariate analysis, in addition to PCI >12 (OR = 6.692, 95% CI: 1974-45, 674, p = 0.032), the need to carry out intestinal resection (OR = 4.987, 95% CI: 1350-27, 620, p = 0.046) was an independent factor related with major morbidity (grade III-IV).

CONCLUSIONS

The use of HIPEC after aggressive cytoreductive surgery in patients with ovarian cancer with peritoneal dissemination can be performed with acceptable postoperative morbidity rates. Knowledge of the factors associated with the onset of these postoperative adverse events allows better management of the same and offers the patient a safe procedure.

[Epidural analgesia for surgical treatment of peritoneal carcinomatosis: a risky technique?]

BACKGROUND

To study the risks of haemodynamic instability, and the possible occurrence of spinal haematoma, meningitis and epidural abscess when epidural analgesia is performed for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

We retrospectively analyzed the data of 35 patients treated by HIPEC with oxaliplatin or cisplatin. An epidural catheter was inserted before induction of general anaesthesia. Postoperatively, a continuous epidural infusion of ropivacain, then a patient-controlled epidural analgesia were started.

RESULTS

The epidural catheter was used peroperatively before HIPEC in 12 subjects (34%), and after HIPEC in 23 subjects (66%). The median dose of ropivacain given peroperatively in the epidural catheter was 40 mg (30-75). Norepinephrin was used in two subjects (6%) peroperatively (median infusion rate 0.325 μg/kg per minute [0.32-0.33]), and in four subjects (11%) in the postoperative 24 hours. No spinal haematoma, meningitis or epidural abscess were noted. Five subjects (14%) had a thrombopenia or a prothrombin time less than 60% before catheter removal. Two subjects (6%) had a leukopenia before catheter removal. No thrombopenia or blood coagulation disorders were recorded the day of catheter removal.

CONCLUSION

In this series of 35 patients, the use of epidural analgesia for HIPEC does not seem to be associated with a worse risk of haemodynamic instability, spinal haematoma, meningitis or epidural abscess. HIPEC with platinum salt is not incompatible with the safety of epidural analgesia, with an optimized fluid management peroperatively and the following of perimedullary anesthesia practice guidelines.

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.

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

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

Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy in the treatment of peritoneal carcinomatosis

PURPOSE

Cytoreductive surgery (CS) and intraperitoneal hyperthermic chemotherapy (IPHC) in the treatment of peritoneal carcinomatosis (PC) in 15 patients are described.

SUMMARY

Fifteen patients with PC who were treated with CS and IPHC were retrospectively identified between January 2002 and December 2006. All patients underwent cytoreduction immediately followed by IPHC with mitomycin or cisplatin. The time between undergoing CS and IPHC and the date of the last follow-up appointment or the date of death was used to calculate survival data for each patient. Nine patients had complete cytoreduction, and all but one patient had evidence of invasive disease at the time of surgery. Eleven patients required concomitant bowel resection at the time of debulking. Thirteen patients required blood transfusions during the perioperative period. Nine patients were discharged home, and four were discharged to a rehabilitation facility. Two patients died during the perioperative hospital admission, both of whom had a preoperative Eastern Cooperative Oncology Group (ECOG) performance status score of 2. The median survival time was 8.4 months, similar to the findings of previously published studies. Further studies are needed to see if tumor type, ECOG performance status score, degree of cytoreduction, and the chemotherapy agent used in IPHC can be correlated to quality of life and survival in patients with heterogeneous primary sources of intraabdominal malignancies.

CONCLUSION

Combination treatment with CS followed by IPHC in 15 patients with heterogeneous primary sources of intraabdominal malignancies resulted in a median survival time of 8.4 months.

Drugs, carrier solutions and temperature in hyperthermic intraperitoneal chemotherapy

At the Fifth International Workshop on Peritoneal Surface Malignancy, in Milan, the consensus on technical aspects of cytoreductive surgery (CRS) for peritoneal surface malignancy was obtained through the Delphi process. Conflicting points concerning drugs, carrier solution and optimal temperature for hyperthermic intraperitoneal chemotherapy (HIPEC) were discussed.

"Natural history" of complete cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

BACKGROUND

Combining complete cytoreductive surgery (CCRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a new approach allowing curatively intended treatment of multiple malignant peritoneal tumour seedings. This aggressive treatment is frequently followed by a complicated or an unusual postoperative course, that has yet to be described.

AIM

To describe the clinical and biological post-therapeutic course of patients treated with CCRS plus HIPEC, who were considered uncomplicated cases, and were discharged from hospital before the 15th postoperative day.

PATIENTS AND METHODS

Thirty-two patients were retrospectively selected on these criteria among 232 treated patients, most of whom had received intraperitoneal high-dose oxaliplatin and intravenous 5-fluorouracil. The daily postoperative clinical and biological parameters are presented in graphs using boxplots.

RESULTS

Hyperthermia at 38 degrees C was the rule during the first postoperative week. The daily flow rate of the abdominal drains decreased progressively from 500 ml to 50 ml from day 1 to day 7. The flow rate of the nasogastric tube was high and close to 1000 ml/24 h until day 6. Resumption of digestive transit occurred between day 4 and day 6; it was always a diarrheic transit until day 12. Severe hypophosphoremia was observed at day 2 and day 3. White blood cells gradually decreased until day 12 to half the normal value, haemoglobin remained stable and the platelet count, which was low after surgery, continued to decrease progressively until day 3. Other data are presented.

CONCLUSION

These results, in this selected group of patients, allow a description of the "natural history" of CCRS plus HIPEC, which is not similar to classic uncomplicated postoperative courses following surgery. Knowledge of these "natural" changes may help avoid unnecessary explorations, and allow the early detection of postoperative complications.

Anemia and transfusions in patients undergoing surgery for cancer

Preoperative, operative, and postoperative factors may all contribute to high rates of anemia in patients undergoing surgery for cancer. Allogeneic blood transfusion is associated with both infectious risks and noninfectious risks such as human errors, hemolytic reactions, transfusion-related acute lung injury, transfusion-associated graft-versus-host disease, and transfusion-related immune modulation. Blood transfusion may also be associated with increased risk of cancer recurrence. Blood-conservation measures such as preoperative autologous donation, acute normovolemic hemodilution, perioperative blood salvage, recombinant human erythropoietin (epoetin alfa), electrosurgical dissection, and minimally invasive surgical procedures may reduce the need for allogeneic blood transfusion in elective surgery. This review summarizes published evidence of the consequences of anemia and blood transfusion, the effects of blood storage, the infectious and noninfectious risks of blood transfusion, and the role of blood-conservation strategies for cancer patients who undergo surgery. The optimal blood-management strategy remains to be defined by additional clinical studies. Until that evidence becomes available, the clinical utility of blood conservation should be assessed for each patient individually as a component of preoperative planning in surgical oncology.

Impact of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy on Systemic Toxicity

INTRODUCTION

The purpose of this study was to analyze the postoperative systemic toxicity and procedure-related mortality (PRM) of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal surface malignancies (PSMs).

PATIENTS AND METHODS

A total of 242 (84 males/158 females) patients with PSM underwent 247 consecutive procedures. The mean age was 52 years (range 22-79). CRS was performed using peritonectomy procedures. The HIPEC technique through the closed abdomen was conducted with cisplatin (CDDP 25 mg/m(2)/l of perfusate)+mitomycin C (MMC 3.3 mg/m(2)/l perfusate) or CDDP (43 mg/l perfusate)+doxorubicin (Dx 15.25 mg/l perfusate) at 42.5 degrees C. These dosages were reduced by 30% when the patient had received systemic chemotherapy before the CRS+HIPEC. Systemic toxicities were graded according to the NCI CTCAE v3 criteria.

RESULTS

G3-5 systemic toxicity rate was 11.7 % and adverse events were bone marrow suppression, 13; nephrotoxicity, 14; neutropenic infection, 2 and pulmonary toxicity, 1. Independent risk factors for G3-5 systemic toxicity after multivariate analysis were a dose of CDDP for HIPEC of 240 mg or more (OR 2.78, CI 95% 1.20-6.45) and CDDP+Dx schedule for HIPEC (OR 2.36, CI 95% 1.02-5.45). PRM was 1.2%.

CONCLUSIONS

CRS+HIPEC presented acceptable systemic toxicity and PRM rates. Independent risk factors for systemic toxicity were the CDDP+Dx schedule and CDDP dose for HIPEC.

Optimization of hyperthermic intraperitoneal chemotherapy with oxaliplatin plus irinotecan at 43 degrees C after compete cytoreductive surgery: mortality and morbidity in 106 consecutive patients

BACKGROUND

Peritoneal carcinomatosis (PC), which has hitherto been regarded as a lethal entity, can now be cured with surgery (treating macroscopic tumor seeding) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) (treating residual microscopic disease). The purpose of this study was to analyze the morbidity and mortality of a particular approach associating optimal (R0-R1) cytoreduction, optimal HIPEC combining oxaliplatin and irinotecan, and an optimal homogeneous intraperitoneal temperature of 43 degrees C.

METHODS

A total of 106 consecutive patients were included in this prospective phase 2 study. After complete resection of the PC, HIPEC was performed by the Coliseum technique with oxaliplatin (360 mg/m2) combined with irinotecan (360 mg/m2) in 2 L/m2 of 5% dextrose, over 30 minutes at a real intraperitoneal temperature of 43 degrees C. During the hour preceding HIPEC, patients received 5-fluorouracil (400 mg/m2) and leucovorin (20 mg/m2) intravenously, resulting in tritherapy.

RESULTS

Postoperative mortality and morbidity rates were 4% and 66%, respectively. The most frequent complications were digestive fistula (24%), lung infection (16%), and severe hematological toxicity (11%). Statistical correlation was evidenced between morbidity and the carcinomatosis score (P = .0008), the number of resected organs (P = .0001), the duration of surgery (P = .0001), and blood loss (P = .0001).

CONCLUSIONS

This new approach, optimized in three respects (complete cytoreduction, combination oxaliplatin with irinotecan, and high temperature) has resulted in a relatively high but acceptable incidence of adverse events considering the expected advantage for survival.