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Nogueiro J, Fathi NQ, Guaglio M, Baratti D, Kusamura S, Deraco M. Risk factors for gastrointestinal perforation and anastomotic leak in patients submitted to cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107020. [PMID: 37597284 DOI: 10.1016/j.ejso.2023.107020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/22/2023] [Accepted: 08/11/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Gastrointestinal leak is one of the most feared complications after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) and harbors significant postoperative morbidity and mortality. We aim to identify risk-factors for anastomotic leak (AL) and gastrointestinal perforation (GP) to optimize postoperative outcomes of this population. METHODS We performed a retrospective analysis of 1043 consecutive patients submitted to CRS in a single institution. Potential risk factors for AL and GP, both related to patient overall condition, disease status and surgical technique were reviewed. RESULTS Anastomotic leaks were identified in 5.2% of patients, and GPs in 7.0%. The independent risk-factors for AL were age at surgery (OR1.40; CI95% 1.10-1.79); peritoneal cancer index (PCI) (OR1.04, CI95% 1.01-1.07); Cisplatin dose >240 mg during HIPEC (OR3.53; CI95% 1.47-8.56) and the presence of colorectal (CR) or colo-colic (CC) anastomosis (OR5.09; CI95% 2.71-9.53, and 4.58; CI95% 1.22-17.24 respectively). Male gender and intraoperative red blood cell transfusions were the only independent risk factors for GP identified (OR1.70; CI95% 1.04-2.78 and 1.06; CI95% 1.01-1.12, respectively). Regarding 30-day and 90-day postoperative mortality, independent risk-factors were mainly related to patient's overall condition. CONCLUSION Gastrointestinal leaks are a frequent source of postoperative morbidity, mainly at the expense of GP. A careful and systematic intraoperative revision of all potential gastrointestinal injuries is equally critical to perfecting anastomotic fashioning techniques to decrease gastrointestinal complication rates. We identified multiple risk-factors for AL and GP related to disease status and patient condition. Our study suggests that patient-related conditions are of paramount relevance, highlighting the importance of patient selection and preoperative patient optimization.
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Affiliation(s)
- Jorge Nogueiro
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Fellow from Department of General Surgery, São João University Hospital Center, Porto, Portugal; Medical Faculty, University of Porto, Porto, Portugal
| | - Nik Qisti Fathi
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Fellow from University Putra Malaysia, Malaysia
| | - Marcello Guaglio
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Dario Baratti
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Shigeki Kusamura
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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Acs M, Gerken M, Zustin J, Blaj S, Isgandarova S, Piso P. Prolonged Survival in Peritoneal Metastatic Appendiceal Carcinoma Patients Treated With Combined Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. J Surg Res 2023; 283:839-852. [PMID: 36915011 DOI: 10.1016/j.jss.2022.10.083] [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: 06/18/2022] [Revised: 10/24/2022] [Accepted: 10/29/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Primary treatment for peritoneal dissemination of appendiceal cancer is the combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. The endpoints were overall survival and evaluation of prognostic factors. METHODS Clinicopathological and treatment-related factors were obtained from a prospective database. A total of 84 patients, 55 (65%) primary and 29 (35%) recurrent malignant appendiceal carcinomas with synchronous and metachronous peritoneal metastases, underwent multimodal treatment between 2011 and 2021. The endpoints of the study were overall survival and evaluation of prognostic factors. RESULTS The median follow-up was 4.8 y; the mean age was 54.5 y (range 25-77), with a sex distribution of 69% female and 31% male. The mean peritoneal cancer index was 11.3. The proportion of mucinous, intestinal-type, signet ring cell, and goblet cell carcinoma was 56%, 23%, 11%, and 10%, respectively. The 5-y survival rate of the whole cohort was 56.7%. In primary and recurrent diseases, the overall median survival was 8.4 and 4.9 y. Significantly improved survival was detected after complete cytoreduction resection (hazard ratio [HR] for CCR-2 versus CCR-0: 9.388, 95% confidence interval [CI] 3.026-29.124, P = 0.001) and initial local operation with undelayed admission to the center (HR 0.262, 95% CI 0.089-0.773; P = 0.015). The five independent factors in Kaplan-Meier analysis and univariable Cox regression analysis associated with significant adverse survival were cancer antigen (CA) 19-9 over 37 IU/mL, signet ring cell and intestinal-type histology, positive nodal status, grading, and peritoneal cancer index >20. Neoadjuvant chemotherapy administration did not impact survival (HR 1.220, 95% CI 0.612-2.432, P = 0.571). CONCLUSIONS With multimodal treatment, prolonged survival is attainable in stage IV primary and recurrent appendiceal carcinoma with peritoneal dissemination. Direct referral to specialized centers after confirmation of peritoneal metastasis is recommended because prompt definitive treatment may significantly improve survival.
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Affiliation(s)
- Miklos Acs
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany.
| | - Michael Gerken
- Tumor Center-Institute for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
| | - Jozef Zustin
- Gerhard Domagk Institute of Pathology, University Medical Center Muenster, Muenster, Germany; Institute of Pathology Regensburg, Regensburg, Germany
| | - Sebastian Blaj
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Sabina Isgandarova
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
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Kusamura S, Baratti D, De Simone M, Pasqual EM, Ansaloni L, Marrelli D, Robella M, Accarpio F, Valle M, Scaringi S, Biacchi D, Palopoli C, Gazzanelli S, Guaglio M, Deraco M. Diagnostic and Therapeutic Pathway in Diffuse Malignant Peritoneal Mesothelioma. Cancers (Basel) 2023; 15:cancers15030662. [PMID: 36765620 PMCID: PMC9913096 DOI: 10.3390/cancers15030662] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/24/2023] Open
Abstract
Diffuse malignant peritoneal mesothelioma (DMPM) is a rare form of mesothelioma that carries a very poor prognosis. The 5-year overall survival is about 20% (±5.9). Survival is optimal for patients suitable for cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC), with a median OS ranging from 34 to 92 months. However, selecting patients for surgery remains a complex task and requires a careful preoperative workup, rational analysis of prognostic profiles, and risk prediction models. Systemic chemotherapy could be offered: (1) in the adjuvant setting for high-risk patients; (2) for patients not eligible for CRS; and (3) for those with recurrent disease. It mainly includes the combination of Platin compound with Pemetrexed or immunotherapy. The biology of DMPM is still largely unknown. However, progress has been made on some fronts, such as telomere maintenance mechanisms, deregulation of apoptosis, tyrosine kinase pathways, and mutation of BRCA1-associated protein 1 (BAP1). Future perspectives should include translational research to improve our understanding of the disease biology to identify druggable targets. We should also clear the role of immune checkpoint inhibitors and investigate new locoregional technologies, such as pressurized intraperitoneal aerosol chemotherapy (PIPAC) or normothermic intraperitoneal chemotherapy (NIPEC).
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Affiliation(s)
- Shigeki Kusamura
- Peritoneal Surface Malignancies Unit, Fondazione Istituto Nazionale dei Tumori IRCCS Milano, 20133 Milan, Italy
| | - Dario Baratti
- Peritoneal Surface Malignancies Unit, Fondazione Istituto Nazionale dei Tumori IRCCS Milano, 20133 Milan, Italy
| | | | - Enrico Maria Pasqual
- AOUD Center Advanced Surgical Oncology, DAME University of Udine, 33100 Udine, Italy
| | - Luca Ansaloni
- Unit of General Surgery, San Matteo Hospital, 27100 Pavia, Italy
| | - Daniele Marrelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | | | - Fabio Accarpio
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Rome, Italy
| | - Mario Valle
- Peritoneal Tumours Unit, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
| | | | - Daniele Biacchi
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Rome, Italy
| | - Carmen Palopoli
- U.O.C.—P.S.G. con O.B.I. Azienda Ospedaliera Universitaria “G. Martino”, 98125 Messina, Italy
| | - Sergio Gazzanelli
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Rome, Italy
| | - Marcello Guaglio
- Peritoneal Surface Malignancies Unit, Fondazione Istituto Nazionale dei Tumori IRCCS Milano, 20133 Milan, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancies Unit, Fondazione Istituto Nazionale dei Tumori IRCCS Milano, 20133 Milan, Italy
- Correspondence:
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Wang B, Sun X, Ma R, Yang Z, Tang H, Lu S, Qu J, Wang Y, Rao B, Xu H. Prognostic value of the ascites characteristics in pseudomyxoma peritonei originating from the appendix. Front Surg 2023; 9:967296. [PMID: 36726946 PMCID: PMC9885001 DOI: 10.3389/fsurg.2022.967296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 12/08/2022] [Indexed: 01/17/2023] Open
Abstract
Background Pseudomyxoma peritonei (PMP) is a rare disease, with the overall survival (OS) influenced by many factors. To date, no ascites characteristics have been reported to predict OS of patients with PMP. The present study therefore aims to describe the ascites characteristics for PMP and identify prognostic factors for survival. Methods Between June 2010 and June 2020, 473 PMP patients who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were included in a retrospective study. Survival analysis was performed with the Kaplan-Meier method by the log-rank test and a Cox proportional hazards model. Associations between categorical variables were analyzed using the chi-squared test. Results Among all included patients, 61% were women. The median OS was 47 months (range, 4-124 months) at the last follow-up in December 2020. Ascites characteristics can be divided into light blood ascites, "Jelly" mucus ascites, and faint yellow and clear ascites. Multivariate Cox analysis showed that the degree of radical surgery, ascites characteristics, and pathological grade were independently associated with OS in PMP patients. The chi-squared test documented that faint yellow "Jelly" ascites were related to low-grade PMP and light blood ascites were associated with high-grade PMP (P < 0.01). Conclusions Light blood ascites, incomplete cytoreduction surgery, and high-grade histopathology may predict poor OS in appendix-derived PMP.
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Affiliation(s)
- Bing Wang
- Department of Gastrointestinal Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China,Key Laboratory of Cancer FSMP for State Market Regulation, Beijing, China
| | - Xibo Sun
- Department of Breast Surgery, The Second Affiliated Hospital of Shandong First Medical University, Taian, China
| | - Ruiqing Ma
- Department of Myxoma, Aerospace Center Hospital, Beijing, China
| | - Zhenpeng Yang
- Department of Gastrointestinal Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China,Key Laboratory of Cancer FSMP for State Market Regulation, Beijing, China
| | - Huazhen Tang
- Department of Gastrointestinal Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China,Key Laboratory of Cancer FSMP for State Market Regulation, Beijing, China
| | - Shuai Lu
- Department of Gastrointestinal Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China,Key Laboratory of Cancer FSMP for State Market Regulation, Beijing, China
| | - Jinxiu Qu
- Department of Gastrointestinal Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China,Key Laboratory of Cancer FSMP for State Market Regulation, Beijing, China
| | - Yuying Wang
- Department of Gastrointestinal Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China,Key Laboratory of Cancer FSMP for State Market Regulation, Beijing, China
| | - Benqiang Rao
- Department of Gastrointestinal Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China,Key Laboratory of Cancer FSMP for State Market Regulation, Beijing, China,Correspondence: Benqiang Rao
| | - Hongbin Xu
- Department of Myxoma, Aerospace Center Hospital, Beijing, China
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Baratti D, Kusamura S, Guaglio M, Milione M, Pietrantonio F, Cavalleri T, Morano F, Deraco M. Relapse of Pseudomyxoma Peritonei After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Pattern of Failure, Clinical Management and Outcomes. Ann Surg Oncol 2023; 30:404-414. [PMID: 36094689 DOI: 10.1245/s10434-022-12367-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 07/25/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) have dramatically improved pseudomyxoma peritonei (PMP) prognosis, but treatment failures are still a concern. We investigated the pattern of failure, treatment and outcomes of progressing disease. METHODS A prospective database of 374 PMP patients was reviewed, and 152 patients relapsing after complete CRS/HIPEC were identified. PMP was graded according to the Peritoneal Surface Oncology Group International (PSOGI) classification. Hematogenous metastases and non-regional lymph node involvement were considered as systemic metastases. RESULTS Median follow-up was 78.3 months (95% confidence interval [CI] 66.7-90.4). PMP relapse involved the peritoneum in 112 patients, pleural cavity in 8, both peritoneum and pleura in 8, systemic sites in 11, and both peritoneum and systemic sites in 13 patients. Systemic metastases involved the lung (n = 14), liver (n = 4), distant nodes (n = 3), bone (n = 2), and both lung and distant nodes (n = 1). Survival after diagnosis of PMP relapse was independently associated with curative versus palliative treatment (hazard ratio [HR] 0.52, 95% CI 0.36-0.75; p = 0.001) and PSOGI histology (HR 1.80, 95% CI 1.19-2.74; p = 0.005), but was not influenced by site of failure (p = 0.444). Ten-year overall survival was 77.5% for 62 patients who had curative-intent surgery for PMP relapse, compared with 83.0% for 192 patients who had no recurrences (p = 0.154) and 26.1% for 90 patients who underwent palliative treatments (p = 0.001). CONCLUSIONS Relapse after CRS/HIPEC most commonly involves the peritoneum, but pleural recurrences and systemic metastases occur in a small but clinically relevant number of patients. In selected patients, surgical resection of recurrent disease can result in long survival, irrespective of sites of failure.
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Affiliation(s)
- Dario Baratti
- Peritoneal Malignancy Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Shigeki Kusamura
- Peritoneal Malignancy Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Guaglio
- Peritoneal Malignancy Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Massimo Milione
- Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Filippo Pietrantonio
- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Tommaso Cavalleri
- Peritoneal Malignancy Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Morano
- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Deraco
- Peritoneal Malignancy Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Long-term outcomes of elderly patients with peritoneal metastases of colorectal origin after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Surg Oncol 2022; 44:101848. [PMID: 36126349 DOI: 10.1016/j.suronc.2022.101848] [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: 01/20/2022] [Revised: 08/12/2022] [Accepted: 09/06/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) were reportedly safe for the elderly. However, long-term survival data in this subgroup of patients are scarce. Our aim was to evaluate the peri-operative and long-term outcomes of CRS + HIPEC in colorectal peritoneal metastases (CRC-PM) in patients ≥70 years of age. MATERIAL AND METHODS We retrospectively analyzed our combined institutional databases for patients who underwent CRS + HIPEC for CRC-PM. Clinical and pathological characteristics, as well as overall survival (OS) and progression-free survival (PFS) were compared between the groups. Tumor extent was measured by the peritoneal carcinomatosis index (PCI) and completeness of cytoreduction by the CCR score. Major morbidity was defined according to Clavien-Dindo classification. RESULTS The dataset of 159 patients included 33 elderly and 126 non-elderly patients. Clinical characteristics between the groups differed only in medical comorbidities (Charlson comorbidity index 10 vs. 7, P < 0.001) and delivery of post-HIPEC adjuvant treatment (12.5% vs. 43.8%, P = 0.004). Overall PCI and CCR0 rates were similar between the groups, as were length of stay and major morbidity and mortality rates. Long-term outcomes in the elderly group were lower than those of the non-elderly (median OS: 21.8 vs. 40.5 months, P < 0.001; median PFS: 6 vs. 8 months, P = 0.02, respectively). CONCLUSIONS CRS + HIPEC in selected elderly patients can be safe in terms of postoperative morbidity and mortality. However, despite the same surgical extents and radicality, their long-term outcomes are inferior, possibly due to under-usage of systemic chemotherapy.
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Systemic metastases from low-grade and high-grade pseudomyxoma peritonei: Treatments and outcomes. Eur J Surg Oncol 2022; 48:1590-1597. [DOI: 10.1016/j.ejso.2022.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/30/2021] [Accepted: 01/08/2022] [Indexed: 12/17/2022] Open
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8
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Gangi A, Shah R. The Landmark Series: Appendiceal Primary Peritoneal Surface Malignancy. Ann Surg Oncol 2021; 29:2056-2068. [PMID: 34853944 DOI: 10.1245/s10434-021-10856-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/09/2021] [Indexed: 12/24/2022]
Abstract
Appendiceal primary peritoneal surface malignancies are rare and include a broad spectrum of pathologies ranging from indolent disease to aggressive disease. As such, the data that drive the management of appendiceal peritoneal surface malignancies is generally not based on prospective clinical trial data, but rather consists of level 1 data based on retrospective studies and high-volume institutional experiences. Complete surgical debulking typically offers the best chance for long-term survival. This review highlights the landmark articles on which management of primary appendiceal peritoneal surface malignancies are based.
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Affiliation(s)
- Alexandra Gangi
- Division of Surgical Oncology, Cedars Sinai Medical Center, Los Angeles, CA, USA.
| | - Rupen Shah
- Division of Surgical Oncology, Henry Ford Cancer Institute/Henry Ford Health System, Detroit, MI, USA
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Nizri E, Berger Y, Green E, Kyzer M, Aizic A, Nevo N, Gerstenhaber F, Klausner JM, Gutman M, Lahat G, Hoffman A, Geva R. Lymph Node Metastases from Visceral Peritoneal Colorectal Metastases are Associated with Systemic Recurrence. Ann Surg Oncol 2021; 29:2069-2075. [PMID: 34622371 DOI: 10.1245/s10434-021-10869-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/13/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Visceral peritoneal colorectal metastases (VPCMs) may further metastasize to lymph nodes that drain those organs. The rate of lymph node metastases (LNMs) from VPCMs and their clinical and prognostic significance are unknown. METHODS This study retrospectively analyzed the authors' institutional databases of 160 patients with peritoneal colorectal metastases who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Patients with LNM-VPCM (n = 12) were identified by pathologic reports, and both their short- and long-term outcomes were compared with those of patients without LNM-VPCM. RESULTS The clinical presentation and primary tumor pathologic characteristics did not differ between the two groups. The patients with LNM-VPCM had a higher tumor burden (measured by the peritoneal carcinomatosis index [PCI]) and visible remnant disease compared with those who had no LNM-VPI (10 vs 5.5 [p = 0.03] vs 33.3% vs 6.8% [p = 0.007], respectively). The postoperative outcomes also were comparable. The patients with LNM-VPCM had a shorter overall survival (OS) than those without LNM-VPCM (median OS, 22.5 months; 95% confidence interval [CI], 15.1-29.9 months vs 40.1 months; 95% CI, 38.1-42 months; p = 0.02). However, only tumor grade and PCI were predictors of OS in the multivariate analysis (hazard ratio [HR], 2.33 [p = 0.001]; 1.77 [p = 0.03], respectively). The study showed that LNM-VPCM was associated with systemic but not peritoneal recurrence compared with non-LNM-VPCM (81.8% vs 51.6% for systemic recurrence, respectively; p = 0.05). CONCLUSION The small distinct group of patients defined by LNM-VPCM were prone to systemic recurrence. Given its correlation with systemic recurrence, LNM-VPCM may indicate the need for adjuvant treatment.
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Affiliation(s)
- Eran Nizri
- Peritoneal Surface Malignancy and Melanoma Unit, Department of Surgery A, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel. .,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Yaniv Berger
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Eraan Green
- Peritoneal Surface Malignancy and Melanoma Unit, Department of Surgery A, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Matan Kyzer
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Asaf Aizic
- Institute of Pathology, Tel- Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Nadav Nevo
- Peritoneal Surface Malignancy and Melanoma Unit, Department of Surgery A, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Fabian Gerstenhaber
- Peritoneal Surface Malignancy and Melanoma Unit, Department of Surgery A, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Joseph M Klausner
- Peritoneal Surface Malignancy and Melanoma Unit, Department of Surgery A, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Mordechai Gutman
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Guy Lahat
- Peritoneal Surface Malignancy and Melanoma Unit, Department of Surgery A, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aviad Hoffman
- Department of General Surgery, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ravit Geva
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Oncology Division, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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Sugarbaker PH. Peritonectomy of the colonic mesentery. Case report of a new surgical technology. Int J Surg Case Rep 2021; 86:106369. [PMID: 34507196 PMCID: PMC8433245 DOI: 10.1016/j.ijscr.2021.106369] [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: 08/01/2021] [Revised: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction and importance Malignant peritoneal mesothelioma is a local-regional disease process that requires a comprehensive treatment plan including complete cytoreductive surgery and regional chemotherapy. Case presentation Treatments used in our patient began with a complete cytoreductive surgery. This required visceral resections, parietal peritonectomy, peritonectomy of the small bowel and its mesentery, and a peritoneal resection of the colonic mesentery with sparing of the major vasculature of the large bowel. Clinical discussion Peritoneal resection of the colonic mesentery and other treatments were performed in the absence of major complications. A 20-day hospitalization was required. The patient shows no internal hernias and no evidence of disease by CT follow-up at 4 years postoperatively. Her quality of life is excellent. Conclusions Malignant peritoneal mesothelioma was in the past a disease of limited survival without effective treatment options. Peritoneal resection of the colonic mesentery may be required for complete cytoreduction. A sequence of cytoreductive surgical procedures and regional chemotherapy treatments has made long-term survival possible. Malignant peritoneal mesothelioma has treatment options that combined surgery and regional chemotherapy. A major surgical challenge is complete mesenteric peritonectomy. Complete cytoreduction of the large bowel mesentery requires its resection with sparing major vasculature. Long-term survival is possible with low perioperative morbidity and mortality.
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Affiliation(s)
- Paul H Sugarbaker
- Program in Peritoneal Surface Malignancy, Washington Cancer Institute, Washington, DC, USA.
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11
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Bai M, Wang S, Liang G, Cai Y, Lu Y, Hou N, Ma R, Xu H, Zhang M. Nomogram to Predict Incomplete Cytoreduction for Pseudomyxoma Peritonei. Ann Surg Oncol 2021; 29:885-892. [PMID: 34480280 DOI: 10.1245/s10434-021-10725-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 08/09/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUNDS The completeness of cytoreduction is one of the most important prognostic factors for patients with pseudomyxoma peritonei (PMP). To date, no nomograms have been established to predict incomplete cytoreduction (IC) for patients with PMP. The current study therefore proposed a nomogram to predict individual IC risk for PMP patients. METHODS Between 1 June 2013, and 22 November 2019, 144 consecutive PMP patients who underwent cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for the first time in our center were included in a retrospective study. Possible predictors of cytoreducibility were analyzed using logistic regression modeling to predict IC for PMP patients. A nomogram was developed based on the multivariate analysis and further investigated for internal validation. RESULTS After CRS, the 144 participants were divided into complete CRS (CCRS) (n = 46) and IC (n = 98) subgroups. Four independent predictors (sex, disease duration, anemia, and carbohydrate antigen 19-9 (CA 199)) were included in the prediction model. Then, a nomogram predicting IC was established based on the aforementioned variables, which demonstrated good predictive accuracy (C-index, 0.837; 95 % confidence interval [CI], 0.764-0.894). The predicted probability was close to the actual observed outcome according to the calibration plot. CONCLUSIONS The current work led to the development of a nomogram capable of predicting IC for PMP patients who demonstrated good performance. Risk stratification by the established nomogram had ability to optimize individual IC prediction and help physicians to establish meticulous preoperative plans.
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Affiliation(s)
- Mingjian Bai
- Clinical Laboratory Medicine, Peking University Ninth School of Clinical Medicine, Beijing, China.,Clinical Laboratory Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Urinary Cellular Molecular Diagnostics, Beijing, China
| | - Shilong Wang
- Department of Myxoma, Aerospace Center Hospital, Beijing, China
| | - Guowei Liang
- Department of Clinical Laboratory, Aerospace Center Hospital, Beijing, China
| | - Ying Cai
- Department of Myxoma, Aerospace Center Hospital, Beijing, China
| | - Yiyan Lu
- Department of Pathology, Aerospace Center Hospital, Beijing, China
| | - Nianzong Hou
- Department of Hand and Foot Surgery, Zibo Central Hospital, Zibo, Shandong Province, China
| | - Ruiqing Ma
- Department of Myxoma, Aerospace Center Hospital, Beijing, China
| | - Hongbin Xu
- Department of Myxoma, Aerospace Center Hospital, Beijing, China
| | - Man Zhang
- Clinical Laboratory Medicine, Peking University Ninth School of Clinical Medicine, Beijing, China. .,Clinical Laboratory Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China. .,Beijing Key Laboratory of Urinary Cellular Molecular Diagnostics, Beijing, China.
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12
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Bhatt A, Rousset P, Baratti D, Biacchi D, Benzerdjeb N, H J T de Hingh I, Deraco M, Gushchin V, Kammar P, Labow D, Levine E, Moran B, Mohamed F, Morris D, Mehta S, Nissan A, Alyami M, Adileh M, Barat S, Ben Yacov A, Campbell K, Cummins-Perry K, Cortes-Guiral D, Cohen N, Parikh L, Alammari S, Bashanfer G, Alshukami A, Kundalia K, Goswami G, de Vlasakker VV, Sittig M, Sammartino P, Sardi A, Villeneuve L, Turaga K, Yonemura Y, Glehen O. Patterns of peritoneal dissemination and response to systemic chemotherapy in common and rare peritoneal tumours treated by cytoreductive surgery: study protocol of a prospective, multicentre, observational study. BMJ Open 2021; 11:e046819. [PMID: 34226220 PMCID: PMC8258594 DOI: 10.1136/bmjopen-2020-046819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 06/18/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Despite optimal patient selection and surgical effort, recurrence is seen in over 70% of patients undergoing cytoreductive surgery (CRS) for peritoneal metastases (PM). Apart from the Peritoneal Cancer Index (PCI), completeness of cytoreduction and tumour grade, there are other factors like disease distribution in the peritoneal cavity, pathological response to systemic chemotherapy (SC), lymph node metastases and morphology of PM which may have prognostic value. One reason for the underutilisation of these factors is that they are known only after surgery. Identifying clinical predictors, specifically radiological predictors, could lead to better utilisation of these factors in clinical decision making and the extent of peritoneal resection performed for different tumours. This study aims to study these factors, their impact on survival and identify clinical and radiological predictors. METHODS AND ANALYSIS There is no therapeutic intervention in the study. All patients with biopsy-proven PM from colorectal, appendiceal, gastric and ovarian cancer and peritoneal mesothelioma undergoing CRS will be included. The demographic, clinical, radiological, surgical and pathological details will be collected according to a prespecified format that includes details regarding distribution of disease, morphology of PM, regional node involvement and pathological response to SC. In addition to the absolute value of PCI, the structures bearing the largest tumour nodules and a description of the morphology in each region will be recorded. A correlation between the surgical, radiological and pathological findings will be performed and the impact of these potential prognostic factors on progression-free and overall survival determined. The practices pertaining to radiological and pathological reporting at different centres will be studied. ETHICS AND DISSEMINATION The study protocol has been approved by the Zydus Hospital ethics committee (27 July, 2020) and Lyon-Sud ethics committee (A15-128). TRIAL REGISTRATION NUMBER CTRI/2020/09/027709; Pre-results.
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Affiliation(s)
- Aditi Bhatt
- Surgical Oncology, Zydus Hospital, Ahmedabad, India
| | - Pascal Rousset
- Radiology, Centre Hospitalier Lyon-Sud, Pierre-Benite, France
| | - Dario Baratti
- Surgical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | | | | | - Marcello Deraco
- Surgical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Vadim Gushchin
- Surgical Oncology, Mercy Medical Center, Baltimore, Maryland, USA
| | | | - Daniel Labow
- Surgical Oncology, Mount Sinai Medical Center, New York City, New York, USA
| | - Edward Levine
- Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Brendan Moran
- Peritoneal malignancy unit, Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, UK
| | - Faheez Mohamed
- Peritoneal malignancy unit, Basingstoke and North Hampshire NHS Foundation Trust, Winchester, UK
| | - David Morris
- Peritonectomy Unit, University of New South Wales, Sydney, New South Wales, Australia
| | - Sanket Mehta
- Surgical Oncology, Saifee Hospital, Mumbai, India
| | - Aviram Nissan
- Surgical Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Mohammad Alyami
- Surgical Oncology, King Khaled Hospital, Najran, Saudi Arabia
| | - Mohammad Adileh
- Surgical Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Shoma Barat
- Surgical Oncology, St. George Hospital, Sydney, New South Wales, Australia
| | - Almog Ben Yacov
- Surgical Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Kurtis Campbell
- Surgical Oncology, Mercy Medical Center, Baltimore, Maryland, USA
| | | | | | - Noah Cohen
- Surgical Oncology, Mount Sinai Medical Center, New York City, New York, USA
| | | | - Samer Alammari
- Surgical Oncology, King Khaled Hospital, Najran, Saudi Arabia
| | | | | | - Kaushal Kundalia
- Surgical Oncology, Basingstoke and North Hampshire NHS Foundation Trust, Winchester, UK
| | | | | | - Michelle Sittig
- Surgical Oncology, Mercy Medical Center, Baltimore, Maryland, USA
| | | | - Armando Sardi
- Surgical Oncology, Mercy Medical Center, Baltimore, Maryland, USA
| | | | - Kiran Turaga
- Surgical Oncology, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Yutaka Yonemura
- Surgical Oncology, Kishiwada Tokushukai Hospital, Kishiwada, Japan
| | - Olivier Glehen
- Surgical Oncology, Centre Hospitalier Lyon-Sud, Pierre-Benite, France
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13
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Sugarbaker PH, Chang D. Cytoreductive Surgery Plus HIPEC With and Without NIPEC for Malignant Peritoneal Mesothelioma: A Propensity-Matched Analysis. Ann Surg Oncol 2021; 28:7109-7117. [PMID: 33942167 DOI: 10.1245/s10434-021-10048-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/01/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Malignant peritoneal mesothelioma is a rare and often fatal disease. Dissemination is confined to the abdominal and pelvic peritoneal spaces in a great majority of patients. METHODS Standardized cytoreductive surgery and perioperative chemotherapy was used in all patients. Long-term normothermic intraperitoneal chemotherapy (NIPEC) was added to the treatment of our most recent group of patients. Survival with and without NIPEC was compared using a propensity-matched analysis. RESULTS In a uniform group of 74 patients, the clinical- and treatment-related features that had an impact on survival were age (hazard ratio [HR] 1.99, 95% confidence interval [CI] 0.929-4.238, p = 0.0766), completeness of cytoreduction (HR 2.356, 95% CI 1.113-4.989, p = 0.0251), and treatments administered (HR 3.497, 95% CI 1.199-10.20, p = 0.0219). In the Cox proportional hazards multivariant model, sex and age were borderline significant. Treatments administered were significant (HR 3.549, 95% CI 1.157-10.888, p = 0.0268). Using five features to match 29 patients in the control group (no NIPEC) to 29 patients in the experimental group (with NIPEC), the propensity-matched survival was significantly different (p = 0.0263). CONCLUSIONS The addition of NIPEC was associated with long-term survival in this cohort of patients. A multi-institutional randomized trial may be the next step.
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Affiliation(s)
- Paul H Sugarbaker
- Program in Peritoneal Surface Malignancy, Washington Cancer Institute, Washington, DC, USA.
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14
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Guaglio M, Baratti D, Kusamura S, Reis ACV, Montenovo M, Bartolini V, Battaglia L, Deraco M. Impact of Previous Gynecologic Surgical Procedures on Outcomes of Non-Gynecologic Peritoneal Malignancies Mimicking Ovarian Cancer: Less Is More? Ann Surg Oncol 2021; 28:2899-2908. [PMID: 33641011 DOI: 10.1245/s10434-021-09587-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Non-gynecologic rare peritoneal surface malignancies (PSMs) often are misdiagnosed as disseminated ovarian cancer and initially treated by gynecologic surgeons. This study aimed to assess whether these previous maneuvers (i.e., full surgical staging and/or cytoreductive attempts) affect outcomes after the definitive surgery performed in a tertiary center. METHODS The study reviewed 298 women affected by non-gynecologic PSM who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) after previous gynecologic surgery. Prior surgery was categorized as limited surgery (pLS: abdominal exploration with biopsy plus adnexectomy and/or appendectomy) or extended surgery (pES: full surgical staging or cytoreductive attempts including hysterectomy with bilateral salpingo-oophorectomy). RESULTS Of the 298 patients, 143 had pLS and 153 had pES. Morbidity was similar between the groups (P = 0.143), but the pES group had more severe urinary tract injuries (19 vs. 3; P < 0.001), longer operating time (585.9 vs. 506.7; P = 0.027), and more patients needing more than two anastomoses (41 vs. 26; P = 0.033). Age older than 55 years (odds ratio [OR] 2.42; P = 0.009) and number of anastomoses (OR 3.17; P = 0.002) correlated with severe morbidity; pES correlated with urinary tract grades 3 and 4 injuries (OR 7.9; P = 0.001). The 5-year cumulative incidence of locoregional relapse was significantly higher in the pES group (0.41 vs. 0.27; P = 0.012; median follow-up period, 69 months). The multivariate analysis identified a Peritoneal Carcinomatosis Index (PCI) higher than 20 and pES as independent risk factors. CONCLUSION For women undergoing CRS±HIPEC for non-gynecologic PSM, the risk for locoregional relapse and severe postsurgical urinary tract complications is increased by pES. Therefore, prior full surgical staging or cytoreductive attempts without definitive gynecologic histology should be avoided. Prophylactic ureteral stenting and stricter oncologic follow-up assessment must be considered in this scenario.
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Affiliation(s)
- Marcello Guaglio
- Peritoneal Surface Malignancies Unit, Colorectal Surgical Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Dario Baratti
- Peritoneal Surface Malignancies Unit, Colorectal Surgical Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Shigeki Kusamura
- Peritoneal Surface Malignancies Unit, Colorectal Surgical Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Arthur C V Reis
- Peritoneal Surface Malignancies Unit, Colorectal Surgical Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Fellow of European School of PeritonealSurface Oncology (ESPSO), Department of Gastrointestinal Surgery, Irmandade Santa Casa de Misericórdia de São José Dos Campos, São Paulo, Brazil
| | - Matteo Montenovo
- Peritoneal Surface Malignancies Unit, Colorectal Surgical Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Valentina Bartolini
- Peritoneal Surface Malignancies Unit, Colorectal Surgical Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Battaglia
- Colorectal Surgical Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancies Unit, Colorectal Surgical Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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15
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Baratti D, Kusamura S, Niger M, Perrone F, Milione M, Cattaneo L, Guaglio M, Bartolini V, Pietrantonio F, Deraco M. Prognostic Impact of Primary Side and RAS/RAF Mutations in a Surgical Series of Colorectal Cancer with Peritoneal Metastases. Ann Surg Oncol 2020; 28:3332-3342. [PMID: 32974694 DOI: 10.1245/s10434-020-09161-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/31/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Selecting patients with colorectal cancer peritoneal metastases (CRC-PMs) for surgery is still a concern. Biological features have the potential to improve prognostic stratification, but their significance in this clinical setting is still unclear. We assessed the prognostic impact of primary side and KRAS/NRAS/BRAF/PIK3CA mutations in patients treated with either cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) or CRS alone. METHODS We reviewed a prospective database of 152 CRC-PM patients selected to undergo perioperative systemic chemotherapy and CRS with or without HIPEC. Extensive mutational analysis of KRAS, NRAS, BRAF, and PIK3CA was performed by polymerase chain reaction (PCR). In 68 patients, Ion Torrent next-generation sequencing technology was used to characterize the hotspot regions of 50 genes. RESULTS The primary tumor was right-sided in 61 patients (40.1%) and left-sided in 91 patients (59.9%). Right-sided primaries were associated with mutated KRAS (p = 0.01) and normal carcinoembryonic antigen (CEA; p = 0.03). KRAS was mutated in 71/152 patients (46.7%), NRAS in 7/152 patients (4.6%), BRAF in 10/152 patients (6.6%), PIK3CA in 17/78 patients (25.0%), TP53 in 37/68 patients (54.4%), APC in 25/68 patients (36.7%), SMAD4 in 13/68 patients (19.1%), and FBXW7 in 5/68 patients (7.4%). Median follow-up was 54.9 months and median survival from PM diagnosis was 45.1 months. The right-sided primary (hazard ratio [HR] 1.62, 95% confidence interval [CI] 0.43-0.89; p = 0.011), BRAF mutations (HR 2.21, 95% CI 1.05-4.63; p = 0.038), and Peritoneal Cancer Index (HR 1.47, 95% CI 1.03-2.10; p = 0.036) independently correlated with poorer survival, while APC mutations univariately correlated with better survival (p = 0.03). CONCLUSIONS BRAF mutations and right-sided primary are adverse prognostic factors that may be used to optimize therapeutic strategies. APC may be involved in CRC-PM development and progression.
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Affiliation(s)
- Dario Baratti
- Peritoneal Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Shigeki Kusamura
- Peritoneal Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Monica Niger
- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Perrone
- Laboratory of Molecular Pathology, Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Massimo Milione
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laura Cattaneo
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Guaglio
- Peritoneal Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Valentina Bartolini
- Peritoneal Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Filippo Pietrantonio
- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Deraco
- Peritoneal Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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16
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Comparative study of mucinous and non-mucinous appendiceal neoplasms with peritoneal dissemination treated by cyoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Eur J Surg Oncol 2020; 47:1132-1139. [PMID: 33280949 DOI: 10.1016/j.ejso.2020.08.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/07/2020] [Accepted: 08/20/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Appendiceal non-mucinous neoplasms (AnMN) are rare and poorly understood malignancies with no standard treatment. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is largely used to treat peritoneal disseminations from appendiceal mucinous neoplasms (AMN), but its role with AnMN is unclear. METHODS A prospective database of 315 patients with advanced appendiceal primaries undergoing CRS/HIPEC during 1996-2020 was reviewed. Baseline characteristics, operative and long-term outcomes of AnMN were compared with those of AMN. AMN were categorized according to PSOGI classification into high-grade, low-grade, and acellular mucin (AC), based on peritoneal disease histology. RESULTS Twenty-three patients (7.3%) with goblet cell carcinoma (GCC; n = 9), intestinal-type adenocarcinoma (ITAC; n = 12), and mixed adeno-neuroendocrine carcinoma (MANEC; n = 2) were identified. AnMN patients were more likely to be males (P = 0.006), have preoperative systemic chemotherapy (P = 0.001), grossly incomplete CRS (P = 0.001), and nodal metastases (P = 0.001), but not systemic relapse after CRS/HIPEC (P = 0.133). Median follow-up was 25.1 months (range 0.8-77.3) for AnMN, and 80.9 months (range 0.1-279.2) for AMN. Median overall survival was 24.0 months for AnMN, 66.2 months for high-grade AMN (P = 0.015), 160.0 months for low-grade ANM (P = 0.001), and not reached for AC (P = 0.001). Among AnMN patients, median survival was 23.4 months for GCC, 38.7 months for ITAC, 20.3 months for MANEC (P = 0.855). In the overall series, histological subtype (P = 0.001), incomplete cytoreduction (P = 0.001), and positive lymph-nodes (P = 0.003) correlated with poorer survival at multivariate analysis. CONCLUSIONS AnMN share with AMN a predominant local-regional dissemination pattern, but prognosis after CRS/HIPEC is worse. This strategy needs to be carefully considered for AnMN. PATIENTS
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17
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Prospective Comparative Analysis of Total Versus Involved Field Parietal Peritonectomy During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC) for Peritoneal Surface Malignancies from Colorectal Cancer. Indian J Surg 2020. [DOI: 10.1007/s12262-019-02017-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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18
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Kyriazanos I, Papageorgiou D, Zoulamoglou M, Marougkas M, Stamos N, Ivros N, Kalles V. Total extraperitoneal access for parietal peritonectomy for peritoneal surface malignancy: The ‘cocoon’ technique. Eur J Obstet Gynecol Reprod Biol 2020; 251:258-262. [DOI: 10.1016/j.ejogrb.2020.05.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023]
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19
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Reis ACV, Kusamura S, Azmi N, Fumagalli L, Piccioni F, Valenza F, Baratti D, Guaglio M, Cavalleri A, Garrone G, Barretta F, Deraco M. Hemodynamic and respiratory implications of high intra-abdominal pressure during HIPEC. Eur J Surg Oncol 2020; 46:1896-1901. [PMID: 32147425 DOI: 10.1016/j.ejso.2020.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/05/2020] [Accepted: 02/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND cytoreduction surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is currently the standard of care for some peritoneal surface malignancies. There is experimental evidence supporting that high Intra Abdominal Pressure (IAP) during HIPEC could enhance the uptake of drugs by tumor tissues. However, few papers are describing the hemodynamic and respiratory effects of increased IAP during HIPEC. AIMS to evaluate the hemodynamic and respiratory association with different IAPs during HIPEC. METHODS This is part of an IRB board approved prospective randomized controlled trial conducted at The National Tumor Institute of Milan from 2014 to 2017 (NCT0294979). Patients diagnosed with Pseudomyxoma (PMP) or Peritoneal Metastasis of Colorectal Cancer (PM-CRC) were submitted to CRS and then randomized to receive low IAP (8-12 mmHg) or high IAP (18-22 mmHg) HIPEC. Hemodynamic and respiratory data were collected in eight different time-points during the whole procedure. RESULTS 33 patients (n low = 15, n high = 18) with PM-CRC and PMP were analysed. The mean IAP in the low IAP HIPEC group was 11.4 mmHg (SD: 2.5) and 18.1 mmHg (SD: 2.5) in the high IAP HIPEC group (p«0.001). There was no difference in the hemodynamic parameters between both groups, except for the central venous pressure (CVP) that was significantly higher in the high IAP group (p = 0.006). High IAP was well tolerated in the experimental arm with no hemodynamic and ventilation instability observed during the intervention. CONCLUSION We conclude that high IAP at the level of 18-22 mmHg during HIPEC has no significant hemodynamic parameters difference, being feasible and safe in our study.
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Affiliation(s)
- Artur C V Reis
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy; Irmandade Santa Casa de Misericórdia de São José Dos Campos, Department of Gastrointestinal Surgery, São Paulo, Brazil.
| | - Shigeki Kusamura
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Norfarizan Azmi
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Luca Fumagalli
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy
| | - Federico Piccioni
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy
| | - Franco Valenza
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy; University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Dario Baratti
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Marcello Guaglio
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Adalberto Cavalleri
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Laboratory of Department of Preventive and Predictive Medicine, Italy
| | - Giulia Garrone
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Laboratory of Department of Preventive and Predictive Medicine, Italy
| | - Francesco Barretta
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Department of Clinical Epidemiology and Trial Organization, Milan, Italy
| | - Marcello Deraco
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy.
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20
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Bhatt A, Glehen O. Extent of Peritoneal Resection for Peritoneal Metastases: Looking Beyond a Complete Cytoreduction. Ann Surg Oncol 2020; 27:1458-1470. [PMID: 31965374 DOI: 10.1245/s10434-020-08208-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Indexed: 12/17/2022]
Abstract
Completeness of cytoreduction is one of the most important prognostic factors impacting outcomes of cytoreductive surgery (CRS). To what extent the surrounding normal peritoneum needs to be removed is not known. We hypothesized that the extent of peritoneal resection should be different for different tumors and performed this study to find evidence to support this rationale. To determine the extent of resection of surrounding tissue for any tumor, the mechanisms of tumor development and spread, tumor morphology, the possibility of finding disease in the surrounding normal tissue, and the pattern of lymph node metastases should be known. Surgical resections also depend on patterns of recurrence and the impact of varying extent of resection on survival. We performed a review of literature pertaining to pathways and patterns of peritoneal cancer spread to determine the scientific basis for the extent of peritonectomy. We also reviewed studies comparing less and more extensive peritoneal resection. There is no consensus on the extent of lymphadenectomy required for most PM. Based on this review, we provide recommendations for the extent of peritoneal resection and the extent of lymph node dissection that should be performed for some common peritoneal tumors and identify areas that require further research. We propose that a systematic method of synoptic reporting of pathological specimens of CRS should be developed to capture information regarding the disease distribution within the peritoneal cavity and morphology of PM from different tumors. This can in future be used to establish standard guidelines for such resections.
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Affiliation(s)
- Aditi Bhatt
- Department of Surgical Oncology, Zydus Hospital, Ahmedabad, India
| | - Olivier Glehen
- Department of Surgical Oncology, Centre Hospitalier Lyon-Sud, Lyon, France.
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21
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Mercier F, Mohamed F, Cazauran JB, Kepenekian V, Vaudoyer D, Cotte E, Glehen O, Passot G. An update of peritonectomy procedures used in cytoreductive surgery for peritoneal malignancy. Int J Hyperthermia 2020; 36:744-752. [PMID: 31401893 DOI: 10.1080/02656736.2019.1635717] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Complete cytoreduction is acknowledged to be an effective way to achieve macroscopic tumor clearance for a variety of tumors confined to the peritoneal cavity. Recent trials have shown that surgery respecting anatomical planes results in excellent outcomes and even the chance of cure for some from what was once thought to be life-limiting disease. Objective: To describe peritonectomy procedures in the current era. Method: A thorough and systematic method for cytoreductive surgery aimed at complete surgical resection of peritoneal metastases (PMs) was described. Results: The general principles of cytoreductive surgery were set out including preoperative preparation, patient positioning and incision. Strategies for assessing disease extent and planning surgical steps were outlined and established peritonectomy procedures such as Glisson's capsulectomy, omentectomy, left and right diaphragmatic peritonectomy, lesser omentectomy, stripping of the omental bursa, and pelvic peritonectomy were described. Novel techniques such as anterior pancreatic peritonectomy, small bowel mesenteric peritonectomy and cardiophrenic lymph node dissection were explained, and illustrated with accompanying video. Conclusion: Peritoneal metastases present a challenge to the surgeon which calls for a unique skill set if optimal outcomes are to be achieved. Attempts to standardize the surgical techniques described will allow further refinement as new technological advances occur.
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Affiliation(s)
- Frédéric Mercier
- a Faculté de Médecine de Université de Montréal , Montréal , Canada.,b Department of Surgical Oncology, Centre Hospitalier Universitaire de Montréal (CHUM) , Montréal , Canada.,c Department of General Surgery, Centre Hospitalier Lyon Sud , Pierre Bénite , France.,d Hospices Civils de Lyon , Lyon , France
| | - Faheez Mohamed
- e Peritoneal Malignancy Institute Basingstoke , Basingstoke , UK
| | - Jean-Baptiste Cazauran
- c Department of General Surgery, Centre Hospitalier Lyon Sud , Pierre Bénite , France.,d Hospices Civils de Lyon , Lyon , France
| | - Vahan Kepenekian
- c Department of General Surgery, Centre Hospitalier Lyon Sud , Pierre Bénite , France.,d Hospices Civils de Lyon , Lyon , France.,f EMR UCBL/HCL 3738, Faculté de Médecine Lyon-Sud, Université Lyon 1 , Lyon , France
| | - Delphine Vaudoyer
- c Department of General Surgery, Centre Hospitalier Lyon Sud , Pierre Bénite , France.,d Hospices Civils de Lyon , Lyon , France
| | - Eddy Cotte
- c Department of General Surgery, Centre Hospitalier Lyon Sud , Pierre Bénite , France.,d Hospices Civils de Lyon , Lyon , France.,f EMR UCBL/HCL 3738, Faculté de Médecine Lyon-Sud, Université Lyon 1 , Lyon , France
| | - Olivier Glehen
- c Department of General Surgery, Centre Hospitalier Lyon Sud , Pierre Bénite , France.,d Hospices Civils de Lyon , Lyon , France.,f EMR UCBL/HCL 3738, Faculté de Médecine Lyon-Sud, Université Lyon 1 , Lyon , France
| | - Guillaume Passot
- c Department of General Surgery, Centre Hospitalier Lyon Sud , Pierre Bénite , France.,d Hospices Civils de Lyon , Lyon , France.,f EMR UCBL/HCL 3738, Faculté de Médecine Lyon-Sud, Université Lyon 1 , Lyon , France
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22
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Somashekhar S, Ashwin K, Yethadka R, Zaveri SS, Ahuja VK, Rauthan A, Rohit KC. Impact of extent of parietal peritonectomy on oncological outcome after cytoreductive surgery and HIPEC. Pleura Peritoneum 2019; 4:20190015. [PMID: 31799371 PMCID: PMC6881664 DOI: 10.1515/pp-2019-0015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/11/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In peritoneal surface malignancy (PSM), in spite of optimal cytoreductive surgery (CRS), majority of recurrences that occur are intraperitoneal. In patients with PSM, studies employing fluorescent imaging and microscopic examination have shown normal looking peritoneum may harbor active disease. This study was done to assess the recurrence pattern, oncological outcomes, and morbidity and mortality of the extent of peritonectomy in patients who underwent total parietal peritonectomy (TPP) or involved field peritonectomy (IFP) as a part of the procedure during CRS and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS This was a retrospective analysis of prospectively collected data, from February 2013 to December 2017. A total of 163 patients with PSM underwent TPP or IFP with CRS plus HIPEC. Their oncological outcomes, recurrence pattern, postoperative morbidity and mortality were analyzed. RESULTS Of the 163 cases, the primary organs of origin were ovary, colorectal, appendicular pseudomyxoma, stomach, mesothelioma and others (67.4%, 16.5%, 6.1%, 4.9%, 2% and 2%), respectively. TPP was performed in 70 patients and IFP in 93 patients. TPP group had higher mean PCI (16 vs. 14), longer duration of surgery (11 vs. 9 h), and more blood loss (1,243 vs. 675 mL). Overall G3-G4 morbidity was comparable in both groups (42.8% vs. 33.3%) as was mortality (5.7% vs. 4.4%). Kaplan-Meier analysis showed that with a median follow-up of 45 months, TPP group had a recurrence-free survival (RFS) of 26 months and overall survival (OS) was yet to be achieved, whereas the IFP group had a RFS and OS of 21 and 43 months, respectively. CONCLUSIONS Performing TPP reduces the chance of missing the microscopic disease, therefore can minimize local recurrence, and better oncological outcomes. TPP can be performed with acceptable morbidity and mortality, at the cost of increased duration of surgery and higher blood loss.
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Affiliation(s)
- S.P. Somashekhar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, BengaluruIndia
| | - K.R. Ashwin
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, BengaluruIndia
| | - Ramya Yethadka
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, BengaluruIndia
| | - Shabber S. Zaveri
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, BengaluruIndia
| | - Vijay K Ahuja
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, BengaluruIndia
| | - Amit Rauthan
- Department of Medical Oncology, Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore, Karnataka, India
| | - Kumar C. Rohit
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, BengaluruIndia
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Baratti D, Kusamura S, Azmi N, Guaglio M, Montenovo M, Deraco M. Colorectal Peritoneal Metastases Treated by Perioperative Systemic Chemotherapy and Cytoreductive Surgery With or Without Mitomycin C-Based HIPEC: A Comparative Study Using the Peritoneal Surface Disease Severity Score (PSDSS). Ann Surg Oncol 2019; 27:98-106. [PMID: 31691116 DOI: 10.1245/s10434-019-07935-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND The Prodige-7 trial has questioned the role of hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal metastases from colorectal cancer (CRC-PM). PATIENTS AND METHODS We compared a prospectively collected group of 48 patients undergoing oxaliplatin/irinotecan-based perioperative systemic chemotherapy (s-CT) with targeted agents, and cytoreductive surgery (CRS) (no-HIPEC group) with 48 controls undergoing the same perioperative s-CT and CRS/HIPEC (HIPEC group). Patients were matched (1:1) according to the Peritoneal Surface Disease Severity Score, completeness of cytoreduction, history of extraperitoneal disease (EPD), and Peritoneal Cancer Index. RESULTS The groups were comparable, except for a higher number of patients in the HIPEC group with World Health Organization performance status 0, pN2 stage primary tumor, and treated with preoperative s-CT. Forty-one patients in the no-HIPEC group and 43 patients in the HIPEC group had optimal comprehensive treatment (P = 0.759), defined as complete cytoreduction of PM and margin-negative EPD resection. Median follow-up was 31.6 months in the no-HIPEC group and 39.9 months in the HIPEC group. Median overall survival was 39.3 months in the no-HIPEC group and 34.8 months in the HIPEC group (P = 0.702). In the two groups, severe morbidity occurred in 14 (29.2%) and 13 (27.1%) patients, respectively (P = 1.000), with no operative deaths. On multivariate analysis, left-sided primary and curative treatment independently correlated with better survival while HIPEC did not (hazard ratio 0.73; 95% confidence interval 0.47-1.15; P = 0.178). CONCLUSIONS Our results confirmed that, in selected patients, perioperative s-CT and surgical treatment of CRC-PM resulted in unexpectedly high survival rates. Mitomycin C-based HIPEC did not increase morbidity but did not impact prognosis.
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Affiliation(s)
- Dario Baratti
- Peritoneal Malignancy Program, Department of Surgery, National Cancer Institute, Milan, Italy.
| | - Shigeki Kusamura
- Peritoneal Malignancy Program, Department of Surgery, National Cancer Institute, Milan, Italy
| | - Norfarizan Azmi
- Department of General Surgery, Hospital Tuanku Ja'afar, Seremban, Negeri Sembilan, Malaysia
| | - Marcello Guaglio
- Peritoneal Malignancy Program, Department of Surgery, National Cancer Institute, Milan, Italy
| | - Matteo Montenovo
- Peritoneal Malignancy Program, Department of Surgery, National Cancer Institute, Milan, Italy
| | - Marcello Deraco
- Peritoneal Malignancy Program, Department of Surgery, National Cancer Institute, Milan, Italy
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24
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Bhatt A, Yonemura Y, Benzerdjeb N, Mehta S, Mishra S, Parikh L, Kammar P, Shah MY, Prabhu A, Shaikh S, Patel MD, Isaac S, Glehen O. Pathological assessment of cytoreductive surgery specimens and its unexplored prognostic potential-a prospective multi-centric study. Eur J Surg Oncol 2019; 45:2398-2404. [PMID: 31337527 DOI: 10.1016/j.ejso.2019.07.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/15/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND AIM The grade/histological subtype is one of the most important prognostic markers in patients undergoing cytoreductive surgery (CRS). Our aim was to study other potential prognostic information that can be derived from the pathological evaluation of CRS specimens and provide a broad outline for evaluation of these. METHODS This prospective study (July to December 2018) included all patients undergoing cytoreductive surgery (CRS). A protocol for pathological evaluation was laid down which was based on existing practices at the participating centers and included evaluation of the pathological PCI, regional node involvement, response to chemotherapy, morphology of peritoneal metastases (PM) and distribution in the peritoneal cavity. RESULTS In 191 patients undergoing CRS at 4 centers, the pathological and surgical PCI differed in over 75%. Nodes in relation to peritoneal disease were positive in 13.6%. Disease in normal peritoneum adjacent to tumor nodules was seen in >50% patients with ovarian cancer and mucinous apppendiceal tumors. 23.8% of evaluated colorectal PM patients had a complete response and 25.0% ovarian cancer patients had a near complete pathological response to chemotherapy. CONCLUSIONS Pathological evaluation of extent and distribution of peritoneal disease differs from the surgical evaluation in majority of the patients. Lymph node involvement in relation of peritoneal disease is common. The morphological presentation of PM in ovarian cancer and mucinous appendiceal tumors merits evaluation of more extensive resections in these patients. Standardized methods of synoptic reporting of CRS specimens could help capture vital prognostic information that may in future influence how these patients are treated.
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Affiliation(s)
- Aditi Bhatt
- Dept. of Surgical Oncology, Zydus Hospital, Ahmedabad, India.
| | - Yutaka Yonemura
- Peritoneal Metastases Center, Kishiwada Tokushukai Hospital, Osaka, Japan
| | | | - Sanket Mehta
- Dept. of Surgical Oncology, Saifee Hospital, Mumbai, India
| | - Suniti Mishra
- Dept. of Pathology, Fortis Hospital, Bangalore, India
| | - Loma Parikh
- Dept. of Pathology, Zydus Hospital, Ahmedabad, India
| | - Praveen Kammar
- Dept. of Surgical Oncology, Saifee Hospital, Mumbai, India
| | - Mita Y Shah
- Dept. of Pathology, Saifee Hospital, Mumbai, India
| | - Aruna Prabhu
- Dept of Surgical Oncology, Thangam Cancer Centre, Nammakkal, India
| | - Sakina Shaikh
- Dept. of Surgical Oncology, Zydus Hospital, Ahmedabad, India
| | - Mahesh D Patel
- Dept. of Surgical Oncology, Zydus Hospital, Ahmedabad, India
| | - Sylvie Isaac
- Dept. of Pathology, Centre Hospitalier Lyon-sud, Lyon, France
| | - Olivier Glehen
- Dept. of Surgical Oncology, Centre Hospitalier Lyon-sud, Lyon, France
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25
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Kusamura S, Azmi N, Fumagalli L, Baratti D, Guaglio M, Cavalleri A, Garrone G, Battaglia L, Barretta F, Deraco M. Phase II randomized study on tissue distribution and pharmacokinetics of cisplatin according to different levels of intra-abdominal pressure (IAP) during HIPEC (NCT02949791). Eur J Surg Oncol 2019; 47:82-88. [PMID: 31262599 DOI: 10.1016/j.ejso.2019.06.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/28/2019] [Accepted: 06/12/2019] [Indexed: 01/01/2023] Open
Abstract
AIMS To evaluate the effects of high intra-abdominal pressure (IAP) during hyperthermic intraperitoneal chemotherapy (HIPEC) on cisplatin uptake by residual tumor and normal tissues, pharmacokinetics, and short-term surgical outcomes. PATIENTS & METHODS Patients with peritoneal metastasis from colorectal cancer or pseudomyxoma peritonei were randomized to closed-abdomen HIPEC with low-IAP or high-IAP, after complete cytoreduction. High-IAP was obtained increasing the volume of perfusate maintaining constant the cisplatin concentration (42 mg/L). We determined the Platinum concentration using an Inductive Coupled Plasma Mass Spectrometry System. Randomization was stratified according to tumor type. To consider the multiple sampling in the three tissues types of interest, we performed linear mixed models to assess the differences of cisplatin concentration between study arms. We also compared AUC perfusate/plasma ratios (Wilcoxon-Mann-Whitney) and perioperative severe complication rates (chi-square) between study arms. RESULTS 38 cases were randomly assigned to IAP arms (n = 19 each). Median IAPs were 19 mmHg and 11 mmHg in the high and low arms, respectively. Cisplatin concentrations did not differ in the tumor residual tissues and in the muscular fascia [22.8 ng/mg (SD: 25.5) vs. 15.9 ng/mg (SD: 13.3), p = 0.181] and [50.3 ng/mg (SD: 40.1) vs. 42.0 ng/mg (SD: 38.3), p = 0.426, respectively], whereas in the mesenteric peritoneum it did [5.4 ng/mg (SD: 7.82) vs. 2.7 ng/mg (SD: 2.9), p = 0.048]. Pharmacokinetic advantage did not differ between the two arms. High-IAP did not increase perioperative severe complications rate (NCI-CTCAE.v3). CONCLUSIONS high-IAP HIPEC increases cisplatin distribution in the mesenteric peritoneum, is safe, and could be considered to obtain microscopic cytoreduction.
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Affiliation(s)
- Shigeki Kusamura
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Norfarizan Azmi
- Fellow of European School of Peritoneal Surface Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Anesthesiology Unit, Italy
| | - Luca Fumagalli
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Anesthesiology Unit, Italy
| | - Dario Baratti
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Marcello Guaglio
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Adalberto Cavalleri
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Laboratory of Department of Preventive and Predictive Medicine, Italy
| | - Giulia Garrone
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Laboratory of Department of Preventive and Predictive Medicine, Italy
| | - Luigi Battaglia
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Francesco Barretta
- Department of Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Marcello Deraco
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy.
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26
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Farrell R. Is peritonectomy and hyperthermic intraperitoneal chemotherapy a new standard of treatment for advanced epithelial ovarian cancer? Aust N Z J Obstet Gynaecol 2019; 59:335-340. [DOI: 10.1111/ajo.12953] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 12/28/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Rhonda Farrell
- Prince of Wales Private Hospital Sydney New South Wales Australia
- Department of SurgerySt George HospitalUNSW Sydney New South Wales Australia
- Chris O’Brien LifehouseCamperdown Sydney New South Wales Australia
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27
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Piso P, Nedelcut SD, Rau B, Königsrainer A, Glockzin G, Ströhlein MA, Hörbelt R, Pelz J. Morbidity and Mortality Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Data from the DGAV StuDoQ Registry with 2149 Consecutive Patients. Ann Surg Oncol 2018; 26:148-154. [PMID: 30456672 DOI: 10.1245/s10434-018-6992-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are performed for well-selected patients with peritoneal surface malignancies. This combined treatment is potentially associated with an increased rate of complications. OBJECTIVE The aim of this paper was to analyze the morbidity and mortality of CRS and HIPEC in the German national registry. METHODS We present a retrospective analysis of 2149 consecutive patients from 52 hospitals. The data were prospectively documented in the DGAV StuDoQ Registry between February 2011 and December 2016. RESULTS Almost two-thirds of all patients had a colorectal malignancy; therefore, the most frequently performed resections were colectomies (54%) and rectal resections (30%). Only 36.2% of all patients had no anastomosis, and fewer than 20% of all patients were older than 70 years of age (16.4%). Enteric fistula and anastomotic leaks occurred in 10.5% of all cases. The reoperation rate was 14.6% (95% confidence interval [CI] 11.51-18.1). Major grade 3 and 4 complications (Clavien-Dindo classification) occurred in 19.3% of all patients, half of which were due to surgical complications. The overall 30-day postoperative hospital mortality was 2.3% (95% CI 1.02-3.85). Multivariate analysis showed an increased risk for morbidity associated with pancreatic resections (odds ratio [OR] 2.4), rectal resection (OR 1.5), or at least one anastomosis (OR 1.35), and mortality with reoperation (OR 8.7) or age > 70 years (OR 3.35). CONCLUSIONS CRS and HIPEC are associated with acceptable morbidity and low mortality. These results show that CRS and HIPEC can be safely performed nationwide when close mentoring by experienced centers is provided.
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Affiliation(s)
- Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany.
| | - Sebastian D Nedelcut
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Beate Rau
- Department of Surgery, Campus Virchow-Klinikum and Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, Eberhard-Karls University Hospital, Tübingen, Germany
| | - Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Surgery, Städtisches Klinikum München GmbH, Klinikum Bogenhausen, München, Germany
| | - Michael A Ströhlein
- Department of Abdominal, Vascular and Transplant Surgery, Köln-Merheim Medical Center, Witten/Herdecke University, Köln, Germany
| | - Rüdiger Hörbelt
- Department of Surgery, University Hospital of Giessen-Marburg, Giessen, Germany
| | - Jörg Pelz
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Würzburg, Germany
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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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29
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Should a History of Extraperitoneal Disease Be a Contraindication to Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Cancer Peritoneal Metastases? Dis Colon Rectum 2018; 61:1026-1034. [PMID: 30086051 DOI: 10.1097/dcr.0000000000001156] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Survival improvements have been reported in selected patients affected by colorectal peritoneal metastases who were undergoing cytoreductive surgery with intraperitoneal hyperthermic chemotherapy. Treatment of peritoneal metastases associated with extraperitoneal disease is still controversial. OBJECTIVE We assessed the prognostic impact of a history of extraperitoneal disease that was curatively treated either at the same time as or before the onset of peritoneal metastases. DESIGN We reviewed 2 prospective databases. Peritoneal involvement was scored by Peritoneal Cancer Index. SETTINGS Our study was conducted in 2 high-volume peritoneal malignancy management institutions. PATIENTS A total of 148 patients with peritoneal metastases were included. In 27 patients, extraperitoneal disease involving the liver (n = 23), lung (n = 1), both lung and liver (n = 2), or inguinal lymph nodes and liver (n = 1) was curatively treated either simultaneously with peritoneal metastases (n = 22) or before their onset (n = 5). INTERVENTIONS All of the macroscopic tumors were removed by means of peritonectomy procedures and visceral resections. Microscopic residual disease was treated by mitomycin C/cisplatin-based hyperthermic intraperitoneal chemotherapy. MAIN OUTCOME MEASURES Overall survival was the primary outcome measure. RESULTS After a median follow-up of 34.6 months (95% CI, 22.6-65.7 mo), 5-year survival of patients treated for both peritoneal and extraperitoneal disease versus peritoneal metastases alone was 16.5% versus 52.0% (p = 0.019). After multivariate analysis, reduced survival correlated with extraperitoneal disease (p = 0.001), Peritoneal Cancer Index >19 (p = 0.004), and peritoneal residual disease >2.5 mm (p = 0.018). Three prognostic groups were defined, and median survival was not reached for group 1 (Peritoneal Cancer Index ≤19 and no extraperitoneal disease), reached in 27.0 months for group 2 (Peritoneal Cancer Index ≤9 and extraperitoneal disease), and reached in 11.6 months for group 3 (Peritoneal Cancer Index >19 and no extraperitoneal disease or Peritoneal Cancer Index >9 and extraperitoneal disease). LIMITATIONS The main study limitation is its observational nature. CONCLUSIONS A history of extraperitoneal disease is associated with poorer prognosis. However, survival benefit may be obtained in selected patients with limited peritoneal involvement. See Video Abstract at http://links.lww.com/DCR/A655.
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30
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Batista TP, Sarmento BJQ, Loureiro JF, Petruzziello A, Lopes A, Santos CC, Quadros CDA, Akaishi EH, Cordeiro EZ, Coimbra FJF, Laporte GA, Castro LS, Batista RMSS, Aguiar S, Costa WL, Ferreira FO. A proposal of Brazilian Society of Surgical Oncology (BSSO/SBCO) for standardizing cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) procedures in Brazil: pseudomixoma peritonei, appendiceal tumors and malignant peritoneal mesothelioma. ACTA ACUST UNITED AC 2018; 44:530-544. [PMID: 29019584 DOI: 10.1590/0100-69912017005016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 06/08/2017] [Indexed: 12/13/2022]
Abstract
Cytoreductive surgery plus hypertermic intraperitoneal chemotherapy has emerged as a major comprehensive treatment of peritoneal malignancies and is currently the standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome as well as malignant peritoneal mesothelioma. Unfortunately, there are some worldwide variations of the cytoreductive surgery and hypertermic intraperitoneal chemotherapy techniques since no single technique has so far demonstrated its superiority over the others. Therefore, standardization of practices might enhance better comparisons between outcomes. In these settings, the Brazilian Society of Surgical Oncology considered it important to present a proposal for standardizing cytoreductive surgery plus hypertermic intraperitoneal chemotherapy procedures in Brazil, with a special focus on producing homogeneous data for the developing Brazilian register for peritoneal surface malignancies.
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Affiliation(s)
- Thales Paulo Batista
- - Medicina Integral Professor Fernando Figueira Institute, Department of Surgery / Oncology, Recife, PE, Brazil.,- University of Pernambuco, Department of Surgery, Recife, PE, Brazil
| | | | | | - Andrea Petruzziello
- - Marcelino Champagnat Hospital, Department of Surgical Oncology, Curitiba, PR, Brazil.,- AC Camargo Cancer Center, Department of Abdominal Surgery, São Paulo, SP, Brazil
| | - Ademar Lopes
- - AC Camargo Cancer Center, Department of Pelvic Surgery, São Paulo, SP, Brazil
| | | | | | - Eduardo Hiroshi Akaishi
- - Hospital das Clínicas, University of São Paulo, Department of Surgical Oncology, São Paulo, SP, Brazil
| | | | | | - Gustavo Andreazza Laporte
- - Santa Casa de Misericórdia de Porto Alegre, Department of Surgical Oncology, Porto Alegre, RS, Brazil
| | - Leonaldson Santos Castro
- - Complexo Hospitalar de Niterói, Service of Surgical Oncology, Niterói, RJ, Brazil.,- Nacional Cancer Institute, Service of Abdomino-Pelvic Surgery, Rio de Janeiro, RJ, Brazil
| | | | - Samuel Aguiar
- - AC Camargo Cancer Center, Department of Pelvic Surgery, São Paulo, SP, Brazil
| | - Wilson Luiz Costa
- - AC Camargo Cancer Center, Department of Abdominal Surgery, São Paulo, SP, Brazil
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31
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Radical treatment of peritoneal carcinomatosis: Times are changing. Cir Esp 2018; 97:125-127. [PMID: 30037471 DOI: 10.1016/j.ciresp.2018.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/18/2018] [Indexed: 11/23/2022]
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Tsunoda AT, Ribeiro R, Reis RJ, da Cunha Andrade C, Moretti Marques R, Baiocchi G, Fin F, Zanvettor PH, Falcao D, Batista TP, Azevedo B, Guitmann G, Pessini SA, Nunes JS, Campbell LM, Linhares JC, Carneiro V, Coimbra F. Surgery in ovarian cancer - Brazilian Society of Surgical Oncology consensus. BJOG 2018; 125:1243-1252. [PMID: 29900651 DOI: 10.1111/1471-0528.15328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2018] [Indexed: 12/22/2022]
Abstract
Surgical management in epithelial ovarian cancer (EOC) has a significant impact in overall survival and progression-free survival. The Brazilian Society of Surgical Oncology (BSSO) supported a taskforce of experts to reach a consensus: experienced and specialised trained surgeons, in cancer centres, provide the best EOC surgery. Laparoscopic and/or radiological staging prognosticates the possibility of complete cytoreduction (CC0) and helps to reduce unnecessary laparotomies. Surgical techniques were reviewed. Multidisciplinary input is essential for treatment planning. Quality assurance criteria are proposed and require national consensus. Genetic testing is mandatory. This consensus states the final recommendations from BSSO for management of EOC. TWEETABLE ABSTRACT Brazilian Society of Surgical Oncology consensus for surgery in epithelial ovarian cancer patients.
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Affiliation(s)
- A T Tsunoda
- Gynaecological Oncology Department, Hospital Erasto Gaertner, Curitiba, Brazil.,Albert Einstein Hospital, São Paulo, Brazil.,Positivo University, Curitiba, Brazil
| | - R Ribeiro
- Gynaecological Oncology Department, Hospital Erasto Gaertner, Curitiba, Brazil
| | - R J Reis
- Hospital Erasto Dorneles e Hospital Mãe de Deus, Porto Alegre, Brazil.,Brazilian Lutheran University, Porto Alegre, Brazil
| | - Cem da Cunha Andrade
- Gynaecological Oncology Department, Barretos Cancer Hospital, Barretos, Brazil.,Paulo Prata Medical University, Barretos, Brazil
| | | | - G Baiocchi
- Gynaecological Oncology Department, AC Camargo Cancer Centre, Sao Paulo, Brazil
| | - F Fin
- Gynaecological Oncology Department, Hospital São Vicente, Curitiba, Brazil.,Faculdade Evangélica de Curitiba, Curitiba, Brazil
| | - P H Zanvettor
- Gynaecological Oncology Department, Aristides Maltez Hospital, Salvador, Brazil.,AMO Clinic, Salvador, Brazil
| | - D Falcao
- Gynaecological Oncology Department, Aristides Maltez Hospital, Salvador, Brazil
| | - T P Batista
- Surgery Department, Instituto de Medicina Integral Professor Fernando Figueira, Recife, Brazil
| | - Brb Azevedo
- Hospital São Vicente, Curitiba, Brazil.,Instituto de Hemato Oncologia do Paraná, Curitiba, Brazil
| | - G Guitmann
- Brazilian National Cancer Institute, Rio de Janeiro, Brazil.,Americas Hospital, Rio de Janeiro, Brazil
| | - S A Pessini
- Gynaecological Oncology Department, Fundação Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - J S Nunes
- Hospital Erasto Gaertner, Curitiba, Brazil.,Instituto de Oncologia do Paraná, Curitiba, Brazil
| | | | - J C Linhares
- Gynaecological Oncology Department, Hospital Erasto Gaertner, Curitiba, Brazil.,Instituto de Oncologia do Paraná, Curitiba, Brazil
| | - V Carneiro
- Hospital de Câncer de Pernambuco, Recife, Brazil Instituto de Medicina Integral Professor Fernando Figueira NeoH - Núcleo Especializado em Oncologia e Hematologia D'OR, Recife, Brazil
| | - Fjf Coimbra
- AC Camargo Cancer Centre, Sao Paulo, Brazil.,Brazilian Society of Surgical Oncology 2016/2017, Sao Paulo, Brazil
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Bruno F, Baratti D, Martinetti A, Morelli D, Sottotetti E, Bonini C, Guaglio M, Kusamura S, Deraco M. Mesothelin and osteopontin as circulating markers of diffuse malignant peritoneal mesothelioma: A preliminary study. Eur J Surg Oncol 2018; 44:792-798. [DOI: 10.1016/j.ejso.2018.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 02/06/2018] [Indexed: 02/06/2023] Open
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Sugarbaker PH, Sardi A, Brown G, Dromain C, Rousset P, Jelinek JS. Concerning CT features used to select patients for treatment of peritoneal metastases, a pictoral essay. Int J Hyperthermia 2018; 33:497-504. [PMID: 28540832 DOI: 10.1080/02656736.2017.1317368] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND During the Fifth International Workshop on Peritoneal Surface Malignancy in Milan in 2008, a consensus was reached that contrast-enhanced CT (ceCT) was the principal imaging modality for patients being evaluated for treatment of peritoneal metastases. This fact being accepted, the radiologic criteria for that may exclude patients from a high value cytoreductive surgery (CRS) plus hyperthermic perioperative chemotherapy (HIPEC) have not been reliably determined. METHODS From a consensus of surgeons and radiologists, radiologic images were selected and their determinant radiologic characteristics described. The anatomic pathology causing the abnormal images were identified and characterised. The cytoreductive surgical procedures that may, in selected patients, result in a complete resection of the pathology identified were presented. RESULTS Radiographs of 15 CT images that cause concern when a patient is being evaluated for CRS were listed. The anatomic pathology these images define and possible surgical resections they require were reviewed. The surgical implications of the absence or presence of a single, or of multiple concerning CT features was extracted from the surgical and radiologic literature. CONCLUSIONS There is a definite need to identify new pre-operative imaging parameters to define optimal indication of CRS with HIPEC. The presence of a single concerning radiologic feature is associated with the possibility of an adverse outcome or technically more complex resections associated with increased morbidity and mortality. If two or more of the concerning radiologic features are described from the CT, suboptimal cytoreduction will usually occur.
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Affiliation(s)
- Paul H Sugarbaker
- a Center for Gastrointestinal Malignancies, MedStar Washington Hospital Center , Washington , DC , USA
| | | | - Gina Brown
- c Department of Radiology, The Royal Marsden NHS Foundation Trust NIHR BRC and Imperial College London , Surrey , UK
| | - Clarisse Dromain
- d Department of Radiology , CHUV, University Hospital , Lausanne , Switzerland
| | - Pascal Rousset
- e Department of Radiology , Centre Hospitalier Lyon Sud , Lyon , France
| | - James S Jelinek
- f Department of Radiology , MedStar Washington Hospital Center , Washington , DC , USA
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Virzì S, Iusco D, Baratti D, Bonomi S, Grassi A, Kusamura S, Deraco M. Pilot study of adjuvant hyperthermic intraperitoneal chemotherapy in patients with colorectal cancer at high risk for the development of peritoneal metastases. TUMORI JOURNAL 2018; 99:589-95. [DOI: 10.1177/030089161309900505] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Aims and background The prognosis of peritoneal metastases from colorectal cancer has recently improved with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Although outcomes are further improved when early stage peritoneal metastases are treated, adjuvant hyperthermic intraperitoneal chemotherapy has never been thoroughly addressed. This prospective pilot study assessed feasibility, safety and efficacy of hyperthermic intraperitoneal chemotherapy combined with primary curative surgery in colorectal cancer at high risk for peritoneal metastases. Methods Twelve patients were prospectively selected according to predetermined risk factors for the development of peritoneal metastases. Patients underwent conventional colon surgery, closed-abdomen mitomycin-C plus cisplatin-based hyperthermic intraperitoneal chemotherapy, and cytoreductive surgical procedures, as needed. Results Preoperative tumor-related risk factors were confirmed by intraoperative findings and pathological examination in all patients: minimal synchronous peritoneal metastases (n = 2), synchronous ovarian metastases (n = 1), positive peritoneal washing cytology (n = 2), primary tumor directly invading other organs (n = 6), or penetrating visceral peritoneum (n = 1). Major morbidity occurred in 2 patients and operative death in none. Median follow-up was 49 months (range, 22–72). Peritoneal metastases occurred in 1 patient and distant metastases in 2. Five-year overall survival was 83.3%. Conclusions Preoperative/early intraoperative assessment can reliably identify colorectal cancer patients at high risk for peritoneal metastases. Adjuvant hyperthermic intraperitoneal chemotherapy is well tolerated and safe. These preliminary results would support the design of future phase-III trials of adjuvant hyperthermic intraperitoneal chemotherapy.
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Affiliation(s)
- Salvatore Virzì
- General Surgery Unit, Bentivoglio Hospital, AUSL Bologna, Bentivoglio (BO)
| | - Domenico Iusco
- General Surgery Unit, Bentivoglio Hospital, AUSL Bologna, Bentivoglio (BO)
| | - Dario Baratti
- Peritoneal Surface Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Serena Bonomi
- General Surgery Unit, Bentivoglio Hospital, AUSL Bologna, Bentivoglio (BO)
| | - Antonio Grassi
- General Surgery Unit, Bentivoglio Hospital, AUSL Bologna, Bentivoglio (BO)
| | - Shigeki Kusamura
- Peritoneal Surface Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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Sugarbaker PH. “Total Mesenteric Peritonectomy for Peritoneal Metastases” (with Video) by Jean-Baptiste Cazauran et al. Ann Surg Oncol 2017; 24:3799-3800. [DOI: 10.1245/s10434-017-6100-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Baratti D, Kusamura S, Milione M, Bruno F, Guaglio M, Deraco M. Validation of the Recent PSOGI Pathological Classification of Pseudomyxoma Peritonei in a Single-Center Series of 265 Patients Treated by Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2017; 25:404-413. [PMID: 29159742 DOI: 10.1245/s10434-017-6252-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Controversies still persist regarding the terminology and pathologic classification of appendiceal mucinous neoplasms and associated pseudomyxoma peritonei (PMP). We assessed reproducibility and prognostic significance of the classification recently proposed by the Peritoneal Surface Oncology Group International (PSOGI). METHODS A prospective database of 265 PMP patients uniformly treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) from 1995 to 2017 was reviewed. According to the PSOGI, peritoneal disease was retrospectively classified into three categories: low-grade (LG-PMP), high-grade (HG-PMP), and signet-ring cells (SRC-PMP). Acellular mucin (AC) was classified separately. The extent of peritoneal involvement was quantified by the peritoneal cancer index (PCI). RESULTS Twenty-six patients were diagnosed with AC (9.8%), 197 with LG-PMP (74.4%), 38 with HG-PMP (14.3%), and 4 with SRC-PMP (1.5%). In the overall series, median follow-up was 65.5 months (95% confidence interval 53.7-78.8) and 10-year overall survival was 62.9% (median 148.7 months). Operative death occurred in 10 patients (3.8%) and major complications occurred in 89 patients (33.6%). Ten-year survival was 89.6% for AC, 63.2% for LG-PMP, 40.1% for HG-PMP, and 0 for SRC-PMP. In a multivariate model, the World Health Organization (WHO) pathological classification independently correlated with survival (p = 0.028). In a separate model, the PSOGI classification did not reach statistical significance (p = 0.149). Completeness of cytoreduction and PCI > 22 correlated with prognosis in both models. CONCLUSIONS AC and SRC-PMP pathological categories of the PSOGI classification identified two subsets of patients with favorable and exceedingly dismal prognosis, respectively. It remains unclear whether the PSOGI classification might provide better prognostic stratification than the current WHO classification. Further studies in larger prospective series are needed.
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Affiliation(s)
- Dario Baratti
- Peritoneal Malignancy Program, Department of Surgery, National Cancer Institute, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.
| | - Shigeki Kusamura
- Peritoneal Malignancy Program, Department of Surgery, National Cancer Institute, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Massimo Milione
- Department of Pathology, National Cancer Institute, Milan, Italy
| | - Federica Bruno
- Peritoneal Malignancy Program, Department of Surgery, National Cancer Institute, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marcello Guaglio
- Peritoneal Malignancy Program, Department of Surgery, National Cancer Institute, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marcello Deraco
- Peritoneal Malignancy Program, Department of Surgery, National Cancer Institute, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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Abstract
BACKGROUND Ovarian metastases of GI tumors grow rapidly and are relatively resistant to systemic chemotherapy. They may be unilateral or bilateral and macroscopic or occult. The risk of macroscopic ovarian involvement or occult involvement of macroscopically normal ovaries is unquantified. OBJECTIVE This study aims to quantify the risks of ovarian involvement in patients with peritoneal malignancy undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. DESIGN This was a retrospective analysis of a dedicated prospective malignancy database. SETTINGS This study was conducted at a high-volume tertiary referral center for peritoneal malignancy. PATIENTS Female patients with at least 1 remaining ovary, undergoing complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for appendiceal tumors or colorectal peritoneal metastases between January 2010 and March 2015 were included. OUTCOME MEASURES Data regarding ovarian involvement was extracted from surgical and histological records. RESULTS Two hundred fifty-eight female patients with at least 1 ovary underwent complete cytoreduction and hyperthermic intraperitoneal chemotherapy during the study period. In total, 141 of 258 (54.7%) patients had ovarian tumor involvement, and 80% with at least 1 macroscopically abnormal ovary had bilateral involvement. Of 40 patients with 1 macroscopic ovarian metastasis, microscopic involvement of the contralateral ovary was found in 18 of 40 (45.0%). Of 141 patients in whom both ovaries were macroscopically normal, 24 of 141 (17.0%) patients had microscopic ovarian involvement. LIMITATIONS The retrospective nature limits the interpretation of these results. CONCLUSIONS Occult malignancy was present in 17% when both ovaries looked macroscopically normal and in 45% of contralateral normal-looking ovaries if the other ovary was macroscopically involved. These results help to inform preoperative consent and intraoperative decision making in patients with advanced appendiceal and colorectal malignancy, and are of benefit in managing advanced lower GI tract malignancy.
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Sugarbaker PH. Normothermic intraperitoneal chemotherapy long term (NIPEC-LT) in the management of peritoneal surface malignancy, an overview. Pleura Peritoneum 2017; 2:85-93. [PMID: 30911636 DOI: 10.1515/pp-2017-0012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 05/02/2017] [Indexed: 12/28/2022] Open
Abstract
Background Peritoneal metastases from gynecologic and gastrointestinal cancer is of increasing interest to surgical and medical oncologists because of newly recognized benefits of treatment. In contrast to prior outcomes, prolonged disease-free survival and cure have been reported. Methods To date, the benefits are to use complete surgical removal of the peritoneal metastases combined with hyperthermic intraperitoneal chemotherapy (HIPEC) delivered in the operating room. To supplement the local-regional control, normothermic intraperitoneal chemotherapy used long term (NIPEC-LT) and delivered by an intraperitoneal port has been explored. Results In three high grade malignancies with the preponderance of cytoreductive surgery (CRS) and HIPEC treatment failures within the peritoneal space, NIPEC-LT has been favorably reported in the oncology literature. In ovarian cancer and malignant peritoneal mesothelioma the NIPEC-LT is used an adjuvant treatment in an attempt to preserve a surgical complete response of CRS. In gastric cancer, NIPEC-LT is given as a neoadjuvant treatment with responders going on to radical surgical resection. Responses are monitored by laparoscopy. Conclusions This overview highlights benefits of NIPEC-LT in three diseases where benefits from CRS and HIPEC have been recognized but that local-regional failures persist. Improved results with NIPEC-LT have been reviewed for ovarian cancer, gastric cancer, and peritoneal mesothelioma.
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Affiliation(s)
- Paul H Sugarbaker
- Center for Gastrointestinal Malignancies, MedStar Washington Hospital Center, 106 Irving St., NW, Suite 3900, Washington 20010, DC, USA
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40
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Sugarbaker PH, Chang D. Long-term regional chemotherapy for patients with epithelial malignant peritoneal mesothelioma results in improved survival. Eur J Surg Oncol 2017; 43:1228-1235. [PMID: 28189456 DOI: 10.1016/j.ejso.2017.01.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/16/2016] [Accepted: 01/10/2017] [Indexed: 01/30/2023] Open
Abstract
PURPOSE Malignant peritoneal mesothelioma (MPM) is a rare disease with about 300 new cases per year in the USA. Its natural history is described as local progression within the peritoneal space in the absence of liver metastases or systemic disease. METHODS Cytoreductive surgery (CRS) is a series of peritonectomy procedures and visceral resections with a goal of complete removal of all visible disease from the abdomen and pelvis. Over 20 years, three protocols investigating increasing efficacy of additional chemotherapy treatments added to CRS have been initiated. Initially, hyperthermic perioperative chemotherapy (HIPEC) with doxorubicin and cisplatin was used in the operating room. Then, early postoperative intraperitoneal chemotherapy (EPIC) with paclitaxel was added for the first 5 days after CRS. The third protocol employed HIPEC, then EPIC, and then long-term intraperitoneal (IP) paclitaxel or IP pemetrexed plus intravenous (IV) cisplatin as a adjuvant normothermic intraperitoneal chemotherapy (NIPEC). RESULT The 5-year survival of 42 patients treated with CRS and HIPEC was 44%, for 58 patients treated with EPIC and HIPEC was 52% and 29 patients who received HIPEC, EPIC, and NIPEC was 75% (p = 0.0374). Prognostic variables of age, gender, treatment administered, peritoneal cancer index (PCI) and completeness of cytoreduction were significant by univariate analysis and treatments administered and completeness of cytoreduction significant by multivariate analysis. CONCLUSIONS Long-term regional chemotherapy was associated with improved survival in patients with MPM. In this rare disease, additional phase 2 investigations are suggested.
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Affiliation(s)
- P H Sugarbaker
- Center for Gastrointestinal Malignancies, MedStar Washington Hospital Center, Washington, DC, USA.
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Baratti D, Kusamura S, Milione M, Pietrantonio F, Caporale M, Guaglio M, Deraco M. Pseudomyxoma Peritonei of Extra-Appendiceal Origin: A Comparative Study. Ann Surg Oncol 2016; 23:4222-4230. [PMID: 27352203 DOI: 10.1245/s10434-016-5350-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pseudomyxoma peritonei (PMP) usually originates from appendiceal neoplasms and, less commonly, from extra-appendiceal lesions. To date, the clinical and therapeutic implications of extra-appendiceal origin are largely unknown. METHODS A prospective database of 225 PMP patients uniformly treated by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) was reviewed to identify cases with extra-appendiceal primaries. Histologically, negative appendix defined extra-appendiceal origin. Clinical, pathological, and immunohistochemical features (cytokeratin [CK]-20, CK-7, CDX-2, MUC-2, MUC-5A) were correlated with the site of origin. PMP was categorized into low or high grade, according to the 2010 World Health Organization (WHO) classification. The main independent variable for survival analysis was appendiceal versus extra-appendiceal primary. RESULTS In 19 patients (8.4 %), PMP origin was the ovary (n = 9), uterine cervix (n = 1), mature cystic teratomas (n = 4), and unknown (n = 5). Appendiceal and extra-appendiceal PMP groups were comparable for all characteristics, except for a prevalence of females in the latter. Median follow-up was 64.1 months (95 % confidence interval [CI] 53.9-80.1), and 10-year overall survival was 63.4 % (median 148.2 months; 95 % CI 131.2-165.2) for appendiceal PMP, and 62.0 % (median not reached) for extra-appendiceal PMP. The difference was not significant at univariate ( p = 0.297) and multivariate analysis (hazard ratio 1.51, 95 % CI 0.78-3.14; p = 0.278). High-grade peritoneal histology (p = 0.007), prior systemic chemotherapy (p = 0.003), more than four visceral resections (p = 0.011), and incomplete cytoreduction (p = 0.021) independently correlated with poorer survival. CONCLUSIONS Clinical-pathological features of PMP, and outcome after CRS/HIPEC, did not differ according to the primary site, thus suggesting that PMP is a relatively homogeneous disease that can be produced by a range of histopathologic entities. Extra-appendiceal origin does not contraindicate CRS/HIPEC.
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Affiliation(s)
- Dario Baratti
- Peritoneal Malicnancy Program, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Shigeki Kusamura
- Peritoneal Malicnancy Program, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Massimo Milione
- Department of Pathology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Filippo Pietrantonio
- Department of Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marta Caporale
- Department of Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marcello Guaglio
- Peritoneal Malicnancy Program, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marcello Deraco
- Peritoneal Malicnancy Program, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.
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Mehta SS, Bhatt A, Glehen O. Cytoreductive Surgery and Peritonectomy Procedures. Indian J Surg Oncol 2016; 7:139-51. [PMID: 27065704 DOI: 10.1007/s13193-016-0505-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 01/28/2016] [Indexed: 12/13/2022] Open
Abstract
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has become widely accepted as an effective method of treating peritoneal metastases (PM) from various cancers. CRS performed with the goal of removing all the macroscopic disease and comprises of peritonectomy procedures and visceral resections. CRS is a technically challenging surgery that requires a considerable amount of skill and appropriate patient selection. This article is a review of the techniques and current recommendations for performing CRS.
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Affiliation(s)
- Sanket S Mehta
- Division of Peritoneal Surface Oncology, Saifee Hospital, MK marg, Charni road, Girgaon, Mumbai, 400004 India
| | - Aditi Bhatt
- Fortis Hospitals Limited, 154/9, Bannerghatta Road, Opp. IIM-B, Bangalore, 560076 India
| | - Olivier Glehen
- Department of Surgical Oncology, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495 Pierre Bénite, France ; Université Lyon 1, EMR 3738, 69600 Oullins, France
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Baratti D, Kusamura S, Pietrantonio F, Guaglio M, Niger M, Deraco M. Progress in treatments for colorectal cancer peritoneal metastases during the years 2010-2015. A systematic review. Crit Rev Oncol Hematol 2016; 100:209-22. [PMID: 26867984 DOI: 10.1016/j.critrevonc.2016.01.017] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/25/2015] [Accepted: 01/16/2016] [Indexed: 02/08/2023] Open
Abstract
Peritoneal metastases (PM) from colorectal cancer (CRC) were traditionally associated with bad prognosis. Only recently, cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has resulted in survival improvements. A systematic literature search between January 2010 and June 2015 was performed. Studies were selected and appraised according to predetermined criteria. Nineteen cohort studies, and thirteen comparative studies of CRS/HIPEC were included. The weighted median overall survival was 31.6 months (range 16-51). Major morbidity was 17.6-52.4% (weighted average 32.6%). Mortality was 0-8.1% (weighted average 2.9%). Additional relevant topics, such as CRC-PM prevalence, results by systemic therapies, preoperative work-up, and technical aspects were summarized through a narrative review. The recent literature suggests that CRS/HIPEC is gaining acceptance as standard of care for selected CRC-PM patients. Refinement of selection criteria, and rationalization of comprehensive systemic and local-regional management is ongoing. Prevention and early treatment of PM are new and promising options.
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Affiliation(s)
- Dario Baratti
- Peritoneal Malignancy Program, Fondazione IRCCS Istituto Nazionale Tumori, via Venezian, 1 20133 Milano, Italy
| | - Shigeki Kusamura
- Peritoneal Malignancy Program, Fondazione IRCCS Istituto Nazionale Tumori, via Venezian, 1 20133 Milano, Italy
| | - Filippo Pietrantonio
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, via Venezian, 1 20133 Milano, Italy
| | - Marcello Guaglio
- Peritoneal Malignancy Program, Fondazione IRCCS Istituto Nazionale Tumori, via Venezian, 1 20133 Milano, Italy
| | - Monica Niger
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, via Venezian, 1 20133 Milano, Italy
| | - Marcello Deraco
- Peritoneal Malignancy Program, Fondazione IRCCS Istituto Nazionale Tumori, via Venezian, 1 20133 Milano, Italy.
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Abstract
Cytoreductive surgery is an essential part of a multimodality treatment concept for peritoneal metastases. Indications are primary peritoneal tumors like peritoneal mesothelioma or secondaries from colorectal cancer or pseudomyxoma peritonei. Patients with gastric or ovarian carcinoma or abdominal sarcoma with peritoneal seedings can be treated within studies. Tumor entity, tumor load, and tumor distribution are the most critical issues for patient selection. Complete macroscopic cytoreduction is the strongest prognostic factor and can be achieved by parietal and visceral peritonectomy. The operation should be performed in a standardized manner. Due to possible tumor manifestation in all four quadrants of the abdomen and extensive extraperitoneal dissection, extensive surgical and oncological expertise is prerequisite. Treatment in specialized surgical oncology centers is recommended to minimize morbidity and mortality. The German Society for General and Visceral Surgery is certifying centers of competence for surgical treatment of peritoneal malignancies. Data of all patients are documented in the HIPEC register. The inclusion of patients in studies is recommended.
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Kusamura S, Torres Mesa PA, Cabras A, Baratti D, Deraco M. The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Ann Surg Oncol 2015; 23:1468-73. [PMID: 26572754 DOI: 10.1245/s10434-015-4962-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND We conducted a prognostic analysis of preoperative parameters and Ki-67 determination to develop selection criteria for cytoreductive surgery (CRS) and HIPEC in patients with diffuse malignant peritoneal mesothelioma (DMPM). METHODS DMPM patients treated with CRS and HIPEC at NCI of Milan participated in this study. Multivariate analysis was conducted using Cox proportional hazard model and conditional inference tree method to select independent predictors of overall survival (OS) from the followings pre-cytoreduction parameters: age, sex, ECOG performance status, Charlson comorbidity index, previous systemic chemotherapy, CA-125, histological subtype (epithelioid vs. biphasic/sarcomatoid), Ki-67 (determined with immunohistochemistry), and peritoneal cancer index (PCI). RESULTS A total of 117 patients (male/female: 67/50) with median age of 60.5 (range 22-75) years were included. Eighty-three patients had ECOG performance status = 0, median Charlson comorbidity index was 4 (range 2-9), and 102 cases had epithelioid subtype. Median Ki-67 was 5 % (range 1-60). Ninety-four (80.3 %) cases were optimally cytoreduced. The Cox analysis identified Ki-67, PCI, and histological subtype as independent prognosticators of OS. Conditional inference tree method identified three prognostic subsets: (I) Ki-67 ≤ 9 %; (II) Ki-67 > 9 % and PCI ≤ 17; and (III) Ki-67 > 9 % and PCI > 17. The median OS for subsets I, II, and III were, 86.6, 63.2, and 10.3 months, respectively. CONCLUSIONS Ki-67 is a powerful prognosticator that allows, along with PCI, and histological subtype, a good prediction of OS in patients with DMPM. Patients with Ki-67 > 9 % and PCI > 17 are unlikely to benefit from the procedure and should be considered for other treatment protocols.
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Affiliation(s)
- Shigeki Kusamura
- Peritoneal Surface Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori Milano, Milan, Italy
| | - Pilar Adriana Torres Mesa
- Peritoneal Surface Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori Milano, Milan, Italy.,European School of Peritoneal Surface Oncology (ESPSO), Centro Nacional de Oncología S.A, Bogotá, Colombia
| | - Antonello Cabras
- Pathology department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Dario Baratti
- Peritoneal Surface Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori Milano, Milan, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori Milano, Milan, Italy.
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The role of baseline inflammatory-based scores and serum tumor markers to risk stratify pseudomyxoma peritonei patients treated with cytoreduction (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Eur J Surg Oncol 2015; 41:1097-105. [DOI: 10.1016/j.ejso.2015.04.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 03/26/2015] [Accepted: 04/01/2015] [Indexed: 12/18/2022] Open
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Deraco M, Cabras A, Baratti D, Kusamura S. Immunohistochemical Evaluation of Minichromosome Maintenance Protein 7 (MCM7), Topoisomerase IIα, and Ki-67 in Diffuse Malignant Peritoneal Mesothelioma Patients Using Tissue Microarray. Ann Surg Oncol 2015; 22:4344-51. [PMID: 25777091 DOI: 10.1245/s10434-015-4498-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Indexed: 12/18/2022]
Abstract
PURPOSE Immunohistochemistry and tissue microarray (TMA) were used to perform a prognostic analysis of markers related to cell proliferation in diffuse malignant peritoneal mesothelioma (DMPM). METHODS Clinicopathologic data were extracted from a prospectively collected database containing cases of peritoneal mesothelioma treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the National Cancer Institute of Milan from 1995 to 2013. Eighty-one DMPM patients were recruited and their tissue samples were used to construct TMAs. We evaluated the immunoexpressions of markers related to cell proliferation-topoisomerase IIα, minichromosome maintenance protein 7 (MCM7), and Ki-67-and then conducted a multivariate Cox model to identify the predictors of overall survival (OS) and progression-free survival (PFS) among the following parameters: age, sex, Eastern Cooperative Oncology Group (ECOG) performance status, baseline serum albumin, Charlson Comorbidity Index, previous systemic chemotherapy, histological subtype (epithelioid vs. biphasic/sarcomatoid), peritoneal cancer index, completeness of cytoreduction (CC), and proliferative biological markers. RESULTS The rates of high/intermediate immunoreactivity were 95 % for topoisomerase IIα and 90 % for MCM7, and the median Ki-67 labeling index was 5 %. The independent predictors of OS were baseline serum albumin >3.5 g/dl, CC, and Ki-67 >5 %, whereas those for PFS were an ECOG performance status of 0, baseline serum albumin >3.5 g/dl, Charlson Comorbidity Index >3, previous systemic chemotherapy, morbidity G3-5, and Ki-67 >5 %. The remaining biological markers were not associated with outcome. CONCLUSIONS Ki-67 was found to be a new powerful determinant of outcome. Patients with a Ki-67 labeling index >5 % carry a very poor prognosis and do not benefit from the combined procedure. Further studies should be conducted to confirm the present data.
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Affiliation(s)
- Marcello Deraco
- Peritoneal Surface Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy.
| | - Antonello Cabras
- Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Dario Baratti
- Peritoneal Surface Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Shigeki Kusamura
- Peritoneal Surface Malignancy Program, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
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Hemodynamic Monitoring During Heated Intraoperative Intraperitoneal Chemotherapy Using the FloTrac/Vigileo System. Int Surg 2015; 100:1033-9. [PMID: 25590363 DOI: 10.9738/intsurg-d-14-00138.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cytoreductive surgery with HIPEC has provided a chance for long-term survival in selected patients. However, perioperative management remains a challenge for the anesthesiology team. The aim of this study was to evaluate the changes in hemodynamic parameters during hyperthermic intraperitoneal chemotherapy (HIPEC) using the FloTrac/Vigileo system. Forty-one consecutive patients undergoing cytoreductive surgery and HIPEC were enrolled. Heart rate (HR), esophageal temperature, and cardiac output (CO) steadily increased until the end of HIPEC. In the first half of HIPEC, systolic blood pressure (SBP) and central venous pressure (CVP) increased whereas systemic vascular resistance (SVR) decreased; SVR stabilized in the second half. Diastolic blood pressure (DBP), mean arterial pressure (MAP), and stroke volume (SV) showed no significant variation. Male gender was related to increased CVP, CO, and SV, and decreased SVR; age >55 years was related to increased SBP, and peritoneal cancer index (PCI) was correlated with HR, DBP, and SV. PCI >14 was associated with increased HR and decreased DBP and MAP. American Society of Anesthesiologists score >1 was related to decreased CO and SV. Patients undergoing HIPEC develop a hyperdynamic circulatory state because of the increased temperature, characterized by a steady decrease in SVR and continuous increase in HR and CO. FloTrac/Vigileo system may provide an easy-to-handle, noninvasive monitoring tool.
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Budker VG, Monahan SD, Subbotin VM. Loco-regional cancer drug therapy: present approaches and rapidly reversible hydrophobization (RRH) of therapeutic agents as the future direction. Drug Discov Today 2014; 19:1855-70. [PMID: 25173702 DOI: 10.1016/j.drudis.2014.08.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/10/2014] [Accepted: 08/21/2014] [Indexed: 01/01/2023]
Abstract
Insufficient drug uptake by solid tumors remains the major problem for systemic chemotherapy. Many studies have demonstrated anticancer drug effects to be dose-dependent, although dose-escalation studies have resulted in limited survival benefit with increased systemic toxicities. One solution to this has been the idea of loco-regional drug treatments, which offer dramatically higher drug concentrations in tumor tissues while minimizing systemic toxicity. Although loco-regional delivery has been most prominent in cancers of the liver, soft tissues and serosal peritoneal malignancies, survival benefits are very far from desirable. This review discusses the evolution of loco-regional treatments, the present approaches and offers rapidly reversible hydrophobization of drugs as the new future direction.
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Baratti D, Kusamura S, Iusco D, Bonomi S, Grassi A, Virzì S, Leo E, Deraco M. Postoperative complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy affect long-term outcome of patients with peritoneal metastases from colorectal cancer: a two-center study of 101 patients. Dis Colon Rectum 2014; 57:858-68. [PMID: 24901687 DOI: 10.1097/dcr.0000000000000149] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is an effective but potentially morbid treatment for colorectal cancer peritoneal metastases. The impact of treatment-related morbidity on long-term survival has been reported in various malignancies, but it has never been assessed in this clinical setting. OBJECTIVE The aim of this study was to assess the impact of major postoperative complications on oncological outcomes after cytoreduction and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases. DESIGN Two prospective databases were reviewed. Major complications were defined as grade 3 to 5 according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. The extent of peritoneal involvement was scored by the use of the Peritoneal Cancer Index. SETTINGS This study was conducted in 2 high-volume peritoneal malignancy management centers. PATIENTS One hundred one consecutive patients with peritoneal metastases potentially amenable to macroscopically complete cytoreduction were selected. INTERVENTIONS Peritonectomy procedures and multivisceral resections were used to remove all macroscopic tumor, and mitomycin-C plus cisplatin-based hyperthermic intraperitoneal chemotherapy was used to control microscopic residual disease. MAIN OUTCOME MEASURES The primary outcomes measured were overall and disease-specific survival. RESULTS Mortality and major morbidity were 3.0%, and 23.8%. Median follow-up was 44.9 months (95% CI, 24.1-65.7). Five-year disease-specific survival was 14.3% for patients who experienced major complications and 52.3% for those who did not (p = 0.001). Five-year overall survival was 11.7% for patients who experienced major complications, and 58.8% for those who did not (p = 0.003). At multivariate analysis, major morbidity correlated to both worse overall and disease-specific survival, along with a Peritoneal Cancer Index >19, and suboptimal cytoreduction. Poor performance status correlated only to worse disease-specific survival, and liver metastases correlated to worse overall survival. Longer operative time (OR, 4.1; 95% CI, 1.3-12.6; p = 0.01) and Peritoneal Cancer Index >19 (OR, 2.6; 95% CI, 1.1-6.0; p = 0.02) were independent risk factors for major morbidity. LIMITATIONS This study is limited by its observational design. CONCLUSIONS The prevention of major complications, by refining surgical technique and patient selection, is crucial because it affects oncologic outcome.
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Affiliation(s)
- D Baratti
- 1Peritoneal Surface Malignancy Program,Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy 2General Surgery Unit, Bentivoglio Hospital, Bentivoglio (BO), Italy 3Colorectal Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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