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Nassour I, Polanco PM. Current Management of Peritoneal Carcinomatosis From Colorectal Cancer: The Role of Cytoreductive Surgery and Hyperthermic Peritoneal Chemoperfusion. CURRENT COLORECTAL CANCER REPORTS 2017; 13:144-153. [PMID: 28890671 PMCID: PMC5586145 DOI: 10.1007/s11888-017-0361-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Peritoneal carcinomatosis (PC) from colorectal cancer (CRC) is a disease with a poor prognosis, often thought to be a terminal illness with no hope except for palliative treatment. New therapeutic modalities combining cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have shown favorable outcomes and may provide a significant survival benefit in a selected group of patients. The main rational for CRS is to remove all visible tumor burden to allow for the chemotherapeutic agent (HIPEC) to eradicate any microscopic residual disease. The Amsterdam statement formulated at the 9th International Congress on Peritoneal Surface Malignancies supports the use of CRS with HIPEC as a standard of care for selected patients with small-to-moderate volume PC from CRC. Selecting appropriate patients who would benefit from CRS/ HIPEC is paramount to derive the maximum oncological outcomes while minimizing the risks of postoperative complications and mortality. In this paper, we will review the role for CRS/HIPEC in the management of PC from CRC.
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Affiliation(s)
| | - Patricio M. Polanco
- University of Texas Southwestern Medical Center
- VA North Texas Health Care System, Department of Veterans
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Randle RW, Votanopoulos KI, Shen P, Levine EA, Stewart JH. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Levine EA, Stewart JH, Shen P, Russell GB, Loggie BL, Votanopoulos KI. Intraperitoneal chemotherapy for peritoneal surface malignancy: experience with 1,000 patients. J Am Coll Surg 2013; 218:573-85. [PMID: 24491244 DOI: 10.1016/j.jamcollsurg.2013.12.013] [Citation(s) in RCA: 197] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/10/2013] [Indexed: 02/09/2023]
Abstract
BACKGROUND Peritoneal dissemination of abdominal malignancy (carcinomatosis) has a clinical course marked by bowel obstruction and death; it traditionally does not respond well to systemic therapy and has been approached with nihilism. To treat carcinomatosis, we use cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS A prospective database of patients has been maintained since 1992. Patients with biopsy-proven peritoneal surface disease were uniformly evaluated for, and treated with, CS and HIPEC. Patient demographics, performance status (Eastern Cooperative Oncology Group), resection status, and peritoneal surface disease were classified according to primary site. Univariate and multivariate analyses were performed. The experience was divided into quintiles and outcomes compared. RESULTS Between 1991 and 2013, a total of 1,000 patients underwent 1,097 HIPEC procedures. Mean age was 52.9 years and 53.1% were female. Primary tumor site was appendix in 472 (47.2%), colorectal in 248 (24.8%), mesothelioma in 72 (7.2%), ovary in 69 (6.9%), gastric in 46 (4.6%), and other in 97 (9.7%). Thirty-day mortality rate was 3.8% and median hospital stay was 8 days. Median overall survival was 29.4 months, with a 5-year survival rate of 32.5%. Factors correlating with improved survival on univariate and multivariate analysis (p ≤ 0.0001 for each) were preoperative performance status, primary tumor type, resection status, and experience quintile (p = 0.04). For the 5 quintiles, the 1- and 5-year survival rates, as well as the complete cytoreduction score (R0, R1, R2a) have increased, and transfusions, stoma creations, and complications have all decreased significantly (p < .001 for all). CONCLUSIONS This largest reported single-center experience with CS and HIPEC demonstrates that prognostic factors include primary site, performance status, completeness of resection, and institutional experience. The data show that outcomes have improved over time, with more complete cytoreduction and fewer serious complications, transfusions, and stomas. This was due to better patient selection and increased operative experience. Cytoreductive surgery with HIPEC represents a substantial improvement in outcomes compared with historical series, and shows that meaningful long-term survival is possible for selected carcinomatosis patients. Multi-institutional cooperative trials are needed to refine the use of CS and HIPEC.
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Affiliation(s)
- Edward A Levine
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
| | - John H Stewart
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Perry Shen
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Gregory B Russell
- Section on Biostatistics, Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Brian L Loggie
- Surgical Oncology Section, Department of General Surgery, Creighton University School of Medicine, Omaha, NE
| | - Konstantinos I Votanopoulos
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
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Katragadda L, Shahid Z, Restrepo A, Muzaffar J, Alapat D, Anaissie E. Preemptive intravenous immunoglobulin allows safe and timely administration of antineoplastic therapies in patients with multiple myeloma and parvovirus B19 disease. Transpl Infect Dis 2013; 15:354-60. [DOI: 10.1111/tid.12067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 10/18/2012] [Accepted: 10/29/2012] [Indexed: 11/30/2022]
Affiliation(s)
- L. Katragadda
- The Myeloma Institute; University of Arkansas for Medical Sciences; Little Rock; Arkansas; USA
| | - Z. Shahid
- The Myeloma Institute; University of Arkansas for Medical Sciences; Little Rock; Arkansas; USA
| | - A. Restrepo
- The Myeloma Institute; University of Arkansas for Medical Sciences; Little Rock; Arkansas; USA
| | - J. Muzaffar
- The Myeloma Institute; University of Arkansas for Medical Sciences; Little Rock; Arkansas; USA
| | - D. Alapat
- Department of Pathology; University of Arkansas for Medical Sciences; Little Rock; Arkansas; USA
| | - E. Anaissie
- Division of Hematology and Oncology; University of Cincinnati; Cincinnati; Ohio; USA
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Nouér SA, Nucci M, Kumar NS, Grazziutti M, Restrepo A, Anaissie E. Baseline platelet count and creatinine clearance rate predict the outcome of neutropenia-related invasive aspergillosis. Clin Infect Dis 2012; 54:e173-83. [PMID: 22423136 DOI: 10.1093/cid/cis298] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Invasive aspergillosis (IA) is a life-threatening infection for immunocompromised patients. Improvement in IA outcome has been hampered by lack of early prognostic factors, namely, those available before starting chemotherapy (baseline) or early in the course of IA (nonbaseline). We hypothesized that prognostic factors can be identified before chemotherapy, ≤7 days from the first positive serum Aspergillus galactomannan index (s-GMI). METHODS We analyzed 98 patients with multiple myeloma who developed neutropenia-related IA and had a positive s-GMI. Three response criteria were used: kinetics of s-GMI, European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) definitions, and 6-week survival. Baseline and nonbaseline variables were analyzed separately. RESULTS Independent response predictors at baseline were a platelet count ≥65,000 platelets/mm(3) (odds ratio [OR], 1.009; 95% confidence interval [CI], 1.001-1.017; P = .03) by s-GMI kinetics, and a platelet count ≥65,000 platelets/mm(3) (OR, 1.009; 95% CI, 1.002-1.017; P = .01) and a creatinine clearance rate ≥53 mL/min (OR, 1.024; 95% CI, 1.006-1.042; P = .009) by EORTC/MSG criteria, with response rates of 83% and 28% when both variables were above or below these cutoffs, respectively (P < .001). Only baseline creatinine clearance rate ≥53 mL/min predicted 6-week survival (P = .003). Normalization of the s-GMI ≤7 days after the first positive s-GMI and neutrophil recovery were the nonbaseline factors associated with positive outcomes. CONCLUSIONS Two simple, inexpensive to measure, widely available, and routinely collected prechemotherapy values, platelet count and creatinine clearance rate, predict IA outcome and stratify patients into low-, intermediate-, and high-risk categories, while early evaluation of s-GMI allows timely treatment modification. These findings may improve patient outcomes by optimizing management strategies for this serious infection and may prove valuable in designing clinical trials of interventions to improve IA outcomes.
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Affiliation(s)
- Simone Aranha Nouér
- Department of Preventive Medicine, Universidade Federal do Rio de Janeiro, Brazil
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Checkpoint signaling, base excision repair, and PARP promote survival of colon cancer cells treated with 5-fluorodeoxyuridine but not 5-fluorouracil. PLoS One 2011; 6:e28862. [PMID: 22194930 PMCID: PMC3240632 DOI: 10.1371/journal.pone.0028862] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 11/16/2011] [Indexed: 12/19/2022] Open
Abstract
The fluoropyrimidines 5-fluorouracil (5-FU) and FdUrd (5-fluorodeoxyuridine; floxuridine) are the backbone of chemotherapy regimens for colon cancer and other tumors. Despite their widespread use, it remains unclear how these agents kill tumor cells. Here, we have analyzed the checkpoint and DNA repair pathways that affect colon tumor responses to 5-FU and FdUrd. These studies demonstrate that both FdUrd and 5-FU activate the ATR and ATM checkpoint signaling pathways, indicating that they cause genotoxic damage. Notably, however, depletion of ATM or ATR does not sensitize colon cancer cells to 5-FU, whereas these checkpoint pathways promote the survival of cells treated with FdUrd, suggesting that FdUrd exerts cytotoxicity by disrupting DNA replication and/or inducing DNA damage, whereas 5-FU does not. We also found that disabling the base excision (BER) repair pathway by depleting XRCC1 or APE1 sensitized colon cancer cells to FdUrd but not 5-FU. Consistent with a role for the BER pathway, we show that small molecule poly(ADP-ribose) polymerase 1/2 (PARP) inhibitors, AZD2281 and ABT-888, remarkably sensitized both mismatch repair (MMR)-proficient and -deficient colon cancer cell lines to FdUrd but not to 5-FU. Taken together, these studies demonstrate that the roles of genotoxin-induced checkpoint signaling and DNA repair differ significantly for these agents and also suggest a novel approach to colon cancer therapy in which FdUrd is combined with a small molecule PARP inhibitor.
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Cohen DJ, Newman E, Iqbal S, Chang RY, Potmesil M, Ryan T, Donahue B, Chandra A, Liu M, Utate M, Hiotis S, Pachter LH, Hochster H, Muggia F. Postoperative intraperitoneal 5-fluoro-2'-deoxyuridine added to chemoradiation in patients curatively resected (R0) for locally advanced gastric and gastroesophageal junction adenocarcinoma. Ann Surg Oncol 2011; 19:478-85. [PMID: 21769462 DOI: 10.1245/s10434-011-1940-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE Chemoradiation after surgery for locally advanced gastric cancer improves overall and relapse-free survival compared with observation. However, locoregional recurrences remain high. Accordingly, we instituted this pilot/feasibility study, including intraperitoneal 5-fluoro-2'-deoxyuridine (IP FUDR) as part of the treatment. METHODS Gastric/gastroesophageal junction adenocarcinoma stage Ib-IV (M0) patients who underwent R(0) resection were eligible and had IP catheters inserted at time of surgery. IP FUDR (3 g/dose/day) was given during study days 1-3 and 15-17 before combined 5-fluorouracil, leucovorin, and external beam radiation (45 Gy). Endpoints included toxicity, completion rate, locoregional recurrence, and survival. RESULTS Twenty-eight patients (22 men) were enrolled from 2002-2006 at two institutions; their median age was 59.5 years. After R(0) resection, a median 22 (range, 8-102) lymph nodes were examined, and 22 patients had positive nodes. AJCC stages were IB (n = 8), II (n = 10), IIIA (n = 5), IIIB (n = 1), and IV (n = 4). Full-dose IP FUDR and chemoradiation treatment was completed in 20 and 25 patients, respectively. At nearly 4-year median follow-up, 11 patients were disease-free, 5 were alive with disease, 7 were dead of disease, and 1 was dead from other cause; 4 have been lost to follow-up. Recurrences were local in one, intra-abdominal in six, distant in two, multiple sites in two, and unknown in one. The median relapse-free survival is 65.3 months, and the median overall survival has not yet been reached. CONCLUSIONS IP FUDR before chemoradiation after R(0) gastric cancer resection is well tolerated without compromising completion of postoperative adjuvant treatment. Larger randomized trials studying IP FUDR as part of gastric cancer multidisciplinary treatment are needed to prove efficacy in reducing regional recurrence and improving survival.
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Affiliation(s)
- Deirdre J Cohen
- Division of Medical Oncology, New York University Cancer Center, NYU Medical Center, New York, NY, USA.
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Huehls AM, Wagner JM, Huntoon CJ, Geng L, Erlichman C, Patel AG, Kaufmann SH, Karnitz LM. Poly(ADP-Ribose) polymerase inhibition synergizes with 5-fluorodeoxyuridine but not 5-fluorouracil in ovarian cancer cells. Cancer Res 2011; 71:4944-54. [PMID: 21613406 PMCID: PMC3138894 DOI: 10.1158/0008-5472.can-11-0814] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
5-Fluorouracil (5-FU) and 5-fluorodeoxyuridine (FdUrd, floxuridine) have activity in multiple tumors, and both agents undergo intracellular processing to active metabolites that disrupt RNA and DNA metabolism. These agents cause imbalances in deoxynucleotide triphosphate levels and the accumulation of uracil and 5-FU in the genome, events that activate the ATR- and ATM-dependent checkpoint signaling pathways and the base excision repair (BER) pathway. Here, we assessed which DNA damage response and repair processes influence 5-FU and FdUrd toxicity in ovarian cancer cells. These studies revealed that disabling the ATM, ATR, or BER pathways using small inhibitory RNAs did not affect 5-FU cytotoxicity. In stark contrast, ATR and a functional BER pathway protected FdUrd-treated cells. Consistent with a role for the BER pathway, the poly(ADP-ribose) polymerase (PARP) inhibitors ABT-888 (veliparib) and AZD2281 (olaparib) markedly synergized with FdUrd but not with 5-FU in ovarian cancer cell lines. Furthermore, ABT-888 synergized with FdUrd far more effectively than other agents commonly used to treat ovarian cancer. These findings underscore differences in the cytotoxic mechanisms of 5-FU and FdUrd and suggest that combining FdUrd and PARP inhibitors may be an innovative therapeutic strategy for ovarian tumors.
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Affiliation(s)
- Amelia M. Huehls
- Division of Oncology Research, Mayo Clinic, College of Medicine, Rochester, Minnesota
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, College of Medicine, Rochester, Minnesota
| | - Jill M. Wagner
- Division of Oncology Research, Mayo Clinic, College of Medicine, Rochester, Minnesota
| | - Catherine J. Huntoon
- Division of Oncology Research, Mayo Clinic, College of Medicine, Rochester, Minnesota
| | - Liyi Geng
- Division of Oncology Research, Mayo Clinic, College of Medicine, Rochester, Minnesota
| | - Charles Erlichman
- Division of Medical Oncology, Mayo Clinic, College of Medicine, Rochester, Minnesota
| | - Anand G. Patel
- Division of Oncology Research, Mayo Clinic, College of Medicine, Rochester, Minnesota
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, College of Medicine, Rochester, Minnesota
| | - Scott H. Kaufmann
- Division of Oncology Research, Mayo Clinic, College of Medicine, Rochester, Minnesota
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, College of Medicine, Rochester, Minnesota
| | - Larry M. Karnitz
- Division of Oncology Research, Mayo Clinic, College of Medicine, Rochester, Minnesota
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, College of Medicine, Rochester, Minnesota
- Department of Radiation Oncology, Mayo Clinic, College of Medicine, Rochester, Minnesota
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Parson EN, Lentz S, Russell G, Shen P, Levine EA, Stewart JH. Outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface dissemination from ovarian neoplasms. Am J Surg 2011; 202:481-6. [PMID: 21474115 DOI: 10.1016/j.amjsurg.2011.02.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Revised: 02/04/2011] [Accepted: 02/04/2011] [Indexed: 12/30/2022]
Abstract
BACKGROUND Few data exist on the treatment of peritoneal surface dissemination (PSD) from ovarian cancer (OC) with hyperthermic intraperitoneal chemotherapy (HIPEC). This work represents a review of the authors' institution's experience with HIPEC for PSD from OC. METHODS Fifty-one patients with OC treated with HIPEC between 1996 and 2009 were identified in a prospectively managed database. All patients underwent maximal tumor debulking followed by HIPEC with mitomycin C, carboplatin, or paclitaxel. RESULTS The median survival in this cohort was 29 months. When stratified by resection status, patients undergoing R0 and R1 resections experienced longer median survival than those who underwent R2 resections (47 vs 12 months, P = .0002). Intraoperative blood loss ≤ 400 mL resulted in greater 5-year survival than blood loss > 400 mL (60% vs 15%, P = .025). CONCLUSIONS This experience demonstrates that long-term survival is anticipated in patients who undergo complete cytoreduction followed by HIPEC for PSD from OC. These findings not only highlight the potential utility of HIPEC in the treatment of OC but also underscore the importance of maximal cytoreduction followed by HIPEC in this cohort of patients.
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Affiliation(s)
- E Nicole Parson
- Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Stewart JH, Shen P, Levine EA. Intraperitoneal hyperthermic chemotherapy: an evolving paradigm for the treatment of peritoneal surface malignancies. Expert Rev Anticancer Ther 2009; 8:1809-18. [PMID: 18983241 DOI: 10.1586/14737140.8.11.1809] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Unfortunately, advanced colorectal cancer is often present at the time the disease is diagnosed. Many intra-abdominal malignancies spread throughout the peritoneal cavity, which is known as carcinomatosis. Peritoneal carcinomatosis is uniformly a terminal disease with a median survival of 6 months. Systemic chemotherapy is palliative and generally provides limited improvement in survival. Conventional surgery has typically been limited to ileostomy, colostomy or intestinal bypass procedures. Cytoreductive surgery alone has long been used to treat macroscopic disease, with limited success. However, cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy (IPHC) has evolved into a novel approach for peritoneal surface malignancy. IPHC was initially described in a canine model by Spratt. Although the first clinical series of peritoneal perfusion were small, Japanese trials, which utilized IPHC for prophylaxis in patients with gastric adenocarcinoma, Fujimoto was the first to report an improvement in survival for established gastric cracinomatosis. This early work provided the proof-of-principle for what has evolved into current management with aggressive cytoreduction and IPHC. The present review will outline the rationale, current practice and future directions of IPHC in the management of peritoneal surface malignancies.
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Affiliation(s)
- John H Stewart
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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Stewart JH, Shen P, Levine EA. Translation considerations for hyperthermic intraperitoneal chemotherapy. Curr Probl Cancer 2009; 33:194-202. [PMID: 19647616 DOI: 10.1016/j.currproblcancer.2009.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- John H Stewart
- Tumor Immunotherapy Program, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Stewart JH, Levine EA, Shen P. The Current Role of Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Dissemination of Appendiceal Tumors. Curr Probl Cancer 2009; 33:142-53. [DOI: 10.1016/j.currproblcancer.2009.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy for Peritoneal Surface Malignancy: Non-Colorectal Indications. Curr Probl Cancer 2009; 33:168-93. [DOI: 10.1016/j.currproblcancer.2009.06.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Levine EA, Stewart JH, Russell GB, Geisinger KR, Loggie BL, Shen P. Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy: experience with 501 procedures. J Am Coll Surg 2007; 204:943-53; discussion 953-5. [PMID: 17481516 DOI: 10.1016/j.jamcollsurg.2006.12.048] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2006] [Accepted: 12/15/2006] [Indexed: 12/17/2022]
Abstract
BACKGROUND Peritoneal dissemination of abdominal malignancy (PSD) has a clinical course marked by bowel obstruction and death. We have been using aggressive cytoreductive surgery with intraperitoneal hyperthermic chemotherapy (IPHC) to treat PSD. The purpose of this article was to review our experience with IPHC. STUDY DESIGN A prospective database of patients undergoing IPHC has been maintained since 1991. Patients were uniformly evaluated and treated. Demographics, performance status, resection status, primary site, and experience quartile were compared with outcomes. Univariate and multivariate analyses were performed. RESULTS A total of 460 patients underwent 501 IPHC procedures. Average age was 53.0 years, and 50.4% were women. The 30-day mortality rate was 4.8%, the complication rate was 43%, and median hospital stay was 9 days. Median followup was 55.4 months, median survival was 22.2 months, and 5-year survival rate was 27.8%. Factors correlating with improved survival were performance status (p=0.0001), primary tumor (p=0.0001), resection status (p=0.0001), complications (p=0.002), previous IPHC (p=0.006), and experience quartile (p=0.031). On multivariate analysis, primary tumor site, performance status, resection status, and development of complications (p < 0.001) predicted outcomes. CONCLUSIONS Our experience demonstrated that preoperative criteria for better outcomes include primary tumor site and performance status. Completeness of resection and development of postoperative complications are also crucial, and outcomes have improved over time. Cytoreductive surgery and IPHC represent substantial improvements in outcomes compared with historic series and best-available systemic therapy. Longterm survival is possible for selected patients who undergo the procedure.
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Affiliation(s)
- Edward A Levine
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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15
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de Bree E, Tsiftsis DD. Experimental and pharmacokinetic studies in intraperitoneal chemotherapy: from laboratory bench to bedside. RECENT RESULTS IN CANCER RESEARCH. FORTSCHRITTE DER KREBSFORSCHUNG. PROGRES DANS LES RECHERCHES SUR LE CANCER 2007; 169:53-73. [PMID: 17506249 DOI: 10.1007/978-3-540-30760-0_5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, Herakleion, Greece
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Stewart JH, Shen P, Russell GB, Bradley RF, Hundley JC, Loggie BL, Geisinger KR, Levine EA. Appendiceal neoplasms with peritoneal dissemination: outcomes after cytoreductive surgery and intraperitoneal hyperthermic chemotherapy. Ann Surg Oncol 2006; 13:624-34. [PMID: 16538401 DOI: 10.1007/s10434-006-9708-2] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Accepted: 08/16/2005] [Indexed: 12/12/2022]
Abstract
BACKGROUND Appendiceal neoplasms frequently present with peritoneal dissemination (PD) and have a clinical course marked by bowel obstruction and subsequent death. Few data have correlated outcome with appendiceal histology after cytoreductive surgery and intraperitoneal hyperthermic chemotherapy (IPHC). We have reviewed our experience with cytoreductive surgery and IPHC for PD from the appendix. METHODS A total of 110 cases of PD from proven appendiceal neoplasms treated with IPHC were identified from a prospectively managed database. Tumor samples were classified on pathologic review as disseminated peritoneal adenomucinosis (n = 55), peritoneal mucinous carcinomatosis (PMCA) with intermediate features (n = 18), PMCA (n = 29), or high-grade nonmucinous lesions (n = 8). A retrospective review was performed with long-term survival as the primary outcome measure. RESULTS A total of 116 IPHCs were performed on 110 patients for appendiceal PD between 1993 and 2004. The 1-, 3-, and 5-year survival rates for all cases were 79.9% +/- 4.1%, 59.0% +/- 5.7%, and 53.4% +/- 6.5%, respectively. When stratified by histology, disseminated peritoneal adenomucinosis and intermediate tumors had better 3-year survival rates (77% +/- 7% and 81% +/- 10%) than PMCA and high-grade nonmucinous lesions (35% +/- 10% and 15% +/- 14%; P = .0032 for test of differences between groups). Age at presentation (P = .0134), performance status (P < .0001), time between diagnosis and IPHC (P = .0011), resection status (P = .0044), and length of hyperthermic chemoperfusion (P = .0193) were independently associated with survival. CONCLUSIONS The data show that long-term survival is anticipated in most patients who are treated with cytoreduction and IPHC for appendiceal PD. The findings presented herein underscore the important prognostic characteristics that predict outcome after IPHC in patients with PD. In all, this work establishes a framework for the consideration of IPHC in future trials for appendiceal PD.
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Affiliation(s)
- John H Stewart
- Department of General Surgery, Surgical Oncology Service, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
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Stewart JH, Shen P, Levine EA. Intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy: current status and future directions. Ann Surg Oncol 2005; 12:765-77. [PMID: 16132375 DOI: 10.1245/aso.2005.12.001] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2004] [Accepted: 05/11/2005] [Indexed: 12/11/2022]
Abstract
Natural history studies have shown that peritoneal carcinomatosis is uniformly fatal, with a median survival in the range of approximately 6 months. For more than a decade, a handful of centers have pursued aggressive intraperitoneal cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy as an alternative approach to this disease. Strict selection criteria, variation in intraperitoneal chemotherapy, and the vagaries of what represents "cytoreductive surgery" make many of our colleagues, particularly those in medical oncology, reticent to refer patients for such an aggressive therapy. This article establishes a conceptual framework for understanding the role of intraperitoneal hyperthermic chemotherapy in the treatment of peritoneal surface malignancy. This procedure continues to make advancements in the oncological community despite formidable challenges. The advancement of centers of excellence and the initiation of further phase II trials will help to define the optimal treatment approach for peritoneal carcinomatosis.
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Affiliation(s)
- John H Stewart
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
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Katz MH, Barone RM. The rationale of perioperative intraperitoneal chemotherapy in the treatment of peritoneal surface malignancies. Surg Oncol Clin N Am 2003; 12:673-88. [PMID: 14567024 DOI: 10.1016/s1055-3207(03)00034-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In summary, the use of perioperative intraperitoneal chemotherapy is a rational and scientifically sound treatment option for patients with peritoneal carcinomatosis. By delivering chemotherapeutic agents directly into the peritoneal cavity in the perioperative period, after cytoreductive procedures resulting in minimal residual tumor load, the cytotoxicity, efficacy, and safety of these agents can be maximized. The use of this treatment strategy in the intraoperative or perioperative period ensures that the efficacy of the chemotherapeutic agents is not reduced by limitations of abdominal compartmentalization and scarring. Treating patients under hyperthermic conditions may confer an additional benefit. Although the use of perioperative chemotherapy or hyperthermic intraperitoneal chemotherapy is not yet part of the standard of care for the treatment of advanced abdominal malignancies, both basic science and clinical investigations have confirmed the validity of these regimens. Further clinical studies in a cooperative group setting are necessary to prove the efficacy of perioperative intraperitoneal chemotherapy in both the treatment and prevention of peritoneal surface malignancy.
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Affiliation(s)
- Matthew H Katz
- Department of Surgery, University of California at San Diego, Medical Center, 200 West Arbor Drive, San Diego, CA 92103, USA
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Garcia AA, Muggia FM, Spears CP, Jeffers S, Silberman H, Pujari M, Koda RT. Phase I and pharmacologic study of i.v. hydroxyurea infusion given with i.p. 5-fluoro-2'-deoxyuridine and leucovorin. Anticancer Drugs 2001; 12:505-11. [PMID: 11459996 DOI: 10.1097/00001813-200107000-00003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Preclinical data suggests that the action of fluoropyrimidines may be enhanced by the addition of hydroxyurea. We developed a phase I trial to determine the maximum tolerated dose and pharmacokinetics of i.v. hydroxyurea (HU) in combination with i.p. 5-fluoro-2'-deoxyuridine (FUdR) and leucovorin (LV). Eligible patients had metastatic carcinoma confined mostly to the peritoneal cavity, and adequate hepatic, renal and bone marrow function. Patients were treated with a fixed dose of FUdR (3 g) and LV (640 mg) administered on days 1--3. HU was administered as a 72-h infusion starting simultaneously with i.p. therapy on day 1. The following dose levels were studied: 2.0, 2.5, 3.0 and 3.6 g/m(2)/day. Pharmacokinetics were studied in blood and peritoneal fluid. Twenty-eight patients were accrued. Steady-state plasma and peritoneal fluid HU levels increased with increasing dose, and steady state was achieved within 12 h of continuous dosing. The steady-state HU plasma:peritoneal fluid concentration ratio ranged from 1.06 x 10(3) to 1.25 x 10(3) and the plasma HU clearance ranged from 4.63 to 5.81 l/h/m(2). Peritoneal fluid AUC = 137,639 +/- 43,914 microg/ml x min, t(1/2) = 100.9 +/- 56.4 min and Cl = 25.29 +/- 10.88 ml/min. Neutropenia represented the dose-limiting toxicity. We conclude that i.p. FUdR and LV in combination with i.v. HU is well tolerated. The addition of systemic HU increased the incidence of myelosuppression.
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Affiliation(s)
- A A Garcia
- 1University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA 90033, USA
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Muggia FM, Jeffers S, Muderspach L, Roman L, Rosales R, Groshen S, Safra T, Morrow CP. Phase I/II study of intraperitoneal floxuridine and platinums (cisplatin and/or carboplatin). Gynecol Oncol 1997; 66:290-4. [PMID: 9264578 DOI: 10.1006/gyno.1997.4778] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Previous studies have shown that intraperitoneal (i.p.) floxuridine (FUDR) is tolerated at a dose of 3 g x 3 days given in 1.5-2 L of normal saline (NS). In a randomized phase II trial by the Southwest Oncology Group, this treatment was selected for further study because of a favorable 1-year progression-free survival. We have now evaluated ip FUDR in full doses combined with i.p. cisplatin given on the third day at a dose of 60 mg/m2 in 500 mL of NS. Intraperitoneal carboplatin was partially or fully substituted for i.p. cisplatin in patients with symptomatic neuropathies. All patients also received i.p. leucovorin, as previously piloted for fluoropyrimidine modulation. Seven patients with symptomatic ascites or measurable tumors were entered, as were 11 asymptomatic patients with minimal residual (< or = 1 cm) epithelial ovarian cancer. Six cycles of the combination of i.p. FUDR + cisplatin were completed in three patients; however, the combination of FUDR with both platinums was particularly well tolerated. Intraperitoneal FUDR + carboplatin (AUC of 5) was associated with some grade 3 and 4 thrombocytopenia and neutropenia. Eight of these 11 patients are alive, and 3 have been continuously with no evidence of disease exceeding 32 months. The regimen of i.p. FUDR + i.p. cisplatin (or i.p. FUDR with both platinums) is suitable for a phase III trial testing i.p. therapy either from the outset (e.g., i.p. up front) or after achieving clinical complete responses from initial treatment without intervening relapse (i.e., i.p. consolidation) in comparison to i.p. cisplatin.
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Affiliation(s)
- F M Muggia
- University of Southern California-Kenneth Norris, Jr., Comprehensive Cancer Center, Los Angeles 90033, USA
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