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Geisel D, Langen U, Rüdiger T. Oral administration of bromelain and acetylcysteine in pseudomyxoma peritonei (PMP) caused by low-grade appendiceal mucinous neoplasm (LAMN): a case report. J Med Case Rep 2023; 17:297. [PMID: 37381056 DOI: 10.1186/s13256-023-04024-7] [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: 12/21/2022] [Accepted: 05/21/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Pseudomyxoma Peritonei (PMP) is a severe neoplastic clinical syndrome characterised by secretion of mucin from tumors often originating in the appendix. The standard treatment includes cytoreductive surgery (CRS) combined with heated intraperitoneal chemotherapy (HIPEC). A new perspective in PMP treatment aims at the mucins themselves as a therapeutic target. CASE PRESENTATION Here we report the first case of PMP with peritoneal dissemination of mucinous implants caused by low-grade appendiceal mucinous neoplasm (LAMN) in a 58-year-old white male exclusively treated by appendectomy and oral administration of bromelain and acetylcysteine in the context of a medical self-experimentation (by co-author T.R.). Observation so far covers a period of 48 months including regular magnetic resonance imaging (MRI) with stable findings. CONCLUSIONS Oral administration of bromelain and acetylcysteine can be used in the treatment of PMP caused by LAMN without relevant clinical side effects.
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Affiliation(s)
- Dominik Geisel
- Department of Radiology, Charité, Universitätsmedizin Berlin, Campus Virchow-Klinikum, Klinik Für Radiologie, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Ute Langen
- Department of Radiology, Charité, Universitätsmedizin Berlin, Campus Virchow-Klinikum, Klinik Für Radiologie, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Thomas Rüdiger
- Department of Radiology, Charité, Universitätsmedizin Berlin, Campus Virchow-Klinikum, Klinik Für Radiologie, Augustenburger Platz 1, 13353, Berlin, Germany
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Vierra M, Dhiman A, Witmer HDD, Ulrich L, Hindi E, Fenton E, Shergill A, Polite B, Eng OS, Turaga KK. Celecoxib and Myrtol: A Novel Therapy for Recurrent Appendiceal Mucinous Neoplasms With Extensive Peritoneal Dissemination. Am J Clin Oncol 2022; 45:9-13. [PMID: 34857698 DOI: 10.1097/coc.0000000000000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unresectable appendiceal mucinous neoplasms (AMNs) with extensive peritoneal dissemination cause significant morbidity and have limited treatment options. We evaluated a novel combination of Celecoxib and Myrtol in treating such AMNs. METHODS Patients with recurrent AMNs with extensive peritoneal disease treated with a daily regimen of 200 mg Celecoxib and 1200 mg Myrtol Standardized were included. Progression-free survival (PFS) and overall survival (OS) were calculated, and carcinoembryonic antigen (CEA) trends were compared pretreatment and post-treatment in terms of percentage change. RESULTS Thirteen patients with extensive, recurrent disease (median peritoneal carcinomatosis index of 36) were included between 2017 and 2020. The median age was 63 years (interquartile range: 55 to 67) and 7 (54%) were male. A total of 85% had undergone prior cytoreductive surgery while 15% underwent cytoreductive surgery >2 times. 54% had received multiple cycles of systemic chemotherapy before starting Celecoxib-Myrtol. After a median follow-up of 8 months, median PFS and OS were 16 months (interquartile range: 5 to 17) and 27 months, respectively. Nine (69.2%) showed improvement in CEA values 3 months after treatment compared with 3-month pretreatment CEA trends. None had adverse events attributable to Celecoxib-Myrtol. CONCLUSIONS Our feasibility study suggests that a regimen of Celecoxib-Myrtol is well tolerated and may prolong PFS and OS in patients with recurrent AMNs with peritoneal spread.
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Affiliation(s)
- Mason Vierra
- University of Chicago Pritzker School of Medicine
| | - Ankit Dhiman
- Section of General Surgery and Surgical Oncology
- Department of Surgery
| | | | | | - Enal Hindi
- Section of General Surgery and Surgical Oncology
- Department of Surgery
| | - Emily Fenton
- Section of General Surgery and Surgical Oncology
- Department of Surgery
| | - Ardaman Shergill
- Section of Hematology and Oncology, Department of Medicine, University of Chicago Medicine
| | - Blase Polite
- Section of Hematology and Oncology, Department of Medicine, University of Chicago Medicine
| | - Oliver S Eng
- Section of General Surgery and Surgical Oncology
| | - Kiran K Turaga
- Section of General Surgery and Surgical Oncology
- Department of Surgery
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Lam AR, Bazzi K, Valle SJ, Morris DL. Novel Use of Bromelain and Acetylcysteine (BromAc®) for Pleural Involvement in Pseudomyxoma Peritonei. Case Rep Oncol 2021; 14:628-633. [PMID: 33976645 PMCID: PMC8077436 DOI: 10.1159/000514273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 12/05/2022] Open
Abstract
Pseudomyxoma peritonei (PMP) is a rare mucinous disease most commonly arising from the appendix. Pleural involvement arising from established PMP is seen in a small number of cases. Combined cytoreductive surgery and hyperthermic intrathoracic chemotherapy is the treatment of choice when managing intra-thoracic PMP. In cases of recurrence, surgical intervention may be technically challenging and carry higher rates of complications, morbidity, and mortality. Bromelain and acetylcysteine (BromAc<sup>®</sup>) is a novel treatment modality that has demonstrated mucolytic properties. When injected directly into mucinous disease, it facilitates tumour dissolution and allows it to be aspirated. It has recently been tested in the treatment of inoperable peritoneal mucinous disease, with an acceptable safety profile and positive objective response. Here we describe the first two cases of BromAc<sup>®</sup> administered directly into pleural adenomucinosis, with striking differences in response between the two patients likely due to differences in tumour hardness.
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Affiliation(s)
- Anthony R Lam
- Department of Surgery, Peritonectomy Unit, St George Hospital, Kogarah, New South Wales, Australia
| | - Khalil Bazzi
- Department of Surgery, Peritonectomy Unit, St George Hospital, Kogarah, New South Wales, Australia
| | - Sarah J Valle
- Department of Surgery, Peritonectomy Unit, St George Hospital, Kogarah, New South Wales, Australia
| | - David L Morris
- Department of Surgery, Peritonectomy Unit, St George Hospital, Kogarah, New South Wales, Australia.,University of New South Wales, St George Hospital Clinical School, Sydney, New South Wales, Australia
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Narasimhan V, Wilson K, Britto M, Warrier S, Lynch AC, Michael M, Tie J, Akhurst T, Mitchell C, Ramsay R, Heriot A. Outcomes Following Cytoreduction and HIPEC for Pseudomyxoma Peritonei: 10-Year Experience. J Gastrointest Surg 2020; 24:899-906. [PMID: 31090036 DOI: 10.1007/s11605-019-04239-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pseudomyxoma peritonei (PMP) is a rare clinical presentation, with considerable morbidity and mortality if left untreated. In recent decades, there is growing acceptance for the use of cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC). The aim of this study was to report on our 10-year single-center experience on outcomes following CRS and HIPEC for PMP of appendiceal origin. METHODS A retrospective analysis of a prospectively maintained database of all patients undergoing CRS and HIPEC for PMP of appendiceal origin over a 10-year period at a statewide referral center was conducted. RESULTS One hundred and seventy-five cytoreductive procedures were undertaken in 140 patients. The mean patient age was 57.4 years, with a female preponderance (56%). The median PCI was 16, with 73.1% of cases having a complete cytoreduction. Grade III/IV complications occurred in 36 (20.6%) cases, with no mortalities. The median overall and disease-free survival was 100 months and 40 months, respectively, with a 71% 5-year survival. High-grade histology was the main factor identified as an independent predictor of worse overall survival. CONCLUSION CRS and HIPEC are safe with acceptable rates of morbidity. It can provide very favorable survival in patients with PMP. High-grade histology is a key prognostic factor associated with a worse overall survival.
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Affiliation(s)
- Vignesh Narasimhan
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
| | - Kasmira Wilson
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Maneka Britto
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Satish Warrier
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - A Craig Lynch
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Michael Michael
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Jeanne Tie
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Tim Akhurst
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Catherine Mitchell
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Robert Ramsay
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Alexander Heriot
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
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A novel treatment of bromelain and acetylcysteine (BromAc) in patients with peritoneal mucinous tumours: A phase I first in man study. Eur J Surg Oncol 2019; 47:115-122. [PMID: 31679953 DOI: 10.1016/j.ejso.2019.10.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 10/25/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Bromelain (Brom) and Acetylcysteine (Ac) have synergistic activity resulting in dissolution of tumour-produced mucin both in vitro and in vivo. The aim of this study was to determine whether treatment of mucinous peritoneal tumour with BromAc can be performed with an acceptable safety profile and to conduct a preliminary assessment of efficacy in a clinical setting. METHODS Under radiological guidance, a drain was inserted into the tumour mass or intraperitoneally. Each patient could have more than one tumour site treated. Brom 20-60 mg and Ac 1·5-2 g was administered in 5% glucose. At 24 h, the patient was assessed for symptoms including treatment-related adverse events (AEs) and the drain was aspirated. The volume of tumour removed was measured. A repeat dose via the drain was given in most patients. All patients that received at least one dose of BromAc were included in the safety and response analysis. FINDINGS Between March 2018 and July 2019, 20 patients with mucinous tumours were treated with BromAc. Seventeen (85%) of patients had at least one treatment-emergent AE. The most frequent treatment-related AEs were CRP rise (n = 16, 80%), WCC rise (n = 11, 55%), fever (n = 7, 35%, grade I) and pain (n = 6, 30%, grade II/III). Serious treatment-related AEs accounted for 12·5% of all AEs. There were no anaphylactic reactions. There were no deaths due to treatment-related AEs. An objective response to treatment was seen in 73·2% of treated sites. CONCLUSION Based on these preliminary results and our preclinical data, injection of BromAc into mucinous tumours had a manageable safety profile. Considerable mucolytic activity was seen by volume of mucin extracted and radiological appearance. These results support further investigation of BromAC for patients with inoperable mucinous tumours and may provide a new and minimally invasive treatment for these patients.
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Kämäräinen S, Mäki M, Tolonen T, Palleschi G, Virtanen V, Micheli L, Sesay AM. Disposable electrochemical immunosensor for cortisol determination in human saliva. Talanta 2018; 188:50-57. [DOI: 10.1016/j.talanta.2018.05.039] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 02/05/2023]
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Amini A, Masoumi-Moghaddam S, Morris DL. Pseudomyxoma peritonei: current chemotherapy and the need for mucin-directed strategies. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1006627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Amini A, Masoumi-Moghaddam S, Ehteda A, Morris DL. Secreted mucins in pseudomyxoma peritonei: pathophysiological significance and potential therapeutic prospects. Orphanet J Rare Dis 2014; 9:71. [PMID: 24886459 PMCID: PMC4013295 DOI: 10.1186/1750-1172-9-71] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 04/22/2014] [Indexed: 12/22/2022] Open
Abstract
Pseudomyxoma peritonei (PMP, ORPHA26790) is a clinical syndrome characterized by progressive dissemination of mucinous tumors and mucinous ascites in the abdomen and pelvis. PMP is a rare disease with an estimated incidence of 1-2 out of a million. Clinically, PMP usually presents with a variety of unspecific signs and symptoms, including abdominal pain and distention, ascites or even bowel obstruction. It is also diagnosed incidentally at surgical or non-surgical investigations of the abdominopelvic viscera. PMP is a neoplastic disease originating from a primary mucinous tumor of the appendix with a distinctive pattern of the peritoneal spread. Computed tomography and histopathology are the most reliable diagnostic modalities. The differential diagnosis of the disease includes secondary peritoneal carcinomatoses and some rare peritoneal conditions. Optimal elimination of mucin and the mucin-secreting tumor comprises the current standard of care for PMP offered in specialized centers as visceral resections and peritonectomy combined with intraperitoneal chemotherapy. This multidisciplinary approach has reportedly provided a median survival rate of 16.3 years, a median progression-free survival rate of 8.2 years and 10- and 15-year survival rates of 63% and 59%, respectively. Despite its indolent, bland nature as a neoplasm, PMP is a debilitating condition that severely impacts quality of life. It tends to be diagnosed at advanced stages and frequently recurs after treatment. Being ignored in research, however, PMP remains a challenging, enigmatic entity. Clinicopathological features of the PMP syndrome and its morbid complications closely correspond with the multifocal distribution of the secreted mucin collections and mucin-secreting implants. Novel strategies are thus required to facilitate macroscopic, as well as microscopic, elimination of mucin and its source as the key components of the disease. In this regard, MUC2, MUC5AC and MUC5B have been found as the secreted mucins of relevance in PMP. Development of mucin-targeted therapies could be a promising avenue for future research which is addressed in this article.
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Affiliation(s)
- Afshin Amini
- Department of Surgery, St George Hospital, The University of New South Wales, Level 3, Clinical Sciences (WR Pitney) Building, Gray Street, Kogarah, Sydney, NSW 2217, Australia
| | - Samar Masoumi-Moghaddam
- Department of Surgery, St George Hospital, The University of New South Wales, Level 3, Clinical Sciences (WR Pitney) Building, Gray Street, Kogarah, Sydney, NSW 2217, Australia
| | - Anahid Ehteda
- Department of Surgery, St George Hospital, The University of New South Wales, Level 3, Clinical Sciences (WR Pitney) Building, Gray Street, Kogarah, Sydney, NSW 2217, Australia
| | - David Lawson Morris
- Department of Surgery, St George Hospital, The University of New South Wales, Level 3, Clinical Sciences (WR Pitney) Building, Gray Street, Kogarah, Sydney, NSW 2217, Australia
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