1
|
Patel S, Bhatt A, Mehta S, Ramakrishnan AS. Two-stage cytoreductive surgery for 'extensive' pseudomyxoma peritonei: A legitimate alternative or salvage strategy? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108593. [PMID: 39121632 DOI: 10.1016/j.ejso.2024.108593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 08/06/2024] [Accepted: 08/06/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND AND AIM Two-stage cytoreductive surgery (CRS) has been proposed as an alternative to one-stage surgery in patients who have 'extensive' pseudomyxoma peritonei (PMP) and/or are unfit for very extensive surgery, to reduce morbidity. We review current evidence on two-stage CRS focusing on patient selection, interval between procedures, extent of surgery, use of HIPEC, perioperative and oncological outcomes. METHODS This is a narrative review. A literature search on PubMed and Embase was performed using keywords- 'Two-stage cytoreductive surgery', 'pseudomyxoma peritonei', 'high-volume PMP', 'huge PMP', 'cytoreductive surgery', 'HIPEC', 'staged surgery' and 'extensive pseudomyxoma peritonei'. RESULTS Five studies reported outcomes in a total of 114 patients. The indications for two-stage CRS were: in two studies, patients undergoing an incomplete cytoreduction due to undue surgical risk were reevaluated for a second surgery during routine surveillance; severe comorbidities in one; extensive disease with PCI>28 in another and in one, only HIPEC was performed as a second procedure due to intraoperative hemodynamic instability (the two-stage procedure was performed in interest of patient's safety). Major morbidity ranged from 0 to 37.5 % (first-stage) and 25%-38.9 % (second-stage). Short term follow-up demonstrated equivalent short-term oncological outcomes compared to historical data. Long term follow-up and quality-of-life data were not available. CONCLUSIONS The published studies showed different interpretations and applications of the two-stage CRS concept. The reported morbidity was similar to that after single-stage CRS for extensive PMP. Though short-term survival outcomes are acceptable, long-term follow-up is needed. Planned two-stage CRS should currently be reserved for highly selected clinical situations.
Collapse
Affiliation(s)
- Swapnil Patel
- Dept of Surgical Oncology, MPMMCC & HBCH, Tata Memorial Centre, Varanasi, India
| | - Aditi Bhatt
- Dept of Surgical Oncology, KD Hospital, Ahmedabad, India.
| | - Sanket Mehta
- Dept of Surgical Oncology, Specialty Surgical Oncology, Mumbai, India
| | - A S Ramakrishnan
- Dept. of Surgical Oncology, Cancer Institute, WIA, Chennai, India
| |
Collapse
|
2
|
Gwee YX, Chia DKA, So J, Ceelen W, Yong WP, Tan P, Ong CAJ, Sundar R. Integration of Genomic Biology Into Therapeutic Strategies of Gastric Cancer Peritoneal Metastasis. J Clin Oncol 2022; 40:2830. [PMID: 35649219 PMCID: PMC9390822 DOI: 10.1200/jco.21.02745] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The peritoneum is a common site of metastasis in advanced gastric cancer (GC). Diagnostic laparoscopy is now routinely performed as part of disease staging, leading to an earlier diagnosis of synchronous peritoneal metastasis (PM). The biology of GCPM is unique and aggressive, leading to a dismal prognosis. These tumors tend to be resistant to traditional systemic therapy, and yet, this remains the current standard-of-care recommended by most international clinical guidelines. As this is an area of unmet clinical need, several translational studies and clinical trials have focused on addressing this specific disease state. Advances in genomic sequencing and molecular profiling have revealed several promising therapeutic targets and elucidated novel biology, particularly on the role of the surrounding tumor microenvironment in GCPM. Peritoneal-specific clinical trials are being designed with a combination of locoregional therapeutic strategies with systemic therapy. In this review, we summarize the new knowledge of cancer biology, advances in surgical techniques, and emergence of novel therapies as an integrated strategy emerges to address GCPM as a distinct clinical entity.
Collapse
Affiliation(s)
- Yong Xiang Gwee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Daryl Kai Ann Chia
- University Surgical Cluster, National University Health System, Singapore.,Division of Surgical Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore
| | - Jimmy So
- University Surgical Cluster, National University Health System, Singapore.,Division of Surgical Oncology, National University Cancer Institute, Singapore, National University Health System, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Singapore Gastric Cancer Consortium, Singapore
| | - Wim Ceelen
- Department of GI Surgery, Ghent University Hospital, and Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
| | - Wei Peng Yong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore.,Singapore Gastric Cancer Consortium, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Patrick Tan
- Singapore Gastric Cancer Consortium, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore.,Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore.,Genome Institute of Singapore, Agency for Science, Technology and Research, Singapore.,SingHealth/Duke-NUS Institute of Precision Medicine, National Heart Centre Singapore, Singapore.,Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chin-Ann Johnny Ong
- Division of Surgery and Surgical Oncology, Department of Sarcoma, Peritoneal and Rare Tumors (SPRinT), National Cancer Centre Singapore, Singapore.,Division of Surgery and Surgical Oncology, Department of Sarcoma, Peritoneal and Rare Tumors (SPRinT), Singapore General Hospital, Singapore.,Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore.,SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore.,SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore.,Institute of Molecular and Cell Biology, A*STAR Research Entities, Singapore
| | - Raghav Sundar
- Department of Haematology-Oncology, National University Cancer Institute, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Singapore Gastric Cancer Consortium, Singapore.,Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore.,The N.1 Institute for Health, National University of Singapore, Singapore
| |
Collapse
|
3
|
Bhatt A, Glehen O. Hyperthermic Intraperitoneal Chemotherapy in the Treatment Armamentarium of Epithelial Ovarian Cancer: Time to End the Dichotomy. Visc Med 2022; 38:109-119. [PMID: 35614893 PMCID: PMC9082174 DOI: 10.1159/000521239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/29/2021] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> Advanced epithelial ovarian cancer (EOC) is an incurable disease with over 75% of the patients developing recurrence in the peritoneum. Hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising treatment option for both first-line therapy and treatment of recurrence. In this article, we review the rationale and current evidence for performing HIPEC and the role of HIPEC in the light of targeted systemic therapies. <b><i>Summary:</i></b> There are few randomized trials and several retrospective studies on the role of HIPEC in the management of EOC. A 12-month-overall survival (OS) benefit of the addition of HIPEC to interval cytoreductive surgery (CRS) was demonstrated in 1 randomized trial following which HIPEC has been included as a treatment option for this indication in several national/international guidelines. One retrospective propensity score-matched analysis showed a 16-month OS benefit of adding HIPEC to primary CRS. One randomized trial showed no benefit of the addition of carboplatin HIPEC to secondary CRS over secondary CRS alone. For patients undergoing primary CRS and secondary CRS for recurrence, the results of ongoing randomized trials are needed to define the role of HIPEC in these situations. All clinical trials have shown that the morbidity of HIPEC performed after CRS is acceptable. Along with the emergence of HIPEC as a promising surgical therapy, targeted therapies like bevacizumab and poly adenosine diphosphate-ribose polymerase inhibitors have been developed that have shown a survival benefit in selected patients. In principle, HIPEC and targeted therapies work in different ways and it is plausible to assume that their benefit could be additive, and their combination should be evaluated in clinical trials. The impact of prognostic factors like the disease extent, pathological response to systemic chemotherapy (SC), the histological subtype and molecular profile on the benefit of HIPEC, and targeted therapies has not been evaluated in clinical trials. <b><i>Key Messages:</i></b> HIPEC is an important therapeutic strategy in the treatment of EOC. While its role in patients undergoing interval CRS has been established, the results of ongoing randomized trials are needed to define its benefit at other time points. The morbidity of HIPEC in addition to CRS is acceptable. More research is needed to define subgroups that benefit most from HIPEC based on the extent of disease, response to SC, histology, and molecular profile. The combination of HIPEC and maintenance therapies should be evaluated in well-designed randomized clinical trials that evaluate not just the survival benefit and morbidity but also the cost-effectiveness of each therapy.
Collapse
Affiliation(s)
- Aditi Bhatt
- Department of Surgical Oncology, Zydus Hospital, Ahmedabad, India
- *Aditi Bhatt,
| | - Olivier Glehen
- Department of Surgical Oncology, Centre Hospitalier Lyon-Sud, Lyon, France
| |
Collapse
|
4
|
Yonemura Y, Iahibashi H, Sako S, Mizumoto A, Takao N, Ichinose M, Motoi S, Liu Y, Wakama S, Kamada Y, Nishihara K. Advances with pharmacotherapy for peritoneal metastasis. Expert Opin Pharmacother 2020; 21:2057-2066. [PMID: 32783786 DOI: 10.1080/14656566.2020.1793957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION A new treatment strategy involving cytoreductive surgery (CRS) combined with perioperative intraperitoneal (IP) chemotherapy was proposed in 1999 by the Peritoneal Surface Oncology Group International, and the strategy is now justified as a state-of-the-art treatment to improve the long-term survival of patients with peritoneal metastasis (PM). To achieve cure in the patients with PM, complete removal of macroscopic tumors and eradication of micrometastasis on the peritoneum, left after CRS are essential. Systemic chemotherapy is not indicated for the treatment of PM. In contrast, intraperitoneal (IP) chemotherapy brings about significantly higher locoregional dose intensity in the peritoneal cavity and subperitoneal tissues. In combination with anticancer drugs, hyperthermia enhances cytotoxicity against cancer cells. AREA COVERED This article provides a systematic overview of PM from various cancers including gastric, colorectal, small bowel, appendiceal cancer, and mesothelioma. It also includes all the essential aspects of therapy. EXPERT OPINION CRS plus perioperative intraperitoneal chemotherapy is safe with acceptable morbidity and mortality. It is justified as a standard treatment to improve the long-term survival of patients with PM and is now performed with curative intent for PM from various malignancies.
Collapse
Affiliation(s)
- Yutaka Yonemura
- Department of Regional Cancer Therapies, Peritoneal Surface Malignancy Treatment Center, Kishiwada Tokushukai Hospital , Kishiwada City, Oosaka-Fu, Japan.,Department of Peritoneal Surface Malignancy Treatment, Kusatsu General Hospital , Kusatsu City, Shiga, Japan
| | - Haruaki Iahibashi
- Department of Regional Cancer Therapies, Peritoneal Surface Malignancy Treatment Center, Kishiwada Tokushukai Hospital , Kishiwada City, Oosaka-Fu, Japan
| | - Shouzou Sako
- Department of Regional Cancer Therapies, Peritoneal Surface Malignancy Treatment Center, Kishiwada Tokushukai Hospital , Kishiwada City, Oosaka-Fu, Japan
| | - Akiyoshi Mizumoto
- Department of Peritoneal Surface Malignancy Treatment, Kusatsu General Hospital , Kusatsu City, Shiga, Japan
| | - Nobuyuki Takao
- Department of Peritoneal Surface Malignancy Treatment, Kusatsu General Hospital , Kusatsu City, Shiga, Japan
| | - Masumi Ichinose
- Department of Peritoneal Surface Malignancy Treatment, Kusatsu General Hospital , Kusatsu City, Shiga, Japan
| | - Shunsuke Motoi
- Department of Peritoneal Surface Malignancy Treatment, Kusatsu General Hospital , Kusatsu City, Shiga, Japan
| | - Yang Liu
- Department of Regional Cancer Therapies, Peritoneal Surface Malignancy Treatment Center, Kishiwada Tokushukai Hospital , Kishiwada City, Oosaka-Fu, Japan
| | - Satoshi Wakama
- Department of Regional Cancer Therapies, Peritoneal Surface Malignancy Treatment Center, Kishiwada Tokushukai Hospital , Kishiwada City, Oosaka-Fu, Japan
| | - Yasuyuki Kamada
- Department of Regional Cancer Therapies, Peritoneal Surface Malignancy Treatment Center, Kishiwada Tokushukai Hospital , Kishiwada City, Oosaka-Fu, Japan
| | - Kazurou Nishihara
- Department of Regional Cancer Therapies, Peritoneal Surface Malignancy Treatment Center, Kishiwada Tokushukai Hospital , Kishiwada City, Oosaka-Fu, Japan
| |
Collapse
|
5
|
Kim DW, Jee YS, Kim CH, Kim JJ, Park S, Choi SI, Park JM, Kim JH. Multicenter Retrospective Analysis of Intraperitoneal Paclitaxel and Systemic Chemotherapy for Advanced Gastric Cancer with Peritoneal Metastasis. J Gastric Cancer 2020; 20:50-59. [PMID: 32269844 PMCID: PMC7105410 DOI: 10.5230/jgc.2020.20.e6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 11/13/2019] [Accepted: 12/17/2019] [Indexed: 02/06/2023] Open
Abstract
Purpose The objective of the present retrospective analysis was to describe the experience of intraperitoneal (IP) paclitaxel and systemic chemotherapy in patients with peritoneal metastasis (PM) of advanced gastric cancer (AGC) in a multicenter setting in Korea. Materials and Methods The medical records of patients with AGC, who were diagnosed with PM between January 2015 and December 2018, were reviewed. IP catheter was placed in the pouch of Douglas and was used for the administration of IP paclitaxel chemotherapy. Results We reviewed the clinical outcomes of IP paclitaxel and systemic chemotherapy administration in 82 patients at six institutions in Korea. Mean number of IP chemotherapy cycles was 6.6. The mean peritoneal cancer index (PCI) was 21.9. Postoperative complications related to IP catheter and port were observed in 15 patients. The overall median survival was 20.0 months. A significant difference was observed in the survival rate according to the ascites grade (grade I and II, 24.1 months; grade III and IV, 15.3 months; P=0.014) and PCI grade (grade I, 25.6 months; grade II and III, 16.3 months; P=0.023). Conclusions The feasibility of IP paclitaxel and systemic chemotherapy administration was demonstrated in this experience-based retrospective analysis suggesting that the procedure is beneficial in patients with PM of AGC.
Collapse
Affiliation(s)
- Dong-Wook Kim
- Department of Surgery, Dankook University Hospital, Cheonan, Korea
| | - Ye Seob Jee
- Department of Surgery, Dankook University Hospital, Cheonan, Korea
| | - Chang Hyun Kim
- Department of Surgery, Incheon St. Mary's Hospital, Incheon, Korea
| | - Jin-Jo Kim
- Department of Surgery, Incheon St. Mary's Hospital, Incheon, Korea
| | - Sungsoo Park
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Sung Il Choi
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Joong-Min Park
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jong-Han Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | | |
Collapse
|
6
|
Macrì A, Morabito F. The use of intraperitoneal chemotherapy for gastric malignancies. Expert Rev Anticancer Ther 2019; 19:879-888. [PMID: 31544548 DOI: 10.1080/14737140.2019.1671189] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Gastric cancer is the fourth/fifth most common malignancy worldwide, with only a quarter of patients achieving a 5-year survival rate. It has been estimated that 15-50% or more of patients have peritoneal disease upon surgical exploration. Until the early 1990s, peritoneal metastasis was considered as terminal stage of the disease; in the late 1990s, selected patients with peritoneal metastasis were recategorized as local disease. Over the past two decades, the treatment of peritoneal involvement has transformed, and cytoreductive surgery plus intraperitoneal therapy have drastically altered the natural course of several malignancies. Areas covered: We performed a review of studies available on PubMed from 1 January 2014 to 31 July 2019 and the analysis of their reference citations. We describe the most current intraperitoneal chemotherapy opportunities in the treatment of gastric cancer: hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC), laparoscopic hyperthermic intraperitoneal chemotherapy (LHIPEC), neoadjuvant intraperitoneal and systemic chemotherapy (NIPS), LHIPEC + NIPS, extensive intraoperative peritoneal lavage (EIPL), early postoperative intraperitoneal chemotherapy (EPIC), and pressurized intraperitoneal aerosol chemotherapy (PIPAC). Expert opinion: Comprehensive treatment consisting of CRS combined with perioperative intraperitoneal/systemic chemotherapy can, today, be considered an effective strategy to improve the long-term survival of gastric cancer patients with peritoneal metastasis.
Collapse
Affiliation(s)
- Antonio Macrì
- Peritoneal Surface Malignancy and Soft Tissue Sarcoma Program, Messina University Medical School Hospital , Messina , Italy
| | - Federico Morabito
- Peritoneal Surface Malignancy and Soft Tissue Sarcoma Program, Messina University Medical School Hospital , Messina , Italy
| |
Collapse
|