Preoperative computed tomography and selection of patients with colorectal peritoneal carcinomatosis for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Application of artificial intelligence in the diagnosis, treatment, and recurrence prediction of peritoneal carcinomatosis

Peritoneal carcinomatosis (PC) is a type of secondary cancer which is not sensitive to conventional intravenous chemotherapy. Treatment strategies for PC are usually palliative rather than curative. Recently, artificial intelligence (AI) has been widely used in the medical field, making the early diagnosis, individualized treatment, and accurate prognostic evaluation of various cancers, including mediastinal malignancies, colorectal cancer, lung cancer more feasible. As a branch of computer science, AI specializes in image recognition, speech recognition, automatic large-scale data extraction and output. AI technologies have also made breakthrough progress in the field of peritoneal carcinomatosis (PC) based on its powerful learning capacity and efficient computational power. AI has been successfully applied in various approaches in PC diagnosis, including imaging, blood tests, proteomics, and pathological diagnosis. Due to the automatic extraction function of the convolutional neural network and the learning model based on machine learning algorithms, AI-assisted diagnosis types are associated with a higher accuracy rate compared to conventional diagnosis methods. In addition, AI is also used in the treatment of peritoneal cancer, including surgical resection, intraperitoneal chemotherapy, systemic chemotherapy, which significantly improves the survival of patients with PC. In particular, the recurrence prediction and emotion evaluation of PC patients are also combined with AI technology, further improving the quality of life of patients. Here we have comprehensively reviewed and summarized the latest developments in the application of AI in PC, helping oncologists to comprehensively diagnose PC and provide more precise treatment strategies for patients with PC.

Predictive factors of non-completion of cytoreductive surgery in colorectal peritoneal metastasis

INTRODUCTION

Cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) is the only potentially curative treatment that can improve the survival prognosis for patients with peritoneal metastasis (PM) of colorectal origin. The main independent prognostic factors are extent of disease, as measured by the Peritoneal Cancer Index (PCI), and completion of CRS (CC-0 or R1). Despite thorough preoperative work-up for selection of surgical candidates, 20%-25 % of CRS procedures are stopped after exploration during laparotomy. These patients undergo "open-and-close" procedures associated with a risk of complications and without any benefit. The aim of this study was to identify preoperative predictors of non-resectability and/or non-completion of CRS in patients with colorectal PMs who were candidates for surgery.

MATERIALS AND METHODS

Retrospective, monocentric study including patients admitted for CRS ± HIPEC at the Jules Bordet Institute between January 01, 2010 and December 31, 2021. The preoperative epidemiological, pathological, clinical, radiological, and biological features of patients with unresectable disease were compared with those of patients treated with CRS.

RESULTS

One hundred nineteen patients were included, 60 men and 59 women (median age 61 years). Twenty-one CRS procedures (17.65 %) were stopped during exploratory laparotomy. Statistically significant factors associated with non-completion were age (p = 0.0183), PCI (p = 0.0001), presence of sub/occlusive episode(s) prior to CRS (p = 0.0012), and multifocal-diffuse uptakes on PET-scan (p = 0.0017).

CONCLUSION

Almost 18 % of patients had an "open-and-close" procedure. PCI was the major determinant of non-completion of CRS. Other predictive factors of unresectability of colorectal PM were age, the presence of sub/occlusive episodes, and PET/CT with multiple peritoneal uptakes.

External validation of prognostic scores and comparison of predictive accuracy for patients with colorectal cancer with peritoneal metastases considered for cytoreductive surgery and intraperitoneal chemotherapy

BACKGROUND AND OBJECTIVES

Prognostic scores are developed to facilitate the selection of patients with colorectal cancer peritoneal metastases (CRPM) for treatment with cytoreductive surgery (CRS) ± intraperitoneal chemotherapy (IPC). Three prominent prognostic scores are the Peritoneal Surface Disease Severity Score (PSDSS), the Colorectal Peritoneal Metastases Prognostic Surgical Score (COMPASS), and the modified COloREctal-Pc (mCOREP). We externally validate these scores and compare their predictive accuracy.

METHODS

Data from consecutive CRPM patients who underwent CRS/IPC from 1996 to 2018 was used to externally validate COMPASS, PSDSS, and mCOREP. Analysis evaluated the efficacy of each score in predicting (1) open-close laparotomy-those found at laparotomy to not be eligible for curative intent CRS/IPC, (2) surgical futility-those who underwent open-close laparotomy, palliative debulking surgery, or had an overall survival of less than 12 months, and (3) overall and recurrence-free survival (OS, RFS).

RESULTS

Prognostic scores were calculated for the 174-patient external validation cohort. COMPASS was most accurate in predicting open-close laparotomy, futile surgery, and survival (OS and RFS). Area under the curve (AUC) for open-close prediction was 0.78 (95% confidence interval, CI: 0.68-0.87), representing useful discrimination. However, AUC for futility prediction was 0.62 (95% CI: 0.52-0.71), and C-statistic for OS was 0.65 indicating only possibly helpful discrimination. C-statistic for RFS was 0.59 indicating poor discrimination.

CONCLUSION

While COMPASS showed the best statistical behavior, accuracy for several clinically relevant outcomes remains low, and thus applicability to clinical practice limited.

Diagnostic and Therapeutic Algorithm for Appendiceal Tumors and Pseudomyxoma Peritonei: A Consensus of the Peritoneal Malignancies Oncoteam of the Italian Society of Surgical Oncology (SICO)

Aim: Pseudomyxoma peritonei (PMP) is an uncommon pathology, and its rarity causes a lack of scientific evidence, precluding the design of a prospective trial. A diagnostic and therapeutic algorithm (DTA) is necessary in order to standardize the disease treatment while balancing optimal patient management and the correct use of resources. The Consensus of the Italian Society of Surgical Oncology (SICO) Oncoteam aims at defining a diagnostic and therapeutic pathway for PMP and appendiceal primary tumors applicable in Italian healthcare. Method: The consensus panel included 10 delegated representatives of oncological referral centers for Peritoneal Surface Malignancies (PSM) affiliated to the SICO PSM Oncoteam. A list of statements regarding the DTA of patients with PMP was prepared according to recommendations based on the review of the literature and expert opinion. Results: A consensus was obtained on 33 of the 34 statements linked to the DTA; two flowcharts regarding the management of primary appendiceal cancer and peritoneal disease were approved. Conclusion: Currently, consensus has been reached on pathological classification, preoperative evaluation, cytoreductive surgery technical detail, and systemic treatment; some controversies still exist regarding the exclusion criteria for HIPEC treatment. A shared Italian model of DTA is an essential tool to ensure the appropriateness and equity of treatment for these patients.

Diffuse malignant peritoneal mesothelioma: A review

Diffuse malignant peritoneal mesothelioma (DMPM) is an unusual and life-threatening locally invasive tumor. The morbidity and mortality of the disease are associated with progressive local effects in the abdominal cavity, such as abdominal distention, painful sensations, and early saturation with reduced oral intake, which eventually lead to intestinal obstruction and cachexia. Computed tomography (CT) has been widely used as a first-line diagnostic tool for DMPM. In addition, the most sensitive immunohistochemical markers of DMPM include WT 1, D2-40, and calmodulin. This paradigm has altered with the advancements in the immunohistochemical analysis of BRCA1-Associated Protein 1 (BAP1) the lack of BAP1 expression shows the diagnosis of malignancy. DMPM is resistant to conventional chemotherapies. Therefore, the gold standard for the treatment of DMPM is the combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The overexpression of the phosphatidylinositol 3-kinase (PI3K)/AKT serine/threonine kinase 1 (AKT)/mammalian target of rapamycin (mTOR) signaling pathway drives the malignant phenotype of DMPM, thereby showing promising potential for the treatment of DMPM. The coordinated activities among multiple RTKs are directly involved in the biological processes of DMPM, suggesting that the combined inhibition of the PI3K and mTOR signaling pathways might be an effective measure. This treatment strategy can be easily implemented in clinical practice. However, the combined inhibition of ERBB1(HER1)/ERBB2 (HER2) and ERBB3 (HER3) requires further investigations. Thus, based on these, the discovery of novel targeted therapies might be crucial to improving the prognosis of DMPM patients.

CT Enterography for Preoperative Evaluation of Peritoneal Carcinomatosis Index in Advanced Ovarian Cancer

To compare the diagnostic performance of routine CT (rCT), CT enterography (CTE) and intraoperative quantification of PCI to surgical and pathological reference standards in patients with advanced ovarian cancer, a retrospective study of 122 patients who underwent cytoreduction surgery for ovarian peritoneal carcinomatosis was conducted. Radiological, surgical, and pathological PCIs were obtained from the corresponding reports, and the latter two were considered reference standards. The radiological techniques used were rCT: 64 MDCT (32 × 1 mm) (100 mL iopromide 370 i.v., 800 mL water p.o.), and CTE: 64 MDCT (64 × 0.5 mm) (130 mL iopromide 370 i.v., 1800 mL mannitol solution p.o., 20 mg buscopan i.v.). Data were grouped by imaging technique and analyzed using total PCI and stratified by tumor burden (low-PCI < 10, high-PCI > 20). Agreement, diagnostic performance and degree of cytoreduction were evaluated. Disappointing results for rCT and CTE were obtained when using a surgical referent, but better diagnostic performance and concordance (0.86 vs. 0.78 vs. 0.62, p < 0.05) was observed when using a pathological referent—surgical PCI overestimates and overstaged patients. PCI is underestimated by rCT rather than CTE. For high-PCI, the ROC curve was mediocre for CTE and useless for rCT, as it failed to identify any cases. For low-PCI, the ROC was excellent (86% CTE vs. 75% rCT). In four cases with low-PCI as determined by rCT, cytoreduction was suboptimal. CTE has a better diagnostic performance than rCT in quantifying PCI in patients with advanced ovarian cancer, suggesting that CTE should be used as the initial technique. Surgical-PCI could be considered as an imperfect standard reference.

Canadian guidelines on the management of colorectal peritoneal metastases

Modern management of colorectal cancer (crc) with peritoneal metastasis (pm) is based on a combination of cytoreductive surgery (crs), systemic chemotherapy, and hyperthermic intraperitoneal chemotherapy (hipec). Although the role of hipec has recently been questioned with respect to results from the prodige 7 trial, the role and benefit of a complete crs were confirmed, as observed with a 41-month gain in median survival in that study, and 15% of patients remaining disease-free at 5 years. Still, crc with pm is associated with a poor prognosis, and good patient selection is essential. Many questions about the optimal management approach for such patients remain, but all patients with pm from crc should be referred to, or discussed with, a pm surgical oncologist, because cure is possible. The objective of the present guideline is to offer a practical approach to the management of pm from crc and to reflect on the new practice standards set by recent publications on the topic.

Distribution Characteristics of Colorectal Peritoneal Carcinomatosis Based on the Positron Emission Tomography/Peritoneal Cancer Index

Background: Colorectal peritoneal carcinomatosis (CRPC) is a primary cause of death in colorectal cancer (CRC) patients. In the past, computed tomography (CT) has been the primary method used to evaluate the distribution of CRPC. This study uses ¹⁸F-FDG positron emission tomography/computed tomography (PET/CT) to investigate the distribution characteristics of CRPC. Materials and Methods: The distribution characteristics of 46 patients with CRC who were treated in the authors' hospital were retrospectively analyzed using the peritoneal cancer index (PCI). Results: The 46 patients in the study showed CRPC involvement in 203 of the 598 abdominal and pelvic regions studied (33.9%, 203/598). The regional proportions of CRPC involvement, from high to low, were as follows: region 6 (13.8%), region 0 (10.3%), region 1 (9.9%), region 5 (8.9%), region 7 (8.4%), region 3 (8.4%), region 2 (7.4%), region 4 (7.4%), region 11 (6.9%), region 8 (6.4%), region 12 (5.4%), region 9 (3.4%), and region 10 (3.4%). Thirty-three patients had a PCI of <20, and 13 patients had a PCI of ≥20. Those 13 were among the 17 (37% 17/46) who had CRPC involvement in all three regions. According to the location of the primary CRC focus, the 46 patients were divided into three groups: right hemicolon, left hemicolon, and rectum. The frequency of CRPC was greater in the rectum group than in the left hemicolon group, and the SUV_max of CRPC was greater in the right hemicolon group than in the left hemicolon group; these differences were statistically significant (p < 0.05). Conclusions: The distribution of CRPC has certain characteristics in the abdominal and pelvic cavities. The PET-PCI scores can provide a basis for the diagnosis and clinical treatment strategies in patients with CRC.

Extent of Peritoneal Metastases on Preoperative DW-MRI is Predictive of Disease-Free and Overall Survival for CRS/HIPEC Candidates with Colorectal Cancer

OBJECTIVE

The aim of this study was to determine whether the extent of peritoneal metastases (PMs) on preoperative diffusion-weighted magnetic resonance imaging (DW-MRI) can be used as a biomarker of disease-free and overall survival in patients with colorectal cancer who are considered for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).

METHODS

For this retrospective cohort study, patients with PMs considered for CRS/HIPEC who underwent DW-MRI for preoperative staging in 2016-2017 were included. The DW-MRI protocol consisted of diffusion-weighted, T2-weighted, and pre- and post-gadolinium T1-weighted imaging of the chest, abdomen, and pelvis. DW-MRI images were evaluated by two independent readers to determine the extent of PMs represented by the Peritoneal Cancer Index (MRI-PCI), as well as extraperitoneal metastases. Cox regression and Kaplan-Meier analysis was performed to determine the prognostic value of DW-MRI for overall and disease-free survival.

RESULTS

Seventy-eight patients were included. CRS/HIPEC was planned for 53 patients and completed in 50 patients (60.5%). Median follow-up after DW-MRI was 23 months (interquartile range 13-24). The MRI-PCI of both readers showed prognostic value for overall survival, independently of whether R1 resection was achieved (hazard ratio [HR] 1.06-1.08; p < 0.05). For the patients who received successful CRS/HIPEC, the MRI-PCI also showed independent prognostic value for disease-free survival for both readers (HR 1.09-1.10; p < 0.05).

CONCLUSION

The extent of PMs on preoperative DW-MRI is an independent predictor of overall and disease-free survival and should therefore be considered as a non-invasive prognostic biomarker.

Analysis and external validation of a nomogram to predict peritoneal dissemination in gastric cancer

OBJECTIVE

Peritoneal dissemination is difficult to diagnose by conventional imaging technologies. We aimed to construct a nomogram to predict peritoneal dissemination in gastric cancer (GC) patients.

METHODS

We retrospectively analyzed 1,112 GC patients in Sun Yat-sen University Cancer Center between 2001 and 2010 as the development set and 474 patients from The Sixth Affiliated Hospital, Sun Yat-sen University between 2010 and 2016 as the validation set. The clinicopathological variables associated with gastric cancer with peritoneal dissemination (GCPD) were analyzed. We used logistic regression analysis to identify independent risk factors for peritoneal dissemination. Then, we constructed a nomogram for the prediction of GCPD and defined its predictive value with a receiver operating characteristic (ROC) curve. External validation was performed to validate the applicability of the nomogram.

RESULTS

In total, 250 patients were histologically identified as having peritoneal dissemination. Logistic regression analysis demonstrated that age, sex, tumor location, tumor size, signet-ring cell carcinoma (SRCC), T stage, N stage and Borrmann classification IV (Borrmann IV) were independent risk factors for peritoneal dissemination. We constructed a nomogram consisting of these eight factors to predict GCPD and found an optimistic predictive capability, with a C-index of 0.791, an area under the curve (AUC) of 0.791, and a 95% confidence interval (95% CI) of 0.762-0.820. The results found in the external validation set were also promising.

CONCLUSIONS

We constructed a highly sensitive nomogram that can assist clinicians in the early diagnosis of GCPD and serve as a reference for optimizing clinical management strategies.

Appendiceal tumours and pseudomyxoma peritonei: Literature review with PSOGI/EURACAN clinical practice guidelines for diagnosis and treatment

Pseudomyxoma Peritonei (PMP) is a rare peritoneal malignancy, most commonly originating from a perforated epithelial tumour of the appendix. Given its rarity, randomized controlled trials on treatment strategies are lacking, nor likely to be performed in the foreseeable future. However, many questions regarding the management of appendiceal tumours, especially when accompanied by PMP, remain unanswered. This consensus statement was initiated by members of the Peritoneal Surface Oncology Group International (PSOGI) Executive Committee as part of a global advisory role in the management of uncommon peritoneal malignancies. The manuscript concerns an overview and analysis of the literature on mucinous appendiceal tumours with, or without, PMP. Recommendations are provided based on three Delphi voting rounds with GRADE-based questions amongst a panel of 80 worldwide PMP experts.

Can [18F]F-FDG PET/CT be used to assess the pre-operative extent of peritoneal carcinomatosis in patients with colorectal cancer?

PURPOSE

To evaluate whether PET/CT could be used to assess the extent of colorectal peritoneal metastases.

METHODS

All patients who underwent a PET/CT scan before a CRS-HIPEC procedure between January 1, 2010 and December 31, 2013 were retrospectively included (n = 35). Two nuclear medicine physicians (observer 1 and observer 2) separately reviewed the scans on intraperitoneal abnormalities. A simplified PCI was used to compare the extent of rPCI versus sPCI.

RESULTS

Included patients had a median age of 60.6 years. Histology of primary tumors were 51.5% adenocarcinomas, 37.1% mucinous adenocarcinoma, and 11.4% SRCC. Median sPCI was 9.5 (5.0-11.8) and median rPCI was 5.0 (3.0-7.0) for observer 1 and 4.0 (3.0-6.0) for observer 2 (p = 0.02 and p = 0.01, respectively). When compared to the surgical data, PET/CT showed a poor correlation for assessing the extent of PC for both adenocarcinoma (observer 1 rho - 0.17, p = 0.51 and observer 2 rho 0.13, p = 0.61) as well as mucinous carcinoma or SRCC (observer 1 rho 0.44, p = 0.08 and observer 2 rho 0.38, p = 0.14).

CONCLUSION

PET/CT underestimates the extent of PC during surgery in both mucinous and non-mucinous CRC and is not recommended for intraperitoneal tumor scoring.

The volume-time index (VTI) is prognostic in patients with colorectal cancer peritoneal metastases undergoing cytoreductive surgery and intraperitoneal chemotherapy

BACKGROUND

Peritoneal cancer index (PCI) is an important prognostic factor in colorectal cancer peritoneal metastases (CRPM), however it fails to consider the time period over which disease burden develops. The volume-time index (VTI) is the ratio between PCI and time from primary tumour resection.

METHODS

A retrospective cohort study of 182 patients managed from 1996 to 2017 was performed.

RESULTS

As stratified by high vs low VTI groups, median overall survival (OS) was 23 months (95% 17-46) vs 44 months (95% 35-72) with a difference in 5-year OS of 20.3% (95%CI 10.2-40.4) vs 40.1% (95%CI 29.7-54.1), p = 0.002. No difference in 5-year recurrence free survival (RFS) exists. On multivariable analysis, an elevated VTI was independently associated with poorer OS (adjusted HR 3.20, 95%CI 1.64-6.23, p < 0.001) and RFS (adjusted HR 1.90, 95%CI 1.10-3.29, p = 0.02).

CONCLUSION

VTI is an independent prognostic factor for OS and RFs in patients with CRPM undergoing CRS/IPC, behaving as a surrogate of tumour aggressiveness.

The accuracy of multi-detector computed tomography and laparoscopy in the prediction of peritoneal carcinomatosis index score in primary ovarian cancer

RATIONALE AND OBJECTIVES

The purpose of this study was to compare the accuracy of MDCT and laparoscopy in the prediction of peritoneal carcinomatosis index score. Reproducibility of MDCT interpretation was also assessed.

METHODS

This prospective study included 85 ovarian cancer patients underwent MDCT and diagnostic laparoscopy before cytoreductive surgery. We calculated the accuracy of diagnostic modalities in the calculation of the peritoneal cancer index score (PCI). Radiologist interobserver agreement was calculated using kappa statistics.

RESULTS

Nine hundred-thirty (84.2%) of the 1105 regions had peritoneal deposits at exploratory laparotomy. Computed tomography (CT) and laparoscopy sensitivity were 94.9%, 98.3%, specificity 86.7%, 80.4%, PPV 97.9 %, 96.8%, NPV 72.2%, 88.8 %, and accuracy 93.8 %, 95.7%, respectively. However, computed tomography (CT) diagnostic performance is less accurate than laparoscopy in pelvic and small intestinal regions; no statistically significant differences were evident regarding total PCI score compared to surgery (p> 0.05). CT and laparoscopy correctly depicted peritoneal carcinomatosis in 88.2%, 90.6% of patients, respectively. Optimal cytoreduction was achieved in 68 (80%) patients.

CONCLUSION

Both CT and laparoscopy seems to be effective tools for assessment of peritoneal carcinomatosis using the PCI score. Dedicated MDCT protocol with routine use of a standardized PCI form may provide better comprehensive multi-regional analysis that may help surgeons referring patients to the best treatment option. Laparoscopy is a valuable tool in cases with a high risk of suboptimal cytoreduction related to disease extent.

The role of single-incision laparoscopic peritoneal exploration in the management of patients with peritoneal metastases

BACKGROUND

The outcome of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) depends on the extent of peritoneal metastases (PM) and the completeness of cytoreduction (CCR). The role of preoperative assessment of PM is to identify potential candidates for CRS/HIPEC and to prevent unwarranted laparotomy for those who are not. Laparoscopy has been utilized for that purpose but with concerns related to technical difficulties and risk of trocar site metastases. Single-incision laparoscopic peritoneal exploration (SILPE) has not yet been evaluated in this setting.

METHODS

This single-center retrospective study examined patients from January 2011 to December 2015 who underwent SILPE for diagnosis and staging of PM. Preoperative, intraoperative, and postoperative data were collected. For the patients who underwent subsequent laparotomy, a comparison between SILPE and laparotomy findings was made.

RESULTS

A total of 183 SILPE were performed. Primary sites were mostly colorectal in 72 cases (39.3%) and gastric in 47 (25.7%). Overall, 157 patients (85.8%) had at least one prior abdominal surgery and 48 (26.2%) had 3 or more. SILPE was successfully achieved in 90.2% of the cases. Two (1.2%) intraoperative complications and five (3%) postoperative complications were observed. Eighty-one patients had laparotomy, with a median of 27 days between SILPE and laparotomy (4-162 days). The peritoneal carcinomatosis index PCI was 9.7 ± 7.5 at SILPE, and 13.5 ± 9.6 at laparotomy. The positive predictive value of SILPE to predict CCR was 79.5%. SILPE sensitivity was 75% and specificity 97%. The lowest sensitivity was in regions 9-12 ranging from 44 to 53%.

CONCLUSION

SILPE can be safely incorporated in the management of patients with PM. It is a safe and feasible staging tool, allowing for preventing unwarranted laparotomy for patients not deemed candidate for CRS/HIPEC. Even though it may underestimate PCI, SILPE accurately predicts the possibility of CCR.

Improved Peritoneal Cavity and Abdominal Organ Imaging Using a Biphasic Contrast Agent Protocol and Spectral Photon Counting Computed Tomography K-Edge Imaging

OBJECTIVES

To validate in vitro the capability of a high-spatial-resolution prototype spectral photon-counting computed tomography (SPCCT) scanner to differentiate between 2 contrast agents and to assess in vivo the image quality and the feasibility to image the peritoneal cavity in rats using the 2 contrast agents simultaneously within the vascular and peritoneal compartments.

MATERIALS AND METHODS

The authors performed SPCCT imaging (100 mAs, 120 kVp) with energy bin thresholds set to 30, 51, 64, 72, and 85 keV in vitro on a custom-made polyoxymethylene cylindrical phantom consisting of tubes with dilutions of both contrast agents and in vivo on 2 groups of adult rats using 2 injection protocols. Approval from the institutional animal ethics committee was obtained. One group received macrocylic gadolinium chelate intraperitoneal (IP) and iodine intravenous (IV) injections (protocol A, n = 3), whereas the second group received iodine IP and gadolinium IV (protocol B, n = 3). Helical scans were performed 35 minutes after IP injection and 20 seconds after IV injection. The SPCCT and contrast material images, that is, iodine and gadolinium maps, were reconstructed with a field of view of 160 mm, an isotropic voxel size of 250 μm, and a matrix size of 640 × 640 pixels using a soft reconstruction kernel. The SPCCT images were reconstructed with 2 different spatial resolutions to compare the image quality (sharpness, diagnostic quality, and organ visualization) of SPCCT (250 μm) with single-energy computed tomography (CT) (600 μm). Two radiologists evaluated the peritoneal opacification index in 13 regions (score = 0-3 per region) on each type of image. Concentrations of contrast agents were measured in the organs of interest.

RESULTS

In vitro, the concentration measurements correlated well with the expected concentrations. The linear regressions both had R values of 0.99, slopes of 0.84 and 0.87, and offsets at -0.52 and -0.38 mg/mL for iodine and gadolinium, respectively. In vivo, the SPCCT images were of better diagnostic quality, with increased sharpness compared with the CT-like images (P < 0.0001). Intraperitoneal diffusion was excellent, with similar peritoneal opacification index on SPCCT images and overlay of contrast material maps (P = 1) without a significant difference between protocol A (37.0 ± 1.7) and protocol B (35.3 ± 1.5) (P = 0.34). Only the contrast material maps demonstrated clear visual separation of the contrast agents, allowing specific quantification of the physiological enhancement in the liver, spleen, and kidney and the urinary clearance in the renal pelvis and bladder. Renal excretion of the contrast agents injected IP was observed and was consistent with blood diffusion.

CONCLUSIONS

Spectral photon-counting CT can be used to perform a complete peritoneal dual-contrast protocol, enabling a good assessment of the peritoneal cavity and abdominal organs in rats.

Can machine learning predict resecability of a peritoneal carcinomatosis?

BACKGROUND

Approximately 20% of initially eligible patients in a HIPEC procedure eventually underwent a simple surgical exploration. These procedures are called 'open & close' (O & C) representing up to 48% of surgery. The objective of this study was to predict the resecability of peritoneal carcinomatosis using a machine-learning model for decision-making support, for eligible patients of HIPEC.

METHODS

The study was conducted as an intention to treat based on three databases including a prospective, between January 2000 and December 2015. A propensity score allowed us to obtain two groups of comparable and matched patients. Subsequently, several algorithm models of classification were studied (simple classification, conditional tree, support vector machine, random forest) to determine the model having the best performance and accuracy.

RESULTS

Two groups of 155 patients were obtained: one group without resection and one group with resection. Nine criteria of non-resecability reflecting the organ involvement have been retained. They were coded according to their importance. Five classification algorithms were tested. The training data included 218 patients and 92 test data. The random forest model exhibited the best performance with an accuracy of close to 98%. Only two errors of predictions were observed.

DISCUSSION

The largest number of patients will allow us to improve the precision prediction. Gathering more data such as biologic, radiologic, and even laparoscopic features, should improve the knowledge of the disease and decrease the number of 'O & C' procedures.

Mucinous appendiceal neoplasms: classification, imaging, and HIPEC

Recent advances, specifically cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), offer advantages compared to the traditional therapeutic approach of systemic chemotherapy in the treatment of peritoneal carcinomatosis from mucinous appendiceal neoplasms (MAN). This review provides an up-to-date, comprehensive summary of the histologic classification of MAN, reviews common imaging findings of mucoceles and pseudomyxoma peritonei, and describes the radiologist's role in the multidisciplinary care team in quantifying disease and in helping select patients for definitive surgery.

Preoperative CA125 value predicts Glisson capsule involvement in patients with peritoneal carcinomatosis undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Aim: The difficulty of detecting lesions smaller than 1 cm in the preoperative period is still a continuing problem in peritoneal carcinomatosis. Methods: The prospective data of 106 peritoneal carcinomatosis patients were included this study. Preoperative AFP, carcinoembryonic antigen, CA19.9, CA125, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, mean platelet value, platelet distribution width, red cell distribution width and radiological findings compared according to Glisson capsule tumor involvement. Results: Preoperative radiological imaging methods have low accuracy in demonstrating Glisson capsule involvement. Inflammatory and serum tumor markers, except CA125, have been shown to be ineffective at detecting preoperative Glisson capsule involvement. CA125 levels higher than 52.4 were found to be significant in indicating Glisson's capsule involvement. Conclusion: CA125 is more sensitive than radiological and nuclear imaging methods in detecting tumors smaller than 1 cm.

Systematic Review of Variations in Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Peritoneal Metastasis from Colorectal Cancer

Background: Cytoreductive surgery (CRS), followed by hyperthermic intraperitoneal chemotherapy (HIPEC), combines radical surgery with abdominal heated chemotherapy, constituting a multimodal treatment approach. Since clear standards for HIPEC conduct in colorectal carcinoma (CRC) are lacking, we aimed to provide a comprehensive structured survey. Data sources and study eligibility criteria: A systematic literature search was performed in PubMed, with keywords “HIPEC” and “colorectal cancer”, according to established guidelines. Articles were systematically screened, selecting 87 publications complemented by 48 publications identified through extended search for subsequent synthesis and evaluation, extracting inter alia details on used drugs, dosage, temperature, exposure times, and carrier solutions. Results: Compiled publications contained 171 reports on HIPEC conduct foremost with mitomycin C and oxaliplatin, but also other drugs and drug combinations, comprising at least 60 different procedures. We hence provide an overview of interconnections between HIPEC protocols, used drugs and carrier solutions as well as their volumes. In addition, HIPEC temperatures and dosing benchmarks, as well as an estimate of in vivo resulting drug concentrations are demonstrated. Conclusions and implications: Owing to recent developments, HIPEC conduct and practices need to be reassessed. Unfortunately, imprecise and lacking reporting is frequent, which is why minimal information requirements should be established for HIPEC and the introduction of final drug concentrations for comparability reasons seems sensible.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei in a liver-transplanted patient: a case report

BACKGROUND

Diagnostic work-ups in transplanted immunosuppressed patients are a challenge as non-specific findings may be interpreted as transplant-related complications. If the disease in question is rare and slowly developing like pseudomyxoma peritonei (PMP), it is even more difficult. Cytoreductive surgery (CRS) and subsequent hyperthermic intraperitoneal chemotherapy (HIPEC) is the recommended treatment for PMP even with extensive peritoneal spread. CRS-HIPEC for PMP after liver transplantation (LTX) has not been described before.

CASE PRESENTATION

A 48-year-old female patient with end-stage primary sclerosing cholangitis (PSC) underwent orthotopic LTX and subsequent pancreaticoduodenectomy after the finding of cholangiocarcinoma in situ in the native common bile duct. Ten years after the transplantation, she developed symptoms and signs suspected to represent graft-related complications. An extensive work-up revealed PMP. Upon reassessment, a cystic mass near the coecum could be seen on computed tomography scan 1 year after transplantation. The multidisiplinary team was hesitant to accept the patient for CRS-HIPEC because of extensive PMP and possible risk to the graft. However, she was eventually accepted and underwent the procedure. The Peritoneal Cancer Index (PCI) was 28 of 39, and surgical debulking was performed followed by HIPEC. The transplant control 2 months after surgery showed no harm to the graft.

CONCLUSIONS

Previous LTX should not exclude the possibility for CRS-HIPEC in PMP, even with extensive burden of disease.

A feasibility study of the use of computed virtual chromoendoscopy for laparoscopic evaluation of peritoneal metastases

BACKGROUND

Detection of an incipient peritoneal carcinomatosis (PC) is still challenging, and there is a crucial need for technological improvements in order to diagnose and to treat early this condition. Fujinon Intelligent Chromo Endoscopy (FICE) is a spectral image processing technology that enhances the contrast of the target tissue. The aim of this study is to investigate the usefulness of FICE system during peritoneal endoscopy and to establish the optimal FICE preset(s) for peritoneal exploration and PC detection.

METHODS

A total of 561 images corresponding to 51 different areas of PC nodules and normal peritoneum were recorded during peritoneal endoscopies (For each area, one white light endoscopy (WLE) image and 10 FICE images). Three groups of 5 evaluators each: senior surgeons, surgical residents and medical students assessed these images. In a first questionnaire, the evaluators gave a score ranging from 1 to 10 to each image, and the three best FICE channels were determined. In a second questionnaire, five criteria were studied specifically: contrast, brightness, vascular architecture, differentiation between organs and detection of PC. The evaluators ranked the WLE and the three best FICE channel images according to these criteria.

RESULTS

The three best FICE channels were channels 6, 2 and 9 with mean scores of 6.21 ± 1.59, 6.17 ± 1.48 and 6.06 ± 1.52, respectively. FICE Channel 2 was superior to WLE and other FICE channels, in terms of contrast (p < 10^-4), visualization of vascular architecture (p < 10^-4), differentiation between organs (p < 10^-4) and detection of PC (p < 10^-4); and ranked first in 38.8, 41.5, 31 and 46.9 % of the cases, respectively.

CONCLUSION

FICE system provides adequate illumination of the abdominal cavity and a unique contrast that enhances the vascular architecture. FICE Channel 2 is the optimal channel for peritoneal exploration and could be a useful tool for the diagnosis of PC during peritoneal explorations.

Correlation of Radiologic with Surgical Peritoneal Cancer Index Scores in Patients with Pseudomyxoma Peritonei and Peritoneal Carcinomatosis: How Well Can We Predict Resectability?

INTRODUCTION

Pseudomyxoma peritonei (PMP) and peritoneal carcinomatosis (PC) arises from primary or secondary peritoneal cancer and can be treated with complete surgical removal of disease. Suitability for surgery is based on a peritoneal cancer index (PCI), with a PCI ≥ 20 representing unresectable disease.

AIMS

Compare preoperative imaging with surgical findings based on PCI.

METHODS

All cases of patients with PMP and PC undergoing cytoreductive surgery ± hyperthermic intraperitoneal chemotherapy (HIPEC) between 2010 and 2014 were included. Two staff radiologists blinded to surgical PCI scores retrospectively reviewed imaging studies to calculate corresponding radiologic PCI scores for each patient. Correlation between radiologic PCI and surgical PCI, as obtained from operative reports, was assessed using Spearman's rho correlation coefficients. Preoperative assessment of a PCI cutoff of 20 on imaging was compared with actual surgical PCI using sensitivity, specificity, and positive and negative predictive values.

RESULTS

Forty-two patients had a mean surgical PCI ± SEM score of 15.1 ± 1.3 and mean radiologic PCI of 15.5 ± 1.5. The most common tumor histologies were appendiceal (60 %) and colon (33 %) adenocarcinoma and were of low tumor grade (67 %). Correlation between individual radiologists and surgical PCI was 0.59 and 0.62, respectively (all p < 0.001). When mean radiologic PCI was used, this correlation with surgical PCI improved to 0.64 and to 0.65 when good quality studies only were considered (all p < 0.001). Radiologic PCI score had a sensitivity of 76 %, a specificity of 69 %, positive predictive value of 85 %, and a negative predictive value of 56 % when compared with the surgical PCI. In patients with a radiologic PCI score ≥ 20, 6/13 (46 %) still achieved adequate cytoreduction.

CONCLUSIONS

Good quality cross-sectional imaging, combined with overreading and formal assessment of all components of the PCI score yields the best correlation with actual surgical findings. Although preoperative assessment of PCI ≥ 20 was reasonably accurate, using this cutoff to assess resectability is problematic as almost half of these patients were still able to undergo adequate cytoreduction. Better assessment of resectability is needed preop, either by refinement of the PCI criteria or routine staging laparoscopy.

Diagnostic Laparoscopy in the Pre-operative Assessment of Patients Undergoing Cytoreductive Surgery and HIPEC for Peritoneal Surface Malignancies

The introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has led to an improvement in the survival of select patients with peritoneal surface malignancies (PSM). However, it is important to carefully identify patients who will benefit from this procedure and to avoid an unnecessary laparotomy in those who will not. The currently available imaging modalities are unable to accurately predict the peritoneal cancer index (PCI) score or the completeness of cytoreduction. In this article, we review the current status of staging laparoscopy in the assessment of patients with PSM who are planned for CRS & HIPEC. We discuss the patient selection, techniques, complications and efficacy of staging laparoscopy. To summarise, staging laparoscopy is a safe and feasible method of pre-operative assessment of patients with PSM. It has a high sensitivity and positive predictive value in identifying patients who can undergo a complete cytoreduction, thereby preventing many patients from undergoing an unnecessary laparotomy. With the exception of pseudomyxoma peritonei, it should be considered as a part of the routine assessment of patients with PSM who are being considered for CRS & HIPEC.

Peritoneal Carcinomatosis from Colon Cancer: A Systematic Review of the Data for Cytoreduction and Intraperitoneal Chemotherapy

A systematic review of the literature on the management of peritoneal carcinomatosis (PC) from colon cancer with cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) was undertaken using OVID Medline. Forty-six relevant studies were reviewed. Mean weighted overall morbidity following CRS and IPC was 49% (range 22-76%) and mortality was 3.6% (range 0-19%). Median overall survival ranged from 15 to 63 months, and 5-year overall survival ranged from 7 to 100%. This represents an improvement over historical treatment with systemic chemotherapy alone, even in the era of modern chemotherapeutic agents. Quality of life following surgery is initially decreased but improves with time and approaches baseline. Available data appear to support the treatment of PC from colon cancer with CRS and IPC. There is a large amount of variability among studies and few high-quality studies exist. Further studies are needed to standardize techniques.

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

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

Extent of colorectal peritoneal carcinomatosis: attempt to define a threshold above which HIPEC does not offer survival benefit: a comparative study

BACKGROUND

The main prognostic factors after complete cytoreductive surgery (CCRS) of colorectal peritoneal carcinomatosis (PC) followed by intraperitoneal chemotherapy (IPC) are completeness of the resection and extent of the disease. This study aimed to determine a threshold value above which CCRS plus IPC may not offer survival benefit compared with systemic chemotherapy.

METHODS

Between March 2000 and May 2010, 180 patients underwent surgery for PC from colorectal cancer with intended performance of CCRS plus IPC.

RESULTS

Among the 180 patients, CCRS plus IPC could be performed for 139 patients (curative group, 77 %), whereas it could not be performed for 41 patients (palliative group, 23 %). The two groups were comparable in terms of age, gender, primary tumor characteristics, and pre- and postoperative systemic chemotherapy. The mean peritoneal cancer index (PCI) was lower in the curative group (11 ± 7) than in the palliative group (23 ± 7) (p < 0.0001). After a median follow-up period of 60 months (range 47-74 months), the 3-year overall survival (OS) rate was 52 % [95 % confidence interval (CI) 43-61 %] in the curative group compared with 7 % (95 % CI 2-25 %) in the palliative group. Comparison of the survivals for each PCI (ranging from 5 to 36) shows that OS did not differ significantly between the two groups of patients when the PCI was higher than 17 (hazard ratio 0.64; range 0.38-1.09).

CONCLUSION

This study confirmed the major prognostic impact of PC extent. When the PCI exceeds 17 in PC of colorectal origin, CCRS plus IPC does not seem to offer any survival benefit.

Comparison between MRI and CT in prediction of peritoneal carcinomatosis index (PCI) in patients undergoing cytoreductive surgery in relation to the experience of the radiologist

BACKGROUND

To compare CT and MRI for peritoneal carcinomatosis index (PCI) assessment and to compare assessments made by the radiologist based on their experiences.

METHOD AND MATERIALS

MRI and CT of abdomen and pelvis were performed on 39 prospectively followed by surgery directly. Two blinded radiologists with different experience levels evaluated PCI separately on different occasions on 19 cases initially and later on the remaining 20. The agreement between the radiologists' assessment and surgical findings in total and per site were recorded.

RESULTS

Total PCI: The experienced radiologist was able to assess total tumor burden correctly on both CT and MRI (kappa = 1.0). For the inexperienced radiologist the assessment was better on CT (kappa = 0.73) compared to MRI (kappa = 0.58). Different sites: The experienced radiologist showed high agreement with kappa = 0.77 for MRI and 0.80 for CT. Corresponding figures were 0.39 and 0.60 for the inexperienced radiologist. For the second phase the agreement levels increased for the inexperienced radiologist increased to 0.80 and 0.70, respectively.

CONCLUSION

CT and MRI are equal when read by experienced radiologist. CT shows better results when read by an inexperienced radiologist compared to MRI, however the results of the latter can easily be improved.

Quality of life in peritoneal carcinomatosis: a prospective study in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC)

BACKGROUND/AIMS

Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (HIPEC) can improve survival in selected patients with peritoneal carcinomatosis, but bear a significant risk of perioperative morbidity. The aim of this study was to prospectively evaluate the quality of life (QoL) following cytoreduction and HIPEC.

METHODS

In this study including 40 patients (65% females) with different primary tumors, the EORTC QLQ-C30 questionnaire was applied prior to CS and HIPEC as well as 3, 9, and 18 months postoperatively.

RESULTS

Global health status was not impaired significantly following HIPEC. Scales and symptom scores that deteriorated 3 months postoperatively (p < 0.05), that is, physical, role, and social functions as well as fatigue, pain, dyspnea, insomnia, and diarrhea, all returned to preoperative values within 9 months.

CONCLUSIONS

Following cytoreductive surgery and HIPEC, QoL returns to preoperative levels within 9 months. Selected patients that are likely to benefit oncologically from HIPEC should not be denied this option for fear of reduced postoperative QoL.

Morbidity, mortality, and oncological outcomes of 401 consecutive cytoreductive procedures with hyperthermic intraperitoneal chemotherapy (HIPEC)

PURPOSE

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are a novel curative treatment option for selected patients with peritoneal carcinomatosis (PC). We aimed to report the mortality rate and the most frequent grade III-IV adverse events and to identify associated prognostic markers. We report oncological outcomes and major prognostic factors influencing overall survival (OS) and disease-free survival.

METHODS

A total of 401 CRS plus HIPEC procedures were performed on 356 patients. Mortality, grade III-IV adverse events, OS, disease-free survival, and prognostic factors were studied.

RESULTS

Based on Common Terminology Criteria for Adverse Events (CTCAE of the National Cancer Institute 2006), mortality rate was 1 % and overall rate of morbidity grade III-IV was 12.5 %. In multivariate analysis, only the number of digestive anastomoses (>1) significantly correlated with adverse events with an odds ratio of 2.8 (p = 0.032). OS was related to histological type of PC, with a median survival reaching 47.6 months for PC of ovarian cancer origin, 45.8 months for that of colorectal origin, 64.2 months for peritoneal mesothelioma, and 8.1 months for PC of gastric cancer origin. Over half the patients with pseudomyxoma are still alive. Major prognostic factors influencing survival were histological type, World Health Organization performance status (WHO PS) (hazard ratio (HR) = 3.56), operating time (HR = 0.45), previous chemotherapy (HR = 2.04), number of peritonectomies (HR = 2.03), and completeness of cytoreduction score (HR = 3.12). Disease-free survival across all groups was 16.8 months.

CONCLUSION

The low mortality rate and 12.5 % grade III-IV morbidity of CRS and HIPEC are acceptable when weighed against overall oncologic survival. This multimodal treatment appears feasible for selected patients and trained centers.

Cytoreduction and heated intraperitoneal chemotherapy for colorectal cancer: are we excluding patients who may benefit?

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are increasingly used to treat peritoneal carcinomatosis from colorectal cancer. It is still relatively unknown which poor prognostic factors to avoid in order to optimize patient selection for CRS + HIPEC.

METHODS

Between February 2003 and October 2011, 68 consecutive colorectal cancer patients who underwent CRS + HIPEC with a complete cytoreduction were identified from a prospective database. Survival analysis was performed using the Kaplan-Meier method, with log rank testing of differences between groups. Multivariate analysis was conducted using Cox proportional hazard regression.

RESULTS

Median follow-up was 30.3 (range, 2-88) months amongst survivors. Patients with a peritoneal cancer index (PCI) of 10 or less showed improved survival over those with a PCI of 11 or higher (P = 0.03). No difference in survival was seen for the other potentially poor prognostic variables including lymph node status, synchronous peritoneal disease, peri-operative systemic chemotherapy, and rectal cancer primary.

CONCLUSIONS

A low PCI was associated with improved survival. Complete CRS + HIPEC appears to result in similar survival outcomes regardless of delivery of peri-operative systemic chemotherapy. Rectal origin, lymph node status, and synchronous peritoneal disease should not be used as an absolute exclusion criteria for CRS + HIPEC based on current data.

Correlation of preoperative magnetic resonance imaging of peritoneal carcinomatosis and clinical outcome after peritonectomy and HIPEC after 3 years of follow-up: preliminary results

Purpose: In patients with peritoneal carcinomatosis, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an evolving approach with curative intention. Previous studies indicate a correlation between preoperative magnetic resonance imaging (MRI) and surgical findings regarding the extent of peritoneal carcinomatosis. The aim of this study was to assess retrospectively whether preoperative MRI can predict the outcome and is therefore a suitable tool for patient selection. Materials and methods: Fifteen patients with laparoscopically proven peritoneal carcinomatosis were preoperatively examined using a 1.5-T whole-body MRI system. Results were correlated with surgical exploration. Follow-up was done by contrast-enhanced abdominal computed tomography and, if suspicious for recurring disease, laparoscopy or laparotomy. Survival time and interval to recurring disease were correlated with the preoperative peritoneal carcinomatosis index (PCI) on MRI (Spearman’s rank correlation). Results: In five patients radical resection could not be achieved (PCI 34 ± 6.9); survival time was 78.2 ± 54.1 days. In seven patients recurring disease was found 430 ± 261.2 days after initial complete cytoreduction (PCI 11.6 ± 6.9); survival time was 765.9 ± 355 days. Two patients are still alive after 3 years. Two patients with initially complete cytoreduction are without recurring disease after 3 years (PCI 5 and 12). One patient was lost for follow-up. Conclusions: Results of the preoperative MRI correlate well with the surgical PCI, postoperative resection status, and survival time. MRI might be a suitable technique for patient selection when considering peritonectomy and HIPEC. In our patients the outcome seems to correlate well with the extent of peritoneal carcinomatosis found by the preoperative MRI.

Efficacy of continuous hyperthermic peritoneal perfusion chemotherapy for malignant seroperitoneum

AIM: To compare the curative effect and adverse effects of continuous hyperthermic peritoneal perfusion chemotherapy versus simple intraperitoneal chemotherapy in the management of malignant seroperitoneum secondary to gastrointestinal tumors.

METHODS: Eighty-four inpatients with malignant seroperitoneum secondary to gastrointestinal tumors treated at our hospital between October 2010 and February 2013 were enrolled in the study. They were randomly and equally divided into either a study group to undergo continuous hyperthermic peritoneal perfusion chemotherapy or a control group to receive intraperitoneal chemotherapy. The differences in curative effect, quality of life and adverse effects were compared between the two groups.

RESULTS: The rate of ascites control was significantly higher in the study group than in the control group (88.33% vs 59.52%, P < 0.05). The rate of improvement of quality of life was also higher in the study group (88.1% vs 53.76%, P < 0.05). Adverse effects included mild nausea and vomiting, temporary abdominal pain, CTCAE grade Ⅰ-Ⅱ bone marrow depression (BMD), and no grade Ⅲ-Ⅳ BMD was identified. No significant differences in adverse effect were observed between the two groups.

CONCLUSION: Continuous hyperthermic peritoneal perfusion chemotherapy is superior to simple intraperitoneal chemotherapy in the management of malignant seroperitoneum in terms of ascite control, improvement of quality of life, and adverse effects.

Comparison of prognostic scores for patients with colorectal cancer peritoneal metastases treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

There are three prognostic scores for the cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) treatment of colorectal cancer peritoneal metastases: the newly introduced COREP (colorectal peritoneal) score, the peritoneal surface disease severity score (PSDS), and the prognostic score (PS). The aim was to determine which prognostic score had the best prognostic value.

METHODS

Between 2006 and 2010, a total of 77 patients with peritoneal metastases from colorectal cancer underwent CRS/HIPEC treatment. The COREP, PSDS, and PS scores were successfully applied to 56 patients (73 %) having sufficient data. The end points were prediction of open-and-close cases (n = 9), R1 resections (n = 41), and survival of <12 months (n = 18). Area under the receiver operating characteristic curves (accuracy) was compared. Subgroup analysis was performed on patients not previously used for the development of the COREP score (n = 24). Multivariable logistic regressions of the three end points were performed as well as Cox regression for overall survival. Furthermore, COREP and peritoneal cancer index were compared.

RESULTS

For open-and-close case prediction, accuracy for the whole group (n = 56) and subgroup (n = 24) was 87 and 88 %, respectively for COREP; 66 and 77 % for PSDS; and 68 and 78 % for PS. For R1 resection prediction, accuracy was 81 and 81 %, 76 and 78 %, and 75 and 77 %, respectively. For prediction of survival of <12 months, accuracy was 83 and 84, 54 and 67 %, and 55 and 56 %, respectively. The COREP score was the only independent prognostic factor in all four multivariable analyses. A COREP score of ≥6 identified patients with poor survival more accurately than a PCI of >20.

CONCLUSIONS

The COREP score predicted open-and-close cases, R1 resections, and poor survival better than PSDS and PS. COREP better identifies patients with poor survival than intraoperative PCI.

CT-Enteroclysis in the preoperative assessment of the small-bowel involvement in patients with peritoneal carcinomatosis, candidates for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

PURPOSE

To assess the performance of CT-Enteroclysis (CTE) in the preoperative evaluation of the small bowel (SB) involvement in patients with peritoneal carcinomatosis (PC), candidates for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

MATERIAL AND METHODS

In this prospective study, 48 consecutive patients (37 women, 11 men, mean age: 57.02 years) with PC of different primaries, eligible for cytoreductive surgery and HIPEC underwent CTE before surgery. Lesions were gathered according to their location (SB wall or mesentery), distribution (jejunum/ileum, proximal/distal) and lesion size (LS, where LS0 is the absence of disease, LS1 < 1 cm, LS < 1-5 cm, and LS3 > 5 cm in maximal diameter). The preoperative CTE classification was correlated with surgical scoring of PC in the SB.

RESULTS

CTE was found to have sensitivity 92%, specificity 96%, PPV 97%, NPV 91%, in assessing PC in the SB/mesentery. CTE exhibited "excellent" agreement with surgical classification of disease extent (overall kappa-weighted coefficient of agreement (κ (w)) was 0.962). Patients (n = 6) found inoperable at surgery manifested extensive plaque-like cover of the SB wall/mesentery on CTE.

CONCLUSIONS

CTE may be considered a reliable imaging technique for the preoperative evaluation of the extent and distribution of PC in the SB/mesentery in order to assist surgical planning or to prevent unnecessary surgery.

Outcome of surgery for colorectal cancer in the presence of peritoneal carcinomatosis

AIM

The detection of peritoneal carcinomatosis (PC) in colorectal cancer patients frequently results in a dilemma with regard to the optimal treatment strategy, especially when PC is encountered unexpectedly during surgery. The aim of this study was to evaluate outcomes of patients undergoing surgery for colorectal carcinoma in the presence of synchronous PC.

METHODS

Patients diagnosed with primary colorectal cancer and synchronous PC in three community hospitals were selected from the Eindhoven Cancer Registry database. Outcomes of postoperative complications, in-hospital mortality and overall survival were collected and analyzed according to the type of intervention performed.

RESULTS

Between 1995 and 2009, 169 colorectal cancer patients were diagnosed with synchronous PC, most of them unexpectedly during surgery (n = 130). 142 patients underwent surgery: primary tumor resection (n = 91), palliative procedure (n = 46) or exploration only (n = 5). In-hospital mortality was 41% after palliative surgery and 14% after primary tumor resection. Median survival was 12 weeks after palliative surgery or exploration as opposed to 55 weeks after primary tumor resection.

CONCLUSION

PC is most often encountered unexpectedly during surgery for colorectal cancer. Results of palliative procedures are very poor with a high in-hospital mortality rate and short survival. Resection of the primary tumor can be performed safely with relatively good outcomes but some patients could have benefited from an even more radical approach when the presence of PC would have been diagnosed at an earlier stage. Improvement of imaging techniques to detect PC prior to surgery is therefore urgently needed. Until this is the case, a high index of suspicion is required when subtle signs of PC are encountered.

Patient selection for cytoreductive surgery in colorectal peritoneal carcinomatosis using serum tumor markers: an observational cohort study

OBJECTIVE

There were 2 objectives: first, to investigate how many patients were excluded from surgery on the basis of the radiological extent of the peritoneal carcinomatosis (PC) or the clinical examination; and second, to develop a score based primarily on serum tumor markers (STMs) that could predict short cancer-specific survival (<12 months).

BACKGROUND

Patient selection and prediction of prognosis is crucial for successful treatment of colorectal PC.

METHODS

All patients with colorectal PC referred for cytoreductive surgery and intraperitoneal chemotherapy (2005-2008) at Uppsala University hospital were included. Patients were divided into 2 groups-nonsurgery and surgery. Clinicopathological and laboratory parameters were collected in the surgery group. A Corep (COloREctal-Pc) score was developed using hazard ratios from histology, hematological status, serial serum tumor markers (STMs), and STM changes over time. Sensitivity, specificity, positive predicted value (PPV), and negative predicted value (NPV) were calculated in a second validating dataset (n = 24) with a survival cutoff of less than 12 months.

RESULTS

A total of 107 patients were included in the study, 42 in the nonsurgery group and 65 in the surgery group. In the nonsurgery group, 2 patients were excluded solely on the basis of the radiological extent of PC and 7 patients on clinical examination. The Corep score ranged from 0 to 18. A score of 6 or more showed a validated sensitivity of 80%, specificity 100%, PPV 1.0, and NPV 0.93.

CONCLUSIONS

Radiological extent of PC was not a main deciding factor for treatment decisions and had less impact than the clinical examination. The Corep score identified patients with short cancer-specific survival that may not be suitable for treatment.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for persistent and recurrent advanced ovarian carcinoma: a multicenter, prospective study of 246 patients

BACKGROUND

Epithelial ovarian carcinoma is the main cause of death from gynaecological cancers in the western world. The initial response rate to the frontline therapy is high. However, the prognosis of persistent and recurrent disease remains poor. During the two past decades, a new therapeutic approach to peritoneal carcinomatosis has been developed, combining maximal cytoreductive effort with hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A retrospective, multicentric study of 246 patients with recurrent or persistent ovarian cancer, treated by cytoreductive surgery and HIPEC in two French centers between 1991 and 2008, was performed.

RESULTS

An optimal cytoreductive surgery was possible in 92.2 % of patients. Mortality and morbidity rates were 0.37 % and 11.6 %, respectively. The overall median survival was 48.9 months. There was no significant difference in overall survival in patients with persistent or recurrent disease. In multivariate analysis, performance status was a significant prognostic factor in patients with extensive peritoneal carcinomatosis (peritoneal cancer index >10).

CONCLUSIONS

Salvage therapy combining optimal cytoreductive surgery and HIPEC is feasible and may achieve long-term survival in highly selected patients with recurrent ovarian carcinoma, including those with platinum resistant disease, with acceptable morbidity.

The role of laparoscopy in peritoneal surface malignancies selected for hyperthermic intraperitoneal chemotherapy (HIPEC)

BACKGROUND

Cytoreductive surgery (CS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) was developed as locoregional treatment for primary or secondary peritoneal tumors. The role of laparoscopy over several stages of diagnosis and the treatment of the patients affected by peritoneal carcinomatosis and selected for CS + HIPEC shows some peculiarities, and their potential application in this field is not fully known. Our aim was to review and summarize the applications, the results, and the future directions of laparoscopy in the management of the patients affected by carcinomatosis and scheduled for CS + HIPEC.

METHODS

Appropriate keywords were adopted to identify the relevant studies on this topic in PubMed/Medline electronic databases.

RESULTS

The role of laparoscopy in diagnosis and staging of patients selected for CS + HIPEC seems to have a great but probably underestimated potential. Laparoscopic CS + HIPEC is technically feasible with an acceptable morbidity profile, especially in patients with low tumor load. In selected patients with malignant ascites, laparoscopic HIPEC achieves a good palliative effect, with a low morbidity profile.

CONCLUSIONS

Laparoscopy plays a partially explored role in diagnosis and staging of patients selected for CS + HIPEC. The use of laparoscopic HIPEC with an adjuvant, curative, or palliative intent seems feasible, but further studies are required in order to explore and validate all potential indications. For all these reasons, it would be advisable to provide every HIPEC center with specific laparoscopic skills.

Variation in the peritoneal cancer index scores between surgeons and according to when they are determined (before or after cytoreductive surgery)

INTRODUCTION

The prognosis of peritoneal carcinomatosis (PC) is highly dependent on the extent of the PC. This extent is calculated by the peritoneal cancer index (PCI). In the future, the indications for complete cytoreductive surgery (CRS) + hyperthermic intraperitoneal chemotherapy (HIPEC) should be partially based on the PCI. This raises the question of the concordance between the PCI scores calculated by different surgeons, and a possible variation before and after CRS.

OBJECTIVE

To analyze variations in the PCI score between surgeons and according to when it is determined (before and after surgery).

PATIENTS AND METHODS

Prospective recording of the PCI score independently calculated by senior and junior surgeons, before CRS (when the surgeon decided to perform this procedure), and after CRS, in 75 consecutive patients. A concordance analysis was conducted.

RESULTS

The origins of the PC were colorectal (n = 38), pseudomyxoma (n = 22), mesothelioma (n = 8) and miscellaneous lesions (n = 7). Concordance between the PCI score was very high (close to 90%) among the senior surgeons and junior surgeons before and after CRS. After CRS, the mean PCI score increased by 1.75 (IC-95%: 2.09-1.41). This high concordance was similar whatever the level of the PCI score and whatever the origin of the tumor.

CONCLUSION

The PCI is a reliable tool for measuring the extent of PC. It is easy to use and inter-surgeon concordance is high. It increases by approximately 2 before and after CRS.

The strengths and limitations of routine staging before treatment with abdominal CT in colorectal cancer

Background

Advanced colorectal cancer (CRC), either locally advanced, metastasized (mCRC) or both, is present in a relevant proportion of patients. The chances on curation of advanced CRC are continuously improving with modern multi-modality treatment options. For incurable CRC the focus lies on palliation of symptoms, which is not necessarily a resection of the primary tumor. Both situations motivate adequate staging before treatment in CRC. This prospective observational study evaluates the outcomes after the introduction of routine staging with abdominal CT before treatment.

Methods

In a prospective observational study of 612 consecutive patients (2007-2009), the ability of abdominal CT to find liver metastases (LM), peritoneal carcinomatosis (PC) and T4 stage in colon cancer (CC) was analysed.

Results

Advanced CRC was present in 58% of patients, mCRC in 31%. The ability to find LM was excellent (99%), cT4 stage CC good (86%) and PC poor (33%). In the group of surgical patients with emergency presentations, the incidences of both mCRC (51%) and locally advanced colon cancer (LACC) (69%) were higher than in the elective group (20% and 26% respectively). Staging tended to be omitted more often in the emergency group (35% versus 12% in elective surgery).

Conclusions

The strengths of staging with abdominal CT are to find LM and LACC, however it fails in diagnosing PC. On grounds of the incidence of advanced CRC, staging is warranted in patients with emergency presentations as well.

Cyto-reductive Surgery combined with Hyperthermic Intra-peritoneal Chemotherapy for Peritoneal Surface Malignancies: current treatment and results

Cyto-reductive Surgery (CS) combined with Hyperthermic Intra-peritoneal Chemotherapy (HIPEC) as loco-regional treatment of Peritoneal Surface Malignancies (PSM) has increasingly gained acceptance in clinical practice. This review summarizes the more relevant studies on this topic. Indications, pre-operative work-up, technical aspects, outcome and future directions of this combined approach in the treatment of Peritoneal Surface Malignancies are discussed here and proposed in an informative and didactic manner.

Use of FDG-PET/CT for peritoneal carcinomatosis before hyperthermic intraperitoneal chemotherapy

BACKGROUND

Peritoneal carcinomatosis (PC) is associated with a very poor prognosis. Complete cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy has been shown to improve survival rates of PC. However, this treatment is beneficial for patients if the complete cytoreductive surgery is macroscopically completed before implementing hyperthermic intraperitoneal chemotherapy. Even so, a strict selection of patients is of fundamental importance because of the invasive nature of the intervention. The aim of this study was to assess the performance of FDG-PET/CT examinations for the diagnosis and evaluation of the extent of PC.

METHODS

A retrospective analysis was conducted on 28 consecutive patients with suspected PC, scheduled for a complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, and who underwent an FDG-PET/CT examination. We compared the results of PET examinations with histological and intraoperative findings. The extent of PC was assessed precisely using a simplified 'peritoneal cancer index', within the three modalities (PET, surgery and histology).

RESULTS

Of 28 patients, 23 had histological PC. The sensitivity and specificity of the PET examination for the diagnosis of PC were, respectively, 82 and 100%. Even if the extent of PC was underestimated by PET, there was a good correlation when compared with histology and intraoperative results.

CONCLUSION

PET presented a good performance level in the diagnosis and evaluation of the extent of PC. PET/CT examinations could be useful to avoid unnecessary surgery.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignant disease

Peritoneal Malignant Disease (PMD) is the presence of tumoral tissue on the peritoneal surface from primary tumors or tumors from other locations (e.g. digestive or gynecologic). It is a regional disease with poor prognosis when treated with repeated "debulking" and traditional systemic chemotherapy. Cytoreduction plus hyperthermic intraperitoneal chemotherapy (HIPEC) is a combined multimodal regional procedure aimed at reducing the macroscopic tumoral mass as much as possible and treating with chemotherapy the microscopic disease that is out of the scope of the surgeon. This combined treatment may change the natural history of PMD, it is translated into a higher overall survival and cancer-free survival and it offers the option of cure in selected cases. The high-complexity procedure is also associated with complications and mortality, but in similar rates as other major oncologic procedures.

Accuracy and clinical relevance of computed tomography scan interpretation of peritoneal cancer index in colorectal cancer peritoneal carcinomatosis: a multi-institutional study

BACKGROUND

Evaluation of peritoneal metastases by computed tomography (CT) scans is challenging and has been reported to be inaccurate.

METHODS

A multi-institutional prospective observational registry study of patients with peritoneal carcinomatosis from colorectal cancer was conducted and a subset analysis was performed to examine peritoneal cancer index (PCI) based on CT and intraoperative exploration.

RESULTS

Fifty-two patients (mean age 52.6 ± 12.4 years) from 16 institutions were included in this study. Inaccuracies of CT-based assessment of lesion sizes were observed in the RUQ (P = 0.004), LLQ (P < 0.0005), RLQ (P = 0.003), distal jejunum (P = 0.004), and distal ileum (P < 0.0005). When CT-PCI was classified based on the extent of carcinomatosis, 17 cases (33%) were underestimations, of which, 11 cases (21%) were upstaged from low to moderate, 4 cases (8%) were upstaged from low to severe, and 2 cases (4%) were upstaged from moderate to severe. Relevant clinical discordance where an upstage occurred to severe carcinomatosis constituted a true inaccuracy and was observed in six cases (12%).

CONCLUSIONS

The actual clinical impact of inaccuracies of CT-PCI was modest. CT-PCI will remain as a mandatory imaging tool and may be supplemented with other tools including positron emission tomography scan or diagnostic laparoscopy, in the patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.