1
|
Torun BC, Sobutay E, Akbulut OE, Saglam S, Yilmaz S, Yonemura Y, Canbay E. Important Predictive Factors for the Prognosis of Patients With Peritoneal Metastasis of Gastric Cancer. Ann Surg Oncol 2024; 31:5975-5983. [PMID: 38806761 DOI: 10.1245/s10434-024-15499-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/07/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND This study investigated predictive factors for patients with peritoneal metastases of gastric cancer (PMGC) who underwent conversion cytoreductive surgery (C-CRS) and hyperthermic intraperitoneal intraoperative chemotherapy (HIPEC) after responding to induction chemotherapy (laparoscopic HIPEC [LHIPEC]) followed by concomitant systemic and intraperitoneal chemotherapy (bidirectional intraperitoneal and systemic chemotherapy [BIC]). METHODS Diagnostic laparoscopy was performed for 62 patients with PMGC between January 2017 and December 2022. The patients underwent LHIPEC and BIC induction chemotherapy using intraperitoneal docetaxel (30 mg/m2) and cisplatin (30 mg/m2), and intravenous chemotherapy for three cycles. The predictive parameters for progression-free and overall survival were analyzed using Kaplan-Meier and Cox regression analyses. The optimal cutoff values for Ki-67 parameters were assessed using receiver operating characteristic curve analysis. RESULTS The study retrospectively examined 36 (58 %) of 62 patients who responded to induction therapy and underwent C-CRS or HIPEC. A Ki-67 index lower than 10 (p = 0.000), lymph node involvement (LNI) less than 2 (p = 0.039), and an omental lesion size score lower than 0.5 cm (p = 0.002) were predictive of recurrence-free and overall survival in addition to completeness of cytoreduction and the peritoneal cancer index. Cox regression analysis showed that the independent factors associated with recurrence-free survival were decreased Ki-67 expression (≥10 % vs <10 %) (hazard ratio [HR] 4.7; 95 % confidence interval [CI] 1.6-5.210; p = 0.020) and LNI higher than 2 (HR 1.92; 95% CIS 0.923-4.0; p = 0.023). CONCLUSIONS Lymph node involvement and decreased Ki-67 expression are independent predictive factors of recurrence-free survival for patients with PMGC after induction chemotherapy.
Collapse
Affiliation(s)
- Bahar Canbay Torun
- Department of General Surgery, University of Ministry of Health, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Erman Sobutay
- Department of General Surgery, Koç Foundation American Hospital, Istanbul, Turkey
| | - Ozge Eren Akbulut
- Department of Anesthesiology, Koç Foundation American Hospital, ICU, Istanbul, Turkey
| | - Sezer Saglam
- Department of Medical Oncology, Demiroglu Bilim University, Istanbul, Turkey
| | - Serpil Yilmaz
- Department of Pathology, Koç Foundation American Hospital, Istanbul, Turkey
| | - Yutaka Yonemura
- Department of Regional Cancer Therapy, Peritoneal Surface Malignancy Center, Kishiwada, Tokushukai Hospital, Kishiwada-Osaka, Japan
| | - Emel Canbay
- NPO for Peritoneal Surface Malignancies Program of Turkey, Husrev Gerede Caddesi, Istanbul, Turkey.
| |
Collapse
|
2
|
Kitai T, Yamanaka K. Conversion surgery for gastric cancer with PM. J Surg Oncol 2024. [PMID: 39155703 DOI: 10.1002/jso.27794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 07/18/2024] [Indexed: 08/20/2024]
Abstract
It remains unclear whether the application of surgery to gastric cancer with peritoneal carcinomatosis prolongs survival. Twenty studies on conversion surgery were reviewed. Key points were the response to chemotherapy, complete resection, and a low tumor burden at the time of surgery. A bidirectional approach has been developed to increase the response rate. There are two different strategies in surgery. The outcomes of ongoing trials may clarify controversial issues.
Collapse
Affiliation(s)
- Toshiyuki Kitai
- Department of Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Japan
| | - Kenya Yamanaka
- Department of Surgery, Shiga General Hospital, Moriyama, Japan
| |
Collapse
|
3
|
Ward EP, Greenbaum A. Exploring the Patient Experience Through Qualitative Methods: The Missing Piece of Cytoreductive Surgery and HIPEC Research. Ann Surg Oncol 2024:10.1245/s10434-024-15997-0. [PMID: 39103683 DOI: 10.1245/s10434-024-15997-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 07/23/2024] [Indexed: 08/07/2024]
Affiliation(s)
- Erin P Ward
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Alissa Greenbaum
- Department of Surgery, Division of Surgical Oncology, University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA.
| |
Collapse
|
4
|
Abbas M, Ramspott JP, Chourio Barboza DE, Pascher A, Wardelmann E, Sporn JC. Modified scoring system for the quantitative assessment of histological regression in peritoneal carcinomatosis after pressurized intraperitoneal aerosol chemotherapy: A pilot study. Oncol Lett 2024; 28:308. [PMID: 38784603 PMCID: PMC11112145 DOI: 10.3892/ol.2024.14441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024] Open
Abstract
Peritoneal carcinomatosis is one of the leading causes of death in patients with gastrointestinal cancer. Newer locoregional treatment concepts include pressurized intraperitoneal aerosol chemotherapy (PIPAC), the regional application of pressurized chemotherapeutic agents to the abdominal cavity, which is usually performed every 4 to 8 weeks. One of the main challenges of PIPAC therapy remains the objective assessment of treatment response. The present study describes a new scoring system to histologically assess the regression of peritoneal cancer following PIPAC therapy, quantitative assessment of histological regression in peritoneal carcinomatosis (QARP). Peritoneal biopsies from 27 patients with peritoneal metastases undergoing PIPAC were obtained and processed in a standardized fashion. Biopsies were scored according to the QARP grading system. The five-tiered system was graded as follows, Grade 0, no residual tumor cells with regressive changes present; grade 1, 1-25% viable tumor cells per tumor focus with regressive changes present; grade 2, 26-50% viable tumor cells per tumor focus with regressive changes present; grade 3, 51-75% viable tumor cells per tumor focus with few regressive changes; grade 4, >75% viable tumor cells per tumor focus with minimal or no regressive changes. Based on the new grading system, the study cohort was divided into QARP responders and QARP non-responders following PIPAC treatment. Higher QARP scores were significantly correlated with higher PCI scores (r=0.32; P=0.007). However, no difference in overall survival was detected between QARP responders and QARP non-responders. Further studies are required to ascertain the reproducibility and prognostic significance of QARP.
Collapse
Affiliation(s)
- Mahmoud Abbas
- Department of Pathology, University Hospital Muenster, D-48149 Muenster, Germany
| | - Jan Philipp Ramspott
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, D-48149 Muenster, Germany
| | | | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, D-48149 Muenster, Germany
| | - Eva Wardelmann
- Department of Pathology, University Hospital Muenster, D-48149 Muenster, Germany
| | - Judith C. Sporn
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, D-48149 Muenster, Germany
| |
Collapse
|
5
|
Ramalho-Vasconcelos F, Gomes R, Bouça-Machado R, Aral M, Nogueiro J, Bouça-Machado T, Sousa-Pinto B, Santos-Sousa H. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in the Treatment of Gastric Cancer: Feasibility, Efficacy and Safety-A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:3320. [PMID: 38893031 PMCID: PMC11173180 DOI: 10.3390/jcm13113320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/31/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is an emerging technique for delivering chemotherapy directly to the peritoneum via a pressurized aerosol. Its growing attention stems from its effectiveness in treating peritoneal carcinomatosis (PC) originating from various primary tumors, with gastric cancer (GC) being among the most prevalent. This study aimed to systematically investigate PIPAC's therapeutic role in gastric cancer peritoneal metastasis (GCPM). Methods: The systematic review and meta-analysis followed the PRISMA 2020 guidelines, searching Pubmed, Web of Science, and SCOPUS databases. The meta-analysis of relative risks and mean differences compared patients undergoing one or two PIPAC sessions with those completing three or more, assessing various outcomes. Results: Eighteen studies underwent qualitative analysis, and four underwent quantitative analysis. Patients with three or more PIPAC procedures had shorter hospital stays (MD = -1.2; 95%CI (-1.9; -0.5); p < 0.001), higher rates of histopathological response (RR = 1.77, 95%CI 1.08; 2.90; p = 0.023), and significantly improved overall survival (MD = 6.0; 95%CI 4.2; 7.8; p < 0.001). Other outcomes showed no significant differences. Conclusions: PIPAC demonstrated efficacy in carefully selected patients, enhancing histopathologic response rates and overall survival without prolonging hospital stays. This study underscores the necessity for randomized controlled trials and precise selection criteria to refine PIPAC's implementation in clinical practice.
Collapse
Affiliation(s)
| | - Raquel Gomes
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - Raquel Bouça-Machado
- Instituto de Medicina Molecular João Lobo Antunes—Edifício Egas Moniz, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Marisa Aral
- São João Local Health Unit, Surgery Department, 4200-319 Porto, Portugal
| | - Jorge Nogueiro
- São João Local Health Unit, Surgery Department, 4200-319 Porto, Portugal
| | | | - Bernardo Sousa-Pinto
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- CINTESIS—Centre for Health Technologies and Services Research, University of Porto, 4200-319 Porto, Portugal
| | - Hugo Santos-Sousa
- São João Local Health Unit, Obesity Integrated Responsibility Unit (CRI-O), 4200-319 Porto, Portugal
| |
Collapse
|
6
|
Li AY, Sedighim S, Tajik F, Khan AM, Radhakrishnan VK, Dayyani F, Senthil M. Regional Therapy Approaches for Gastric Cancer with Limited Peritoneal Disease. J Gastrointest Cancer 2024; 55:534-548. [PMID: 38277055 PMCID: PMC11186907 DOI: 10.1007/s12029-023-00994-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2023] [Indexed: 01/27/2024]
Abstract
PURPOSE Despite advances in systemic therapy, outcomes of patients with gastric cancer (GC) peritoneal carcinomatosis (PC) remain poor, in part because of poor penetrance of systemic therapy into peritoneal metastasis due to the plasma-peritoneal barrier and anarchic intra-tumoral circulation. Hence, regional treatment approach with administration of chemotherapy directly into the peritoneal cavity (intraperitoneal, IP) under various conditions, combined with or without cytoreductive surgery (CRS) has remained an area of significant research interest. The purpose of this review is to provide high-level evidence for regional treatment approaches in the management of GCPC with limited peritoneal disease. METHODS A review of the current literature and ongoing clinical trials for regional IP therapies for GCPC was performed. Studies included in this review comprise of phase III randomized controlled trials, non-randomized phase II studies, high-impact retrospective studies, and active ongoing clinical trials for each available IP modality. RESULTS The three common IP approaches are heated intraperitoneal chemotherapy (HIPEC), normothermic intraperitoneal chemotherapy (NIPEC) and more recently introduced, pressurized intraperitoneal aerosolized chemotherapy (PIPAC). These IP approaches have been combined with systemic therapy and/or CRS with varying degrees of promising results, demonstrating evidence of improvements in survival rates and peritoneal disease control. Patient selection, optimization of systemic therapy, and completeness of cytoreduction have emerged as major factors influencing the design of contemporary and ongoing trials. CONCLUSION IP chemotherapy has a clear role in the management of patients with GCPC, and when combined with CRS in appropriately selected patients has the potential to significantly improve survival. Ongoing and upcoming IP therapy clinical trials hold great promise to shape the treatment paradigm for GCPC.
Collapse
Affiliation(s)
- Amy Y Li
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA
| | - Shaina Sedighim
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA
| | - Fatemeh Tajik
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA
| | - Aaqil M Khan
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA
| | - Vinodh K Radhakrishnan
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA
| | - Farshid Dayyani
- Department of Medicine, University of California, Irvine, Orange, USA
| | - Maheswari Senthil
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA.
| |
Collapse
|
7
|
Reese M, Eichelmann AK, Nowacki TM, Pascher A, Sporn JC. The role of cytoreductive surgery and HIPEC for the treatment of primary and secondary peritoneal malignancies-experience from a tertiary care center in Germany. Langenbecks Arch Surg 2024; 409:113. [PMID: 38589714 DOI: 10.1007/s00423-024-03309-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE Peritoneal surface malignancies (PSM) are commonly known to have a dismal prognosis. Over the past decades, novel techniques such as cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC), and pressurized intraperitoneal aerosol chemotherapy (PIPAC) have been introduced for the treatment of PSM which could improve the overall survival and quality of life of patients with PSM. The decision to proceed with CRS and HIPEC is often challenging due the complexity of the disease, the extent of the procedure, associated side effects, and potential risks. Here, we present our experience with CRS and HIPEC to add to the ongoing discussion about eligibility criteria, technical approach, and expected outcomes and contribute to the evolution of this powerful and promising tool in the multidisciplinary treatment of patients with primary and secondary PSM. METHODS A single-center retrospective chart review was conducted and included a total of 40 patients treated with CRS and HIPEC from April 2020 to September 2022 at the University Hospital Münster Department of Surgery. All patients had histologically confirmed primary or secondary peritoneal malignancies of various primary origins. RESULTS Our study included 22 patients with peritoneal metastases from gastric cancer (55%), 8 with pseudomyxoma peritonei (20%), 4 with mesothelioma of the peritoneum (10%), and 6 patients with PSM originating from other primary tumor locations. Median PCI at time of cytoreduction was 4 (0-25). Completeness of cytoreduction score was 0 in 37 patients (92.5%), 1 in two patients (5%), and 2 in one patient (2.5%). Median overall survival across all patients was 3.69 years. CONCLUSION Complete cytoreduction during CRS and HIPEC can be achieved for patients with low PCI, for patients with high PCI in low-grade malignancies, and even for patients with initially high PCI in high-grade malignancies following a significant reduction of cancer burden due to extensive preoperative treatment with PIPAC and systemic chemotherapy.
Collapse
Affiliation(s)
- Mikko Reese
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Waldeyerstraße 1, 48149, Münster, Germany
| | - Ann-Kathrin Eichelmann
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Waldeyerstraße 1, 48149, Münster, Germany
| | - Tobias M Nowacki
- Department of Medicine B for Gastroenterology, Hepatology, Endocrinology and Clinical Infectiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany
- Department of Gastroenterology, UKM Marienhospital Steinfurt, Mauritiusstr. 5, Steinfurt, 48565, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Waldeyerstraße 1, 48149, Münster, Germany
| | - Judith C Sporn
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Waldeyerstraße 1, 48149, Münster, Germany.
| |
Collapse
|
8
|
Chiu CC. Letter to the Editor of Annals of Surgical Oncology Concerning "Safety and Efficacy of Oxaliplatin Pressurized Intraperitoneal Aerosolized Chemotherapy (PIPAC) in Colorectal and Appendiceal Cancer with Peritoneal Metastases: Results of a Multicenter Phase I Trial in the USA". Ann Surg Oncol 2024; 31:2405-2407. [PMID: 37971615 DOI: 10.1245/s10434-023-14595-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/29/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Chong-Chi Chiu
- Department of General Surgery, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan.
- Department of Medical Education and Research, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan.
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
| |
Collapse
|
9
|
van Hootegem SJM, Chmelo J, van der Sluis PC, Lagarde SM, Phillips AW, Wijnhoven BPL. The yield of diagnostic laparoscopy with peritoneal lavage in gastric adenocarcinoma: A retrospective cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108233. [PMID: 38428107 DOI: 10.1016/j.ejso.2024.108233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/24/2024] [Accepted: 02/25/2024] [Indexed: 03/03/2024]
Abstract
INTRODUCTION Diagnostic laparoscopy (DL) with peritoneal lavage has been adopted as a standard staging procedure for patients with gastric cancer (GC). Evaluation of the value of DL is important given ongoing improvements in diagnostic imaging and treatment. As contemporary data from European centres are sparse, this retrospective cohort study aimed to assess the yield of DL in patients with potentially curable gastric cancer, and to identify predictive factors for peritoneal metastases. METHODS Patients with adenocarcinoma of the stomach, treated between January 2016 and December 2018, were identified from institutional databases of two high volume European Upper-GI centres. Patients who underwent a DL with peritoneal lavage for potentially curable disease after clinical staging with imaging (cT1-4N0-3M0) were included. The primary outcome was the proportion of patients with a positive DL, defined as macroscopic metastatic disease, positive peritoneal cytology washings (PC+) or locally irresectable disease. RESULTS Some 80 of 327 included patients (24.5%) had a positive DL, excluding these patients from neoadjuvant treatment (66 of 327; 20.2%) and/or surgical resection (76 of 327; 23.2%). In 34 of 327 patients (10.3%), macroscopic metastatic disease was seen, with peritoneal deposits in 30 of these patients. Only 16 of 30 patients with peritoneal disease had positive cytology. Some 41 of 327 patients (12.5%) that underwent DL had PC+ in the absence of macroscopic metastases and five patients (1.5%) had an irresectable primary tumour. Diffuse type carcinoma had the highest risk of peritoneal dissemination, irrespective of cT and cN categories. CONCLUSION The diagnostic yield of staging laparoscopy is high, changing the management in approximately one quarter of patients. DL should be considered in patients with diffuse type carcinoma irrespective of cT and cN categories.
Collapse
Affiliation(s)
- S J M van Hootegem
- Department of Surgery, Erasmus MC University, Rotterdam, the Netherlands.
| | - J Chmelo
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle-Upon-Tyne, UK
| | - P C van der Sluis
- Department of Surgery, Erasmus MC University, Rotterdam, the Netherlands
| | - S M Lagarde
- Department of Surgery, Erasmus MC University, Rotterdam, the Netherlands
| | - A W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle-Upon-Tyne, UK; School of Medical Education, Newcastle University, UK
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC University, Rotterdam, the Netherlands
| |
Collapse
|
10
|
Rijken A, Pape M, Simkens GA, de Hingh IHJT, Luyer MDP, van Sandick JW, van Laarhoven HWM, Verhoeven RHA, van Erning FN. Peritoneal metastases from gastric cancer in a nationwide cohort: Incidence, treatment and survival. Int J Cancer 2024; 154:992-1002. [PMID: 37916797 DOI: 10.1002/ijc.34780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 09/28/2023] [Accepted: 10/06/2023] [Indexed: 11/03/2023]
Abstract
The aims of this study were to investigate incidence, risk factors and treatment of synchronous or metachronous peritoneal metastases (PM) from gastric cancer and to estimate survival of these patients using population-based data. Patients diagnosed with gastric cancer in 2015 to 2016 were selected from the Netherlands Cancer Registry. The incidence of synchronous and metachronous PM were calculated. Multivariable regression analyses were performed to identify factors associated with the occurrence of PM. Treatment and survival were compared between patients with synchronous and metachronous PM. Of 2206 patients with gastric cancer, 741 (34%) were diagnosed with PM. Of these, 498 (23%) had synchronous PM. The cumulative incidence of metachronous PM in patients who underwent potentially curative treatment (n = 675) was 22.8% at 3 years. A factor associated with synchronous and metachronous PM was diffuse type histology. Patients diagnosed with synchronous PM more often received systemic treatment than patients with metachronous PM (35% vs 18%, respectively, P < .001). Median overall survival was comparable between synchronous and metachronous PM (3.2 vs 2.3 months, respectively, P = .731). Approximately one third of all patients with gastric cancer are diagnosed with PM, either at primary diagnosis or during 3-year follow-up after potentially curative treatment. Patients with metachronous PM less often received systemic treatment than those with synchronous PM but survival was comparable between both groups. Future trials are warranted to detect gastric cancer at an earlier stage and to examine strategies that lower the risk of peritoneal dissemination. Also, specific treatment options for patients with gastric PM should be further investigated.
Collapse
Affiliation(s)
- Anouk Rijken
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - Marieke Pape
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
- Amsterdam UMC location University of Amsterdam, Medical Oncology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Geert A Simkens
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
- GROW-School for Oncology and Development Biology, Maastricht University, Maastricht, the Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Johanna W van Sandick
- Department of Surgery, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Amsterdam UMC location University of Amsterdam, Medical Oncology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Rob H A Verhoeven
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
- Amsterdam UMC location University of Amsterdam, Medical Oncology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Felice N van Erning
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| |
Collapse
|
11
|
Yang Z, Lu S, Shi M, Yuan H, Wang Z, Ni Z, He C, Zheng Y, Zhu Z, Liu W, Yao X, Zhang J, Li C, Yan M, Yan C, Zhu Z. Oncological outcomes of conversion therapy in gastric cancer patients with peritoneal metastasis: a large-scale retrospective cohort study. Gastric Cancer 2024; 27:387-399. [PMID: 38143257 PMCID: PMC10896904 DOI: 10.1007/s10120-023-01452-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/19/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Data on the long-term oncological outcomes of patients who undergo conversion surgery (CS) in gastric cancer (GC) patients with peritoneal metastasis (PM) are limited. METHODS GC patients with PM who received intraperitoneal (ip) and systemic chemotherapy between April 2015 and January 2021 were enrolled. Multivariate analysis was performed to identify risk factors associated with survival. Clinicopathological and survival outcomes were compared between those with CS and those without CS (NCS). The paclitaxel (PTX) plus tegafur-gimeracil-oteracil potassium capsules (S-1) (PS) + ip PTX and oxaliplatin plus S-1 (SOX) + ip PTX groups were matched in a 1:1 ratio using propensity score matching. Oncological and survival data were collected and analyzed. RESULTS A total of 540 patients who received ip chemotherapy via subcutaneous port and systemic chemotherapy were analyzed and 268 patients were enrolled, including 113 who underwent CS and 155 who did not. Overall survival (OS) were 27.0 months and 11.8 months in the CS and NCS groups (P < 0.0001), respectively. R0 resection was an independent prognostic factor for patients who underwent CS. The OS of patients with or without ovariectomy was 21.3 or 12.0 months (P < 0.0001). No difference of clinicopathological and survival outcomes was found between the PS + ip PTX and SOX + ip PTX groups. CONCLUSION Conversion therapy is safe and adverse events were manageable. CS improves the survival of GC patients with PM after ip and systemic chemotherapy. R0 is an important prognostic factor. Furthermore, outcomes are comparable between the PS + ip PTX and SOX + ip PTX groups.
Collapse
Affiliation(s)
- Zhongyin Yang
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Sheng Lu
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Min Shi
- Department of Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Yuan
- Department of Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenqiang Wang
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Zhentian Ni
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Changyu He
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Yanan Zheng
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Zhenglun Zhu
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Wentao Liu
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Xuexin Yao
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Jun Zhang
- Department of Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chen Li
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Min Yan
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| | - Chao Yan
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China.
| | - Zhenggang Zhu
- Shanghai Key Laboratory of Gastric Neoplasms, Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin er Road, Shanghai, China
| |
Collapse
|
12
|
Kryh-Jensen CG, Fristrup CW, Ainsworth AP, Detlefsen S, Mortensen MB, Pfeiffer P, Tarpgaard LS, Graversen M. What is long-term survival in patients with peritoneal metastasis from gastric, pancreatic, or colorectal cancer? A study of patients treated with systemic chemotherapy and pressurized intraperitoneal aerosol chemotherapy (PIPAC). Pleura Peritoneum 2023; 8:147-155. [PMID: 38144215 PMCID: PMC10739291 DOI: 10.1515/pp-2023-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/27/2023] [Indexed: 12/26/2023] Open
Abstract
Objectives A definition of long-term survival (LTS) in patients with peritoneal metastasis (PM) from gastric cancer (GC), pancreatic cancer (PC) or colorectal cancer (CRC) treated with systemic chemotherapy and pressurized intraperitoneal aerosol chemotherapy (PIPAC) is lacking. We aimed to define LTS and investigate characteristics and treatment response in patients who reached LTS in data from two prospective trials. Methods Retrospective study of patients with GC-, PC-, or CRC-PM from the prospective PIPAC-OPC1 and PIPAC-OPC2 studies. The definition of LTS was based on published systematic reviews and randomized controlled trials. LTS was defined at the time point where 25 % of the patients were alive in these studies. Histology based response was evaluated by the mean Peritoneal Regression Grading Score (PRGS) using biopsies obtained prior to PIPAC 3, and defined by a mean PRGS of ≤2.0 or a decrease of mean PRGS of ≥1, compared to baseline. Results LTS was defined at 21 (GC), 15 (PC), and 24 (CRC) months. Fifty-one (47.2 %) patients (nine GC, 17 PC, 25 CRC) reached LTS calculated from the date of PM diagnosis. All but one received palliative chemotherapy before PIPAC, and 37 % received bidirectional treatment. More than 90 % of the LTS patients had response according to PRGS. The mOS from PIPAC 1 was 23.3, 12.4, and 28.5 months for GC, PC, and CRC LTS patients. Conclusions Patients with PM from GC, PC, and CRC treated with systemic chemotherapy and PIPAC can reach LTS and most show histological response. Causality must be further investigated.
Collapse
Affiliation(s)
- Charlotte G. Kryh-Jensen
- Odense PIPAC Center (OPC), Odense University Hospital, Odense, Denmark
- Upper GI & HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Claus W. Fristrup
- Odense PIPAC Center (OPC), Odense University Hospital, Odense, Denmark
- Upper GI & HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Alan P. Ainsworth
- Odense PIPAC Center (OPC), Odense University Hospital, Odense, Denmark
- Upper GI & HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Odense PIPAC Center (OPC), Odense University Hospital, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Michael B. Mortensen
- Odense PIPAC Center (OPC), Odense University Hospital, Odense, Denmark
- Upper GI & HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Per Pfeiffer
- Odense PIPAC Center (OPC), Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Line S. Tarpgaard
- Odense PIPAC Center (OPC), Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Martin Graversen
- Odense PIPAC Center (OPC), Odense University Hospital, Odense, Denmark
- Upper GI & HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- OPEN – Odense Patient Data Explorative Network, Odense University Hospital, Region of Southern Denmark, Odense, Denmark
| |
Collapse
|
13
|
Ezanno AC, Malgras B, Conan PL, Aime A, Fawaz J, Picchi H, Doat S, Pocard M. Reasons for stopping Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC): A retrospective study to improve future patient selection. PLoS One 2023; 18:e0287785. [PMID: 38033087 PMCID: PMC10688840 DOI: 10.1371/journal.pone.0287785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/13/2023] [Indexed: 12/02/2023] Open
Abstract
To improve the prognosis and maintain quality of life in patients with peritoneal metastasis (PM), a novel treatment has been introduced-pressurized intraperitoneal aerosol chemotherapy (PIPAC). The majority of teams propose at least 3 PIPAC procedures. However, for many patients PIPAC is stopped after only one or two procedures. The aim of this study was to identify the reasons for stopping PIPAC after only one or two procedures and to establish a profile of poor candidates. This retrospective, multicenter cohort study included all patients who underwent PIPAC in three French expert centers between 2015 and 2021. A total of 268 PIPAC procedures were performed in 89 patients. Of them, 48.3% of patients underwent fewer than three procedures: 28.1% had one, 20.2% two and 51.7% three or more PIPAC procedures. The main reason for stopping PIPAC, regardless of the number of procedures, was disease progression, in 55.8% of cases. Other reasons for stopping PIPAC were non-access to the abdominal cavity (7.9%), conversion to cytoreductive surgery (13.5%), post-PIPAC adverse events (7.9%), patients' wishes (10.1%) and death (2.2%). In univariate analysis, patients who received fewer than three PIPACs less frequently had chemotherapy beforehand (91% vs 100%, p = 0.05), less frequently had bimodal treatment (70% vs 87%, p = 0.04), had more ascites (median 80 ml vs 50 ml, p = 0.05) and more frequently had carcinomatosic ascites (48.8% vs 23.9%, p < 0.01). Performing PIPAC alone in chemotherapy-naïve patients with ascites should be avoided.
Collapse
Affiliation(s)
- Anne-Cécile Ezanno
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France
| | - Brice Malgras
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France
- French Military Health Service Academy, Ecole du Val de Grâce, Paris, France
| | - Pierre-Louis Conan
- Department of Infectiology, Begin Military Teaching Hospital, Saint Mandé, France
| | - Adeline Aime
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France
| | - Jade Fawaz
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France
| | - Hugo Picchi
- Department of Oncology, Begin Military Teaching Hospital, Saint Mandé, France
| | - Solène Doat
- Department of Hepato Gastro Enterology, La Pitié Salpétrière Hospital, Paris, France
| | - Marc Pocard
- Department of Digestive Surgery, La Pitié Salpetrière Hospital, Paris, France
- INSERM, U965 CART Unit, Paris, France
| |
Collapse
|
14
|
Santullo F, Ferracci F, Abatini C, Halabieh MAE, Lodoli C, D'Annibale G, Di Cesare L, D'Agostino L, Pecere S, Di Giorgio A, Strippoli A, Pacelli F. Gastric cancer with peritoneal metastases: a single center outline and comparison of different surgical and intraperitoneal treatments. Langenbecks Arch Surg 2023; 408:437. [PMID: 37973620 DOI: 10.1007/s00423-023-03163-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Gastric cancer with peritoneal metastasis (GCPM) has an unfavourable prognosis. Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC) are promising treatment options that have been shown to improve survival. The aim of this study was to assess the impact of different treatments such as systemic chemotherapy, systemic chemotherapy + PIPAC, and CRS + HIPEC in patients with GCPM. MATERIAL AND METHODS This single-centre retrospective study included 82 patients with GCPM treated between January 2016 and June 2021. After first-line chemotherapy, depending on disease response and burden, the patients were divided into three treatment groups: chemotherapy alone, chemotherapy + PIPAC, and CRS + HIPEC. The primary outcome was overall survival (OS) from diagnosis, which was compared among the treatment groups. RESULTS Thirty-seven (45.1%) patients were administered systemic chemotherapy alone, 25 (30.4%) received chemotherapy + PIPAC, and 20 (24.4%) underwent CRS + HIPEC. The CRS + HIPEC group had better OS (median 24 months) than the PIPAC group (15 months, p = 0.01) and chemotherapy group (5 months, p = 0.0001). Following CRS + HIPEC, the postoperative grade 3-4 complication rate was 25%, and no postoperative in-hospital deaths occurred. The median disease-free survival (DFS) was 12 months. Multivariate analysis identified peritoneal carcinomatosis index (PCI) > 7 as an independent predictor of worse DFS. No independent predictors of OS were identified. CONCLUSION Among patients with GCPM, we identified a highly selected population with oligometastatic disease. In this group, CRS + HIPEC provided a significant survival advantage with an acceptable major complication rate compared with other available therapies (systemic chemotherapy alone or in combination with PIPAC).
Collapse
Affiliation(s)
- Francesco Santullo
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Federica Ferracci
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Carlo Abatini
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Miriam Attalla El Halabieh
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Claudio Lodoli
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | | | | | | | - Silvia Pecere
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Andrea Di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Antonia Strippoli
- Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Largo A. Gemelli 8, Rome, Italy
| | - Fabio Pacelli
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| |
Collapse
|
15
|
Daniel SK, Sun BJ, Lee B. PIPAC for Gastrointestinal Malignancies. J Clin Med 2023; 12:6799. [PMID: 37959264 PMCID: PMC10650315 DOI: 10.3390/jcm12216799] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
The peritoneum is a common site of metastases for gastrointestinal tumors that predicts a poor outcome. In addition to decreased survival, peritoneal metastases (PMs) can significantly impact quality of life from the resulting ascites and bowel obstructions. The peritoneum has been a target for regional therapies due to the unique properties of the blood-peritoneum barrier. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) have become accepted treatments for limited-volume peritoneal disease in appendiceal, ovarian, and colorectal malignancies, but there are limitations. Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) improves drug distribution and tissue penetration, allowing for a minimally invasive application for patients who are not CRS/HIPEC candidates based on high disease burden. PIPAC is an emerging treatment that may convert the patient to resectable disease, and may increase survival without major morbidity, as indicated by many small studies. In this review, we discuss the rationale and benefits of PIPAC, as well as sentinel papers describing its application for gastric, colorectal, appendiceal, and pancreatobiliary PMs. While no PIPAC device has yet met FDA approval, we discuss next steps needed to incorporate PIPAC into neoadjuvant/adjuvant treatment paradigms, as well as palliative settings. Data on active clinical trials using PIPAC are provided.
Collapse
Affiliation(s)
- Sara K. Daniel
- Department of Surgery, Stanford University, Stanford, CA 94305, USA
| | | | | |
Collapse
|
16
|
Casella F, Bencivenga M, Brancato G, Torroni L, Ridolfi C, Puccio C, Alloggio M, Meloni F, Fusario D, Marrelli D, Giacopuzzi S, Roviello F, de Manzoni G. Bidirectional Approach with PIPAC and Systemic Chemotherapy for Patients with Synchronous Gastric Cancer Peritoneal Metastases (GCPM). Ann Surg Oncol 2023; 30:5733-5742. [PMID: 37270440 PMCID: PMC10409663 DOI: 10.1245/s10434-023-13572-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/12/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND This study evaluated the efficacy of pressurized intraperitoneal aerosol chemotherapy (PIPAC) with systemic chemotherapy as a bidirectional approach for gastric cancer (GC) patients with synchronous peritoneal metastases (SPM). METHODS A retrospective analysis of a prospective PIPAC database was queried for patients who underwent a bidirectional approach between October 2019 and April 2022 at two high-volume GC surgery units in Italy (Verona and Siena). Surgical and oncological outcomes were analyzed. RESULTS Between October 2019 and April 2022, 74 PIPAC procedures in 42 consecutive patients with Eastern Cooperative Oncology Group performance status ≤2 were performed-32 patients treated in Verona and 10 in Siena. Twenty-seven patients (64%) were female and median age at first PIPAC was 60.5 years (I-III quartiles: 49-68 years). Median Peritoneal Cancer Index (PCI) was 16 (I-III quartiles: 8-26) and 25 patients (59%) had at least two PIPAC procedures. Major complications according to the Common Terminology Criteria for Adverse Events (CTCAE; 3 and 4) occurred in three (4%) procedures, and, according to the Clavien-Dindo classification (>3a), one (1%) severe complication occurred. There were no reoperations or deaths within 30 days. Median overall survival (mOS) from diagnosis was 19.6 months (range 14-24), and mOS from first PIPAC was 10.5 months (range 7-13). Excluding cases with very heavy metastatic peritoneal burden, with PCI from 2 to 26, treated with more than one PIPAC, mOS from diagnosis was 22 months (range 14-39). Eleven patients (26%) underwent curative-intent surgery after a bidirectional approach. R0 was achieved in nine (82%) patients and complete pathological response was obtained in three (27%) cases. CONCLUSIONS Patient selection is associated with bidirectional approach efficacy and feasibility for SPM GC treatment, which may allow potentially curative surgical radicalization in highly selected cases.
Collapse
Affiliation(s)
| | - Maria Bencivenga
- Upper G.I. Surgery Division, University of Verona, Verona, Italy.
| | - Giorgio Brancato
- Upper G.I. Surgery Division, University of Verona, Verona, Italy
| | - Lorena Torroni
- Department of Diagnostics and Public Health, Unit of Epidemiology and Medical Statistics, University of Verona, Verona, Italy
| | - Cecilia Ridolfi
- Upper G.I. Surgery Division, University of Verona, Verona, Italy
| | - Carmelo Puccio
- Upper G.I. Surgery Division, University of Verona, Verona, Italy
| | | | - Francesca Meloni
- Upper G.I. Surgery Division, University of Verona, Verona, Italy
| | - Daniele Fusario
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | | | - Franco Roviello
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | | |
Collapse
|
17
|
Ramos MFKP, Pereira MA, Charruf AZ, Victor CR, Gregorio JVAM, Alban LBV, Moniz CMV, Zilberstein B, Mello ESD, Hoff PMG, Ribeiro Junior U, Dias AR. INTRAPERITONEAL CHEMOTHERAPY FOR GASTRIC CANCER WITH PERITONEAL CARCINOMATOSIS: STUDY PROTOCOL OF A PHASE II TRIAL. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1744. [PMID: 37466566 PMCID: PMC10356002 DOI: 10.1590/0102-672020230026e1744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/26/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Peritoneal carcinomatosis in gastric cancer is considered a fatal disease, without expectation of definitive cure. As systemic chemotherapy is not sufficient to contain the disease, a multimodal approach associating intraperitoneal chemotherapy with surgery may represent an alternative for these cases. AIMS The aim of this study was to investigate the role of intraperitoneal chemotherapy in stage IV gastric cancer patients with peritoneal metastasis. METHODS This study is a single institutional single-arm prospective clinical trial phase II (NCT05541146). Patients with the following inclusion criteria undergo implantation of a peritoneal catheter for intraperitoneal chemotherapy: Stage IV gastric adenocarcinoma; age 18-75 years; Peritoneal carcinomatosis with peritoneal cancer index<12; Eastern Cooperative Oncology Group 0/1; good clinical status; and lab exams within normal limits. The study protocol consists of four cycles of intraperitoneal chemotherapy with paclitaxel associated with systemic chemotherapy. After treatment, patients with peritoneal response assessed by staging laparoscopy undergo conversion gastrectomy. RESULTS The primary outcome is the rate of complete peritoneal response. Progression-free and overall survivals are other outcomes evaluated. The study started in July 2022, and patients will be screened for inclusion until 30 are enrolled. CONCLUSIONS Therapies for advanced gastric cancer patients have been evaluated in clinical trials but without success in patients with peritoneal metastasis. The treatment proposed in this trial can be promising, with easy catheter implantation and ambulatory intraperitoneal chemotherapy regime. Verifying the efficacy and safety of paclitaxel with systemic chemotherapy is an important progress that this study intends to investigate.
Collapse
Affiliation(s)
| | - Marina Alessandra Pereira
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Amir Zeide Charruf
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Carolina Ribeiro Victor
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Radiology and Oncology - São Paulo (SP), Brazil
| | | | - Luciana Bastos Valente Alban
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Radiology and Oncology - São Paulo (SP), Brazil
| | - Camila Motta Venchiarutti Moniz
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Radiology and Oncology - São Paulo (SP), Brazil
| | - Bruno Zilberstein
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Evandro Sobroza de Mello
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Pathology - São Paulo (SP), Brazil
| | - Paulo Marcelo Gehm Hoff
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Radiology and Oncology - São Paulo (SP), Brazil
| | - Ulysses Ribeiro Junior
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Andre Roncon Dias
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Gastroenterology - São Paulo (SP), Brazil
| |
Collapse
|
18
|
Schena CA, Laterza V, De Sio D, Quero G, Fiorillo C, Gunawardena G, Strippoli A, Tondolo V, de'Angelis N, Alfieri S, Rosa F. The Role of Staging Laparoscopy for Gastric Cancer Patients: Current Evidence and Future Perspectives. Cancers (Basel) 2023; 15:3425. [PMID: 37444535 DOI: 10.3390/cancers15133425] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
A significant proportion of patients diagnosed with gastric cancer is discovered with peritoneal metastases at laparotomy. Despite the continuous improvement in the performance of radiological imaging, the preoperative recognition of such an advanced disease is still challenging during the diagnostic work-up, since the sensitivity of CT scans to peritoneal carcinomatosis is not always adequate. Staging laparoscopy offers the chance to significantly increase the rate of promptly diagnosed peritoneal metastases, thus reducing the number of unnecessary laparotomies and modifying the initial treatment strategy of gastric cancer. The aim of this review was to provide a comprehensive summary of the current literature regarding the role of staging laparoscopy in the management of gastric cancer. Indications, techniques, accuracy, advantages, and limitations of staging laparoscopy and peritoneal cytology were discussed. Furthermore, a focus on current evidence regarding the application of artificial intelligence and image-guided surgery in staging laparoscopy was included in order to provide a picture of the future perspectives of this technique and its integration with modern tools in the preoperative management of gastric cancer.
Collapse
Affiliation(s)
- Carlo Alberto Schena
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, 92110 Paris, France
| | - Vito Laterza
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Davide De Sio
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Digestive Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Gayani Gunawardena
- Department of Digestive Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Antonia Strippoli
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Vincenzo Tondolo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, 92110 Paris, France
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Digestive Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Fausto Rosa
- Department of Digestive Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Emergency and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| |
Collapse
|
19
|
Tidadini F, Abba J, Quesada JL, Trilling B, Bonne A, Foote A, Faucheron JL, Arvieux C. Oncological Outcomes After Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in the Treatment of Peritoneal Carcinomatosis. J Gastrointest Cancer 2023; 54:632-641. [PMID: 35778645 DOI: 10.1007/s12029-022-00843-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new surgical technique for the treatment of initially unresectable peritoneal carcinomatosis (PC). Our objective was to assess its oncological outcomes. METHODS Between July 2016 and September 2020, data from 100 PIPAC procedures with oxaliplatin or doxorubicin-cisplatin in 49 patients with PC (all etiologies) were analyzed. We studied the evolution of the peritoneal cancer index (PCI), the need for radical surgery (R0), and overall survival (OS). RESULTS The patients' median age was 65 (59; 71) years, and 55.1% were women. Median PIPAC procedures per patient were 2 (1-3), and 28 (57.1%) underwent more than one PIPAC procedure. Median PCI at the first PIPAC was 19 (15-22). PCI decreased for 37%, remained stable for 29.6%, and increased for 33.4% patients. Four (8.3%) underwent radical R0 surgery after PIPAC. After a median follow-up of 16.1 months (1.5-90.1), the median overall survival from PC diagnosis was 29.1 months (14.8-34.3), with a median gastric and colorectal PC survival of 11.3 (7.2-34.3) and 29.1 months (16.1-31) respectively. Overall survival after the first PIPAC session was 11.6 months (6-17.3), with median survival after gastric and colorectal PCs being 6 (2.9-15.5) and 13.3 months (5-17.6), respectively. Stratification of patients according to the number of lines of systemic chemotherapy, PIPAC procedures, and the chronology of PC onset did not result in a significant difference in survival. CONCLUSION The OS was in line with the literature. PIPAC could delay oncological progression and improve survival. These encouraging results justify the ongoing and future evaluations of PIPAC by prospective randomized trials.
Collapse
Affiliation(s)
- Fatah Tidadini
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, CS 10232, 38043, 38043, CEDEX 09, Grenoble, France
- Lyon Center for Innovation in Cancer, EA 3738, Lyon 1 University, Lyon, France
| | - Julio Abba
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, CS 10232, 38043, 38043, CEDEX 09, Grenoble, France
| | - Jean-Louis Quesada
- Clinical Pharmacology Unit, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France
| | - Bertrand Trilling
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, CS 10232, 38043, 38043, CEDEX 09, Grenoble, France
- UMR 5525, CNRS, TIMC-IMAG, University Grenoble Alps, Grenoble, France
| | - Aline Bonne
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, CS 10232, 38043, 38043, CEDEX 09, Grenoble, France
| | - Alison Foote
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, CS 10232, 38043, 38043, CEDEX 09, Grenoble, France
| | - Jean-Luc Faucheron
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, CS 10232, 38043, 38043, CEDEX 09, Grenoble, France
- UMR 5525, CNRS, TIMC-IMAG, University Grenoble Alps, Grenoble, France
| | - Catherine Arvieux
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, CS 10232, 38043, 38043, CEDEX 09, Grenoble, France.
- Lyon Center for Innovation in Cancer, EA 3738, Lyon 1 University, Lyon, France.
| |
Collapse
|
20
|
Rijken A, Loef C, van de Wouw YAJ, van Erning FN, de Hingh IHJT. Updated Incidence, Treatment and Survival of a Nationwide Cohort of Patients with Peritoneal Metastases of Unknown Origin. Indian J Surg Oncol 2023; 14:67-73. [PMID: 37359941 PMCID: PMC10284780 DOI: 10.1007/s13193-022-01567-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 06/15/2022] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to investigate the incidence, treatment and survival of patients with peritoneal metastases (PM) of unknown origin. All Dutch patients diagnosed in 2017 and 2018 with PM of unknown origin (PM-CUP) were evaluated. Data were extracted from the Netherlands Cancer Registry (NCR). Patients with PM-CUP were categorized into the following histological subtypes: 1) adenocarcinoma, 2) mucinous adenocarcinoma, 3) carcinoid, 4) unspecified carcinoma and 5) other. Treatments were compared between the different histological subtypes in patients with PM-CUP. Overall survival (OS) was calculated using the Kaplan-Meier method for all patients with cancer of unknown origin and between histological subtypes in patients with PM-CUP. Significant differences in OS were assessed by using the log-rank test. In total, 3026 patients were diagnosed with cancer of unknown origin, 513 (17%) among them were diagnosed with PM-CUP. Most PM-CUP patients received best supportive care only (76%), whereas 22% received systemic treatment and 4% underwent metastasectomy. Median OS was 1.1 months for all patients with PM-CUP but varied from 0.6 months to 30.5 months depending on the underlying histology. In this study, PM-CUP were diagnosed in 17% of all patients with cancer of unknown primary and the reported survival in this cohort was extremely poor. Since survival differed among histological subtypes and recently more treatment options became available for a selected group of patients with peritoneal malignancies, it is of great importance to identify the histology of the metastases and whenever possible the primary tumor.
Collapse
Affiliation(s)
- Anouk Rijken
- Department of Surgery, Catharina Cancer Institute, Eindhoven, Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - Caroline Loef
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | | | - Felice N. van Erning
- Department of Surgery, Catharina Cancer Institute, Eindhoven, Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - Ignace H. J. T. de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
- GROW- School for Oncology and Development Biology, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
21
|
Ezanno AC, Malgras B, Pocard M. Pressurized intraperitoneal aerosol chemotherapy, reasons for interrupting treatment: a systematic review of the literature. Pleura Peritoneum 2023; 8:45-53. [PMID: 37304159 PMCID: PMC10249753 DOI: 10.1515/pp-2023-0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/23/2023] [Indexed: 06/13/2023] Open
Abstract
Objectives Pressurized intraperitoneal aerosol chemotherapy (PIPAC) gives encouraging results in the treatment of peritoneal metastasis (PM). The current recommendations require at least 3 sessions of PIPAC. However, some patients do not complete the full treatment course and stop after only 1 or 2 procedures, hence the limited benefit. A literature review was performed, with search terms including "PIPAC" and "pressurised intraperitoneal aerosol chemotherapy." Content Only articles describing the causes for premature termination of the PIPAC treatment were analysed. The systematic search identified 26 published clinical articles related to PIPAC and reporting causes for stopping PIPAC. Summary The series range from 11 to 144 patients, with a total of 1352 patients treated with PIPAC for various tumours. A total of 3088 PIPAC treatments were performed. The median number of PIPAC treatments per patient was 2.1, the median PCI score at the time of the first PIPAC was 19 and the number of patients who did not complete the recommended 3 sessions of PIPAC was 714 (52.8%). Disease progression was the main reason for early termination of the PIPAC treatment (49.1%). The other causes were death, patients' wishes, adverse events, conversion to curative cytoreductive surgery and other medical reasons (embolism, pulmonary infection, etc…). Outlook Further investigations are necessary to better understand the causes for interrupting PIPAC treatment and also improving the selection of patients who are most likely to benefit from PIPAC.
Collapse
Affiliation(s)
- Anne-Cecile Ezanno
- Department of digestive surgery, Begin Military Teaching Hospital, Saint Mandé, France
| | - Brice Malgras
- Department of digestive surgery, Begin Military Teaching Hospital, Saint Mandé, France
- French Military health Service Academy, Ecole du Val de Grâce, Paris, France
| | - Marc Pocard
- Department of digestive surgery, La Pitié Salpétrière Hospital, Paris, France
- INSERM, U965 Cart unit, Paris, France
| |
Collapse
|
22
|
Gastric Cancer with Peritoneal Metastases: Current Status and Prospects for Treatment. Cancers (Basel) 2023; 15:cancers15061777. [PMID: 36980663 PMCID: PMC10046173 DOI: 10.3390/cancers15061777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/01/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
Gastric cancer (GC) has a poor prognostic and only one in four patients will have survived by 5 years after diagnosis. These poor results are due to the fact that most patients are diagnosed in advanced stages; peritoneal metastases (PM) are especially frequent and are difficult to treat. Currently, PM are considered a terminal stage of GC with a poor survival rate and are treated with palliative systemic chemotherapy. Since the beginning of the century, the treatment of PM from different origins has evolved; cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have become the treatment of choice for many malignant diseases that affect the peritoneum. CRS and HIPEC have also been used for patients with GC and PM, achieving survival results that have never been achieved when using systemic chemotherapy alone. The use of HIPEC can even prevent the development of peritoneal recurrences in patients with locally advanced GC as adjuvant therapy, can reduce the volume of peritoneal disease as neoadjuvant therapy, and can control symptoms in a palliative setting. The aim of this review is to collate the current scientific evidence regarding the treatment of PM of GC origin with surgery and intraperitoneal chemotherapy.
Collapse
|
23
|
Luo XF, Luo YH, Zhao XY, Lin XT, Li WL, Jie J, Wu D, Fang G, Pang YZ, Huang A. Application and progress of palliative therapy in advanced gastric carcinomas. Front Oncol 2023; 13:1104447. [PMID: 36969008 PMCID: PMC10035333 DOI: 10.3389/fonc.2023.1104447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/16/2023] [Indexed: 03/11/2023] Open
Abstract
Gastric carcinomas have high morbidity and mortality. It produces no noticeable symptoms in the early stage while causing complex complications in its advanced stage, making treatment difficult. Palliative therapy aims to relieve the symptoms of cancer patients and focuses on improving their quality of life. At present, five palliative therapies for advanced gastric carcinomas are offered: resection, gastrojejunostomy, stenting, chemotherapy, and radiotherapy. In recent years, palliative therapy has been used in the clinical treatment of advanced gastric carcinomas and related complications because of its efficacy in gastric outlet obstruction and gastric bleeding. In the future, multimodal and interdisciplinary palliative therapies can be applied to control general symptoms to improve patients’ condition, prolong their lifespan and improve their quality of life.
Collapse
Affiliation(s)
- Xiao-fan Luo
- Key Laboratory of Basic and Applied Research of Zhuang Medicine Prescriptions, Guangxi University of Traditional Chinese Medicine, Nanning, Guangxi, China
| | - Ye-hao Luo
- School of Second Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xin-yi Zhao
- Key Laboratory of Basic and Applied Research of Zhuang Medicine Prescriptions, Guangxi University of Traditional Chinese Medicine, Nanning, Guangxi, China
| | - Xue-ting Lin
- Key Laboratory of Basic and Applied Research of Zhuang Medicine Prescriptions, Guangxi University of Traditional Chinese Medicine, Nanning, Guangxi, China
| | - Wen-ling Li
- Key Laboratory of Basic and Applied Research of Zhuang Medicine Prescriptions, Guangxi University of Traditional Chinese Medicine, Nanning, Guangxi, China
| | - Jie Jie
- Key Laboratory of Basic and Applied Research of Zhuang Medicine Prescriptions, Guangxi University of Traditional Chinese Medicine, Nanning, Guangxi, China
| | - Di Wu
- Key Laboratory of Basic and Applied Research of Zhuang Medicine Prescriptions, Guangxi University of Traditional Chinese Medicine, Nanning, Guangxi, China
| | - Gang Fang
- Key Laboratory of Basic and Applied Research of Zhuang Medicine Prescriptions, Guangxi University of Traditional Chinese Medicine, Nanning, Guangxi, China
| | - Yu-zhou Pang
- Key Laboratory of Basic and Applied Research of Zhuang Medicine Prescriptions, Guangxi University of Traditional Chinese Medicine, Nanning, Guangxi, China
- *Correspondence: Yu-zhou Pang, ; An Huang,
| | - An Huang
- Zhuang Yao Pharmaceutical Engineering and Technology Research Center, Guangxi University of Traditional Chinese Medicine, Nanning, Guangxi, China
- *Correspondence: Yu-zhou Pang, ; An Huang,
| |
Collapse
|
24
|
Graversen M, Rouvelas I, Ainsworth AP, Bjarnesen AP, Detlefsen S, Ellebaek SB, Fristrup CW, Liljefors MG, Lundell L, Nilsson M, Pfeiffer P, Tarpgaard LS, Tsekrekos A, Mortensen MB. Feasibility and Safety of Laparoscopic D2 Gastrectomy in Combination with Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in Patients with Gastric Cancer at High Risk of Recurrence-The PIPAC-OPC4 Study. Ann Surg Oncol 2023. [PMID: 36867174 DOI: 10.1245/s10434-023-13278-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Patients with gastric adenocarcinoma (GAC) are at high risk of peritoneal recurrence despite perioperative chemotherapy and radical resection. This study evaluated feasibility and safety of laparoscopic D2 gastrectomy in combination with pressurized intraperitoneal aerosol chemotherapy (PIPAC). METHODS This was a prospective, controlled bi-institutional study in patients with GAC at high risk of recurrence treated with PIPAC with cisplatin and doxorubicin (PIPAC C/D) after laparoscopic D2 gastrectomy. High risk was defined as a poorly cohesive subtype with predominance of signet-ring cells, clinical stage ≥ T3 and/or ≥ N2, or positive peritoneal cytology. Peritoneal lavage fluid was collected before and after resection. Cisplatin (10.5 mg/m2) and doxorubicin (2.1 mg/m2) were aerosolized after anastomosis (flow 0.5-0.8 ml/s, maximum pressure 300 PSI). Treatment was feasible and safe if ≤ 20% had Dindo-Clavien ≥ 3b surgical complications or CTCAE ≥ 4 medical adverse events within 30 days. Secondary outcomes were length of stay (LOS), peritoneal lavage cytology, and completion of postoperative systemic chemotherapy. RESULTS Twenty-one patients were treated with a D2 gastrectomy and PIPAC C/D. The median age was 61 years (range 24-76), there were eleven female patients, and 20 patients had preoperative chemotherapy. There was no mortality. Two patients had grade 3b complications that were potentially related to PIPAC C/D (one anastomotic leakage, and one late duodenal blow-out). One patient had severe neutropenia, and nine patients had moderate pain. The LOS was 6 days (4-26). One patient had positive peritoneal lavage cytology before resection, and none were positive after. Fifteen patients had postoperative chemotherapy. CONCLUSIONS Laparoscopic D2 gastrectomy in combination with PIPAC C/D is feasible and safe.
Collapse
Affiliation(s)
- Martin Graversen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark. .,Department of Surgery, Odense University Hospital, Odense, Denmark. .,OPEN - Open Patient data Explorative Network, Odense University Hospital, Region of Southern Denmark, Odense, Denmark. .,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - I Rouvelas
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - A P Ainsworth
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - A P Bjarnesen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - S Detlefsen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - S B Ellebaek
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - C W Fristrup
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - M G Liljefors
- Department of Oncology, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - L Lundell
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - M Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - P Pfeiffer
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - L S Tarpgaard
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - A Tsekrekos
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - M B Mortensen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
25
|
Di Giorgio A, Macrì A, Ferracci F, Robella M, Visaloco M, De Manzoni G, Sammartino P, Sommariva A, Biacchi D, Roviello F, Pastorino R, Pires Marafon D, Rotolo S, Casella F, Vaira M. 10 Years of Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC): A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15041125. [PMID: 36831468 PMCID: PMC9954579 DOI: 10.3390/cancers15041125] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel intraperitoneal drug delivery method of low-dose chemotherapy as a pressurized aerosol in patients affected by peritoneal cancer of primary or secondary origin. We performed a systematic review and meta-analysis with the aim of assessing the feasibility, safety, and efficacy of PIPAC. METHODS A systematic literature search was performed using Medline and Web of Science databases from 1 January 2011, to inception, to 31 December 2021. Data were independently extracted by two authors. The Newcastle-Ottawa Scale was used to assess the quality and risk of bias of studies. Meta-analysis was performed for pathological response, radiological response, PCI variation along treatment, and for patients undergoing three or more PIPAC. Pooled analyses were performed using the Freeman-Tukey double arcsine transformation, and 95% CIs were calculated using Clopper-Pearson exact CIs in all instances. RESULTS A total of 414 papers on PIPAC were identified, and 53 studies considering 4719 PIPAC procedure in 1990 patients were included for analysis. The non-access rate or inability to perform PIPAC pooled rate was 4% of the procedures performed. The overall proportion of patients who completed 3 or more cycles of PIPAC was 39%. Severe toxicities considering CTCAE 3-4 were 4% (0% to 38.5%). In total, 50 studies evaluated deaths within the first 30 postoperative days. In the included 1936 patients were registered 26 deaths (1.3%). The pooled analysis of all the studies reporting a pathological response was 68% (95% CI 0.61-0.73), with an acceptable heterogeneity (I2 28.41%, p = 0.09). In total, 10 papers reported data regarding the radiological response, with high heterogeneity and a weighted means of 15% (0% to 77.8%). PCI variation along PIPAC cycles were reported in 14 studies. PCI diminished, increased, or remained stable in eight, one and five studies, respectively, with high heterogeneity at pooled analysis. Regarding survival, there was high heterogeneity. The 12-month estimated survival from first PIPAC for colorectal cancer, gastric cancer, gynecological cancer and hepatobiliary/pancreatic cancer were, respectively, 53%, 25%, 59% and 37%. CONCLUSIONS PIPAC may be a useful treatment option for selected patients with PM, with acceptable grade 3 and 4 toxicity and promising survival benefit. Meta-analysis showed high heterogeneity of data among up-to-date available studies. In a subset analysis per primary tumor origin, pathological tumor regression was documented in 68% of the studies with acceptable heterogeneity. Pathological regression seems, therefore, a reliable outcome for PIPAC activity and a potential surrogate endpoint of treatment response. We recommend uniform selection criteria for patients entering a PIPAC program and highlight the urgent need to standardize items for PIPAC reports and datasets.
Collapse
Affiliation(s)
- Andrea Di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli—IRCCS, 00168 Rome, Italy
| | - Antonio Macrì
- U.O.C.—P.S.G. con O.B.I. Azienda Ospedaliera Universitaria “G. Martino”—Messina, 98125 Messina, Italy
| | - Federica Ferracci
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli—IRCCS, 00168 Rome, Italy
- Correspondence: or ; Tel.: +39-0630157255
| | - Manuela Robella
- Candiolo Cancer Institute, FPO—IRCCS, Candiolo, 10060 Torino, Italy
| | - Mario Visaloco
- U.O.C.—P.S.G. con O.B.I. Azienda Ospedaliera Universitaria “G. Martino”—Messina, 98125 Messina, Italy
| | | | - Paolo Sammartino
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | - Antonio Sommariva
- Advanced Surgical Oncology Unit, Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Daniele Biacchi
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | - Franco Roviello
- Department of Medicine, Surgery, and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, 53100 Siena, Italy
| | - Roberta Pastorino
- Sezione di Igiene, Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- Department of Woman and Child Health and Public Health—Public Health Area, Fondazione Policlinico Universitario A. Gemelli—IRCCS, 00168 Roma, Italy
| | - Denise Pires Marafon
- Sezione di Igiene, Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Stefano Rotolo
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Francesco Casella
- Upper GI Surgery Division, University of Verona, 37129 Verona, Italy
| | - Marco Vaira
- Candiolo Cancer Institute, FPO—IRCCS, Candiolo, 10060 Torino, Italy
| |
Collapse
|
26
|
Guchelaar NAD, Noordman BJ, Koolen SLW, Mostert B, Madsen EVE, Burger JWA, Brandt-Kerkhof ARM, Creemers GJ, de Hingh IHJT, Luyer M, Bins S, van Meerten E, Lagarde SM, Verhoef C, Wijnhoven BPL, Mathijssen RHJ. Intraperitoneal Chemotherapy for Unresectable Peritoneal Surface Malignancies. Drugs 2023; 83:159-180. [PMID: 36633826 PMCID: PMC9908703 DOI: 10.1007/s40265-022-01828-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/13/2023]
Abstract
Malignancies of the peritoneal cavity are associated with a dismal prognosis. Systemic chemotherapy is the gold standard for patients with unresectable peritoneal disease, but its intraperitoneal effect is hampered by the peritoneal-plasma barrier. Intraperitoneal chemotherapy, which is administered repeatedly into the peritoneal cavity through a peritoneal implanted port, could provide a novel treatment modality for this patient population. This review provides a systematic overview of intraperitoneal used drugs, the performed clinical studies so far, and the complications of the peritoneal implemental ports. Several anticancer drugs have been studied for intraperitoneal application, with the taxanes paclitaxel and docetaxel as the most commonly used drug. Repeated intraperitoneal chemotherapy, mostly in combination with systemic chemotherapy, has shown promising results in Phase I and Phase II studies for several tumor types, such as gastric cancer, ovarian cancer, colorectal cancer, and pancreatic cancer. Two Phase III studies for intraperitoneal chemotherapy in gastric cancer have been performed so far, but the results regarding the superiority over standard systemic chemotherapy alone, are contradictory. Pressurized intraperitoneal administration, known as PIPAC, is an alternative way of administering intraperitoneal chemotherapy, and the first prospective studies have shown a tolerable safety profile. Although intraperitoneal chemotherapy might be a standard treatment option for patients with unresectable peritoneal disease, more Phase II and Phase III studies focusing on tolerability profiles, survival rates, and quality of life are warranted in order to establish optimal treatment schedules and to establish a potential role for intraperitoneal chemotherapy in the approach to unresectable peritoneal disease.
Collapse
Affiliation(s)
- Niels A D Guchelaar
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Bo J Noordman
- Department of Surgery, Division of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.,Department of Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bianca Mostert
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Eva V E Madsen
- Department of Surgery, Division of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - Alexandra R M Brandt-Kerkhof
- Department of Surgery, Division of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands.,Department of Epidemiology, GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - Sander Bins
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Esther van Meerten
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Sjoerd M Lagarde
- Department of Surgery, Division of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgery, Division of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Division of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| |
Collapse
|
27
|
Graversen M, Detlefsen S, Ainsworth AP, Fristrup CW, Knudsen AO, Pfeiffer P, Tarpgaard LS, Mortensen MB. Treatment of Peritoneal Metastasis with Pressurized Intraperitoneal Aerosol Chemotherapy: Results from the Prospective PIPAC-OPC2 Study. Ann Surg Oncol 2023; 30:2634-2644. [PMID: 36602663 DOI: 10.1245/s10434-022-13010-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pressurized Intraperitoneal Aerosol chemotherapy (PIPAC) is a local treatment for peritoneal metastasis (PM). Prospective data are scarce and evaluation of treatment response remains difficult. This study evaluated the use of the Peritoneal Regression Grading score (PRGS) and its prognostic value. PATIENTS AND METHODS This was a prospective, controlled phase II trial in patients with PM from gastrointestinal, gynaecological, hepatopancreatobiliary, primary peritoneal, or unknown primary cancer. Patients in performance status 0-1, with a non-obstructed gastrointestinal tract, and a maximum of one extraperitoneal metastasis were eligible. Colorectal or appendiceal PM had PIPAC with oxaliplatin, other primaries had PIPAC with cisplatin and doxorubicin. Biopsies were taken at each PIPAC and evaluated using the PRGS. Quality-of-life questionnaires were reported at baseline and after three PIPACs. RESULTS One hundred ten patients were treated with 336 PIPACs (median 3, range 1-12). One hundred patients had prior palliative chemotherapy and 45 patients received bidirectional treatment. Complete or major histological response to treatment (PRGS 1-2) was observed in 38 patients (61%) who had three PIPACs, which was the only independent prognostic factor in a multivariate analysis. The median overall survival (mOS) from PIPAC 1 was 10 months, while patients with PM from gastric, colorectal, and pancreatic cancer had a mOS of 7.4, 16.7, and 8.2 months, respectively. Global health scores were significantly reduced, but patients were less fatigued, nauseated, constipated, and had better appetite after three PIPACs. CONCLUSIONS PIPAC with oxaliplatin or cisplatin and doxorubicin was able to induce a major or complete histological response during three PIPACs, which may provide significant prognostic information, both at baseline and after treatment.
Collapse
Affiliation(s)
- Martin Graversen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark. .,Department of Surgery, Odense University Hospital, Odense, Denmark. .,OPEN-Open Patient data Explorative Network, Odense University Hospital, Odense, Region of Southern Denmark, Denmark. .,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark. .,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - S Detlefsen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - A P Ainsworth
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark.,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark
| | - C W Fristrup
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark.,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark
| | - A O Knudsen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - P Pfeiffer
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - L S Tarpgaard
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - M B Mortensen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark.,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
28
|
Tidadini F, Ezanno AC, Trilling B, Aime A, Abba J, Quesada JL, Foote A, Chevallier T, Glehen O, Faucheron JL, Chkair S, Arvieux C. Hospitalization cost of Pressurized Intraperitoneal Aerosol chemotherapy (PIPAC). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:165-172. [PMID: 36008216 DOI: 10.1016/j.ejso.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/21/2022] [Accepted: 07/31/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Pressurized Intraperitoneal Aerosol chemotherapy (PIPAC) is a new surgical technique for the treatment of unresectable peritoneal carcinomatosis. Very little data is available on the costs of this treatment in France as there is currently no code for PIPAC in the French Common Classification of Medical Acts (CCAM). Our objective was to estimate the mean cost of hospitalization for PIPAC in two French public teaching hospitals. METHODS The mean cost of hospitalization was estimated from the mean fixed-rate remuneration paid to the hospital and the mean additional costs of treatment paid by the hospital. At discharge a patient's hospitalization is classified into a diagnosis related group, which determines the fixed-rate remuneration paid to the hospital (obtained from the national hospitals database - PMSI). Costs of medical devices and drug treatments specific to PIPAC, not covered by the fixed-rate remuneration, were obtained from the hospital pharmacies. RESULTS Between July 2016 and November 2021, 205 PIPAC procedures were performed on 79 patients (mean procedures per patient = 2.6). Mean operating room occupancy was 165 min. The mean fixed-rate remuneration received by the hospitals per PIPAC hospitalization was €4031. The actual mean cost per hospitalization was €6562 for a mean length-of-stay of 3.3 days. Thus, each PIPAC hospitalization cost the hospital €2531 on average. CONCLUSION The current reimbursement of PIPAC treatment by the national health system is insufficient and represents only 61% of the real cost. The creation of a new fixed-rate remuneration for PIPAC taking into account this cost differential is necessary.
Collapse
Affiliation(s)
- Fatah Tidadini
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France; Lyon Center for Lnnovation in Cancer, EA 3738, Lyon 1 University, Lyon, France
| | - Anne-Cecile Ezanno
- Department of Visceral and Endocrine Surgery, Bégin Army Teaching Hospital, Saint-Mande, France
| | - Bertrand Trilling
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Adeline Aime
- Department of Visceral and Endocrine Surgery, Bégin Army Teaching Hospital, Saint-Mande, France
| | - Julio Abba
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Louis Quesada
- Clinical Pharmacology Unit, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France
| | - Alison Foote
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Thierry Chevallier
- Department of Biostatistics, Clinical Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France; IDESP, UMR-INSERM, Montpellier, France
| | - Olivier Glehen
- Lyon Center for Lnnovation in Cancer, EA 3738, Lyon 1 University, Lyon, France
| | - Jean-Luc Faucheron
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Sihame Chkair
- Department of Biostatistics, Clinical Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France; IDESP, UMR-INSERM, Montpellier, France
| | - Catherine Arvieux
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France; Lyon Center for Lnnovation in Cancer, EA 3738, Lyon 1 University, Lyon, France; Department of Visceral and Endocrine Surgery, Bégin Army Teaching Hospital, Saint-Mande, France.
| |
Collapse
|
29
|
Baggaley AE, Lafaurie GBRC, Tate SJ, Boshier PR, Case A, Prosser S, Torkington J, Jones SEF, Gwynne SH, Peters CJ. Pressurized intraperitoneal aerosol chemotherapy (PIPAC): updated systematic review using the IDEAL framework. Br J Surg 2022; 110:10-18. [PMID: 36056893 PMCID: PMC10364525 DOI: 10.1093/bjs/znac284] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Alice E Baggaley
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | | | - Sophia J Tate
- Department of Anaesthesia, Swansea Bay University Health Board, Swansea, UK
| | - Piers R Boshier
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Amy Case
- Department of Cancer Services, Swansea Bay University Health Board, Swansea, UK
| | - Susan Prosser
- Department of Library Services, Swansea Bay University Health Board, Swansea, UK
| | - Jared Torkington
- Department of Surgery, University Hospital of Wales, Cardiff, UK
| | - Sadie E F Jones
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Sarah H Gwynne
- Department of Cancer Services, Swansea Bay University Health Board, Swansea, UK
| | - Christopher J Peters
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| |
Collapse
|
30
|
Case A, Prosser S, Peters CJ, Adams R, Gwynne S. Pressurised intraperitoneal aerosolised chemotherapy (PIPAC) for gastric cancer with peritoneal metastases: A systematic review by the PIPAC UK collaborative. Crit Rev Oncol Hematol 2022; 180:103846. [PMID: 36257535 DOI: 10.1016/j.critrevonc.2022.103846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/30/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Gastric cancer with peritoneal metastases (GCPM) carries a poor prognosis. Pressurised Intraperitoneal Aerosolised Chemotherapy (PIPAC) offers pharmacokinetic advantages over intravenous therapy, resulting in higher chemotherapy concentrations in peritoneal deposits, and potentially reduced systemic absorption/toxicity. This review evaluates efficacy, tolerability and impact on quality of life (QOL) of PIPAC for GCPM. METHODS Following registration with PROSPERO (CRD42021281500), MEDLINE, EMBASE and The Cochrane Library were searched for PIPAC in patients with peritoneal metastases, in accordance with PRISMA standards RESULTS: Across 18 included reports representing 751 patients with GCPM (4 prospective, 11 retrospective, 3 abstracts, no phase III studies), median overall survival (mOS) was 8 - 19.1 months, 1-year OS 49.8-77.9%, complete response (PRGS1) 0-35% and partial response (PRGS2/3) 0-83.3%. Grade 3 and 4 toxicity was 0.7-25% and 0-4.1% respectively. Three studies assessing QOL reported no significant difference. CONCLUSION PIPAC may offer promising survival benefits, toxicity, and QOL for GCPM.
Collapse
Affiliation(s)
- A Case
- South West Wales Cancer Centre, Singleton Hospital, Sketty Lane, Swansea SA2 8QA, UK; Swansea University Medical School, Grove Building, Singleton Park, SA2 8PP, UK.
| | - S Prosser
- South West Wales Cancer Centre, Singleton Hospital, Sketty Lane, Swansea SA2 8QA, UK
| | - C J Peters
- Department of Surgery and Cancer, Imperial College London, St Marys Hospital, Praed Street, London W2 1NY, UK
| | - R Adams
- Centre for Trials Research, Cardiff University and Velindre Cancer Centre, Velindre Road, Whitchurch CF14 2TL, UK
| | - S Gwynne
- South West Wales Cancer Centre, Singleton Hospital, Sketty Lane, Swansea SA2 8QA, UK; Swansea University Medical School, Grove Building, Singleton Park, SA2 8PP, UK
| |
Collapse
|
31
|
Rosa F, Schena CA, Laterza V, Quero G, Fiorillo C, Strippoli A, Pozzo C, Papa V, Alfieri S. The Role of Surgery in the Management of Gastric Cancer: State of the Art. Cancers (Basel) 2022; 14:cancers14225542. [PMID: 36428634 PMCID: PMC9688256 DOI: 10.3390/cancers14225542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022] Open
Abstract
Surgery still represents the mainstay of treatment of all stages of gastric cancer (GC). Surgical resections represent potentially curative options in the case of early GC with a low risk of node metastasis. Sentinel lymph node biopsy and indocyanine green fluorescence are novel techniques which may improve the employment of stomach-sparing procedures, ameliorating quality of life without compromising oncological radicality. Nonetheless, the diffusion of these techniques is limited in Western countries. Conversely, radical gastrectomy with extensive lymphadenectomy and multimodal treatment represents a valid option in the case of advanced GC. Differences between Eastern and Western recommendations still exist, and the optimal multimodal strategy is still a matter of investigation. Recent chemotherapy protocols have made surgery available for patients with oligometastatic disease. In this context, intraperitoneal administration of chemotherapy via HIPEC or PIPAC has emerged as an alternative weapon for patients with peritoneal carcinomatosis. In conclusion, the surgical management of GC is still evolving together with the multimodal strategy. It is mandatory for surgeons to be conscious of the current evolution of the surgical management of GC in the era of multidisciplinary and tailored medicine.
Collapse
Affiliation(s)
- Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Carlo Alberto Schena
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Vito Laterza
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonia Strippoli
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Carmelo Pozzo
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Valerio Papa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| |
Collapse
|
32
|
Mehta S, Kammar P, Patel A, Goswami G, Shaikh S, Sukumar V, Trivedi E, Bhatt A. Feasibility and Safety of Taxane-PIPAC in Patients with Peritoneal Malignancies-a Retrospective Bi-institutional Study. Indian J Surg Oncol 2022; 14:1-9. [PMID: 36091624 PMCID: PMC9451111 DOI: 10.1007/s13193-022-01641-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022] Open
Abstract
Taxanes have a favorable pharmacokinetic profile for intraperitoneal application. We report our initial experience with taxane-PIPAC (pressurized intraperitoneal chemotherapy) for unresectable peritoneal metastases from different primary sites in terms of safety, feasibility, response rate, and conversion to resectability. In this retrospective study, PIPAC was performed alone or in combination with systemic chemotherapy. Paclitaxel was used as a single agent, whereas docetaxel was used in combination with cisplatin-adriamycin or oxaliplatin-adriamycin. From December 2019 to December 2021, 47 patients underwent 82 PIPAC procedures (1 PIPAC in 55.3%, 2 in 29.7%, 3 in 14.8%). The most common primary sites were ovarian cancer (31.9%), gastric cancer (23.4%), and colorectal cancer (21.2%). Docetaxel-cisplatin-adriamycin was used in 33 (70.2%) patients, docetaxel-oxaliplatin-adriamycin in 12 (25.5%), and paclitaxel alone in 2 (4.2%) patients. Grade 1-2 complications were observed in 24 (51%) and grade 3-4 complications in 6 (12.7%) patients (8.5% of 82 PIPACs). 16/47 (34.0%) patients had a clinical response to PIPAC. The mean PCI was 25.9 ± 9.2 for the first PIPACs and 22.4 ± 9 for the subsequent PIPACs with an average reduction of 3.6 points [change in PCI ranged from - 14 to + 8]. The PRGS was 1/2 in 4/47 (8.5%) patients (19.0% patients with > 1 PIPAC). A reduction in ascites was observed in 35.4% presenting with ascites. Nine (19.1%) patients had conversion to operability leading to a subsequent cytoreductive surgery in 8 (17%) patients. PIPAC with docetaxel is feasible and safe. The role of PIPAC with both docetaxel and paclitaxel either alone or in combination with other drugs should be investigated in prospective studies.
Collapse
Affiliation(s)
- Sanket Mehta
- Department of Surgical Oncology, Saifee Hospital, Mumbai, India
| | - Praveen Kammar
- Department of Surgical Oncology, Saifee Hospital, Mumbai, India
| | - Ankita Patel
- Department of Surgical Oncology, Zydus Hospital, Thaltej, Ahmedabad, 380054 India
| | - Gaurav Goswami
- Department of Radiology, Zydus Hospital, Ahmedabad, India
| | - Sakina Shaikh
- Department of Surgical Oncology, Zydus Hospital, Thaltej, Ahmedabad, 380054 India
| | - Vivek Sukumar
- Department of Surgical Oncology, Saifee Hospital, Mumbai, India
| | - Esha Trivedi
- Department of Surgical Oncology, Saifee Hospital, Mumbai, India
| | - Aditi Bhatt
- Department of Surgical Oncology, Zydus Hospital, Thaltej, Ahmedabad, 380054 India
| |
Collapse
|
33
|
Kepenekian V, Bhatt A, Péron J, Alyami M, Benzerdjeb N, Bakrin N, Falandry C, Passot G, Rousset P, Glehen O. Advances in the management of peritoneal malignancies. Nat Rev Clin Oncol 2022; 19:698-718. [PMID: 36071285 DOI: 10.1038/s41571-022-00675-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2022] [Indexed: 11/09/2022]
Abstract
Peritoneal surface malignancies (PSMs) are usually associated with a poor prognosis. Nonetheless, in line with advances in the management of most abdominopelvic metastatic diseases, considerable progress has been made over the past decade. An improved understanding of disease biology has led to the more accurate prediction of neoplasia aggressiveness and the treatment response and has been reflected in the proposal of new classification systems. Achieving complete cytoreductive surgery remains the cornerstone of curative-intent treatment of PSMs. Alongside centralization in expert centres, enabling the delivery of multimodal and multidisciplinary strategies, preoperative management is a crucial step in order to select patients who are most likely to benefit from surgery. Depending on the specific PSM, the role of intraperitoneal chemotherapy and of perioperative systemic chemotherapy, in particular, in the neoadjuvant setting, is established in certain scenarios but questioned in several others, although more prospective data are required. In this Review, we describe advances in all aspects of the management of PSMs including disease biology, assessment and improvement of disease resectability, perioperative management, systemic therapy and pre-emptive management, and we speculate on future research directions.
Collapse
Affiliation(s)
- Vahan Kepenekian
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France
| | - Aditi Bhatt
- Department of Surgical Oncology, Zydus hospital, Ahmedabad, Gujarat, India
| | - Julien Péron
- Medical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, UCBL1, Lyon, France
| | - Mohammad Alyami
- Department of General Surgery and Surgical Oncology, Oncology Center, King Khalid Hospital, Najran, Saudi Arabia
| | - Nazim Benzerdjeb
- CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France.,Department of Pathology, Institut de Pathologie Multisite, Hospices Civils de Lyon, UCBL1, Lyon, France
| | - Naoual Bakrin
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France
| | - Claire Falandry
- Department of Onco-Geriatry, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Guillaume Passot
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France
| | - Pascal Rousset
- CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France.,Department of Radiology, Hôpital Lyon Sud, Hospices Civils de Lyon, UCBL1, Lyon, France
| | - Olivier Glehen
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France. .,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France.
| |
Collapse
|
34
|
Adamina M, Warlaumont M, Berger MD, Däster S, Delaloye R, Digklia A, Gloor B, Fritsch R, Koeberle D, Koessler T, Lehmann K, Müller P, Peterli R, Ris F, Steffen T, Weisshaupt CS, Hübner M. Comprehensive Treatment Algorithms of the Swiss Peritoneal Cancer Group for Peritoneal Cancer of Gastrointestinal Origin. Cancers (Basel) 2022; 14:4275. [PMID: 36077810 PMCID: PMC9454505 DOI: 10.3390/cancers14174275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Peritoneal cancer (PC) is a dire finding, yet in selected patients, long-term survival is possible. Complete cytoreductive surgery (CRS) together with combination immunochemotherapy is essential to achieve cure. Hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC) are increasingly added to the multimodal treatment. The Swiss Peritoneal Cancer Group (SPCG) is an interdisciplinary group of expert clinicians. It has developed comprehensive treatment algorithms for patients with PC from pseudomyxoma peritonei, peritoneal mesothelioma, gastric, and colorectal origin. They include multimodal neoadjuvant treatment, surgical resection, and palliative care. The indication for and results of CRS HIPEC and PIPAC are discussed in light of the current literature. Institutional volume and clinical expertise required to achieve best outcomes are underlined, while inclusion of patients considered for CRS HIPEC and PIPAC in a clinical registry is strongly advised. The present recommendations are in line with current international guidelines and provide the first comprehensive treatment proposal for patients with PC including intraperitoneal chemotherapy. The SPCG comprehensive treatment algorithms provide evidence-based guidance for the multimodal care of patients with PC of gastrointestinal origin that were endorsed by all Swiss clinicians routinely involved in the multimodal care of these challenging patients.
Collapse
Affiliation(s)
- Michel Adamina
- Klinik für Viszeral- und Thoraxchirurgie, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Maxime Warlaumont
- Chirurgie Digestive et Cancérologique, CHU de Lille, CH de Cambrai, 59000 Lille, France
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, 1011 Lausanne, Switzerland
| | - Martin D. Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Silvio Däster
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, 4031 Basel, Switzerland
| | - Raphaël Delaloye
- Department of Medical Oncology, University Hospital Basel, 4031 Basel, Switzerland
| | - Antonia Digklia
- Department of Oncology, Lausanne University Hospital CHUV, University of Lausanne, 1011 Lausanne, Switzerland
| | - Beat Gloor
- Department of Visceral Surgery and Medicine, Inselspital, University Bern, 3010 Bern, Switzerland
| | - Ralph Fritsch
- Department of Medical Oncology and Hematology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Dieter Koeberle
- Department of Medical Oncology and Hematology, St. Claraspital, 4002 Basel, Switzerland
- Faculty of Medicine, University of Bern, 3012 Bern, Switzerland
| | - Thibaud Koessler
- Department of Oncology, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Phaedra Müller
- Klinik für Viszeral- und Thoraxchirurgie, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
| | - Ralph Peterli
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, 4031 Basel, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - Thomas Steffen
- Klinik für Allgemein-, Viszeral-, Endokrine und Transplantationschirurgie, Kantonsspital St. Gallen, 9000 St. Gallen, Switzerland
| | | | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, 1011 Lausanne, Switzerland
| |
Collapse
|
35
|
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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/20/2022] [Accepted: 03/08/2022] [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
|
36
|
Drubay V, Nuytens F, Renaud F, Adenis A, Eveno C, Piessen G. Poorly cohesive cells gastric carcinoma including signet-ring cell cancer: Updated review of definition, classification and therapeutic management. World J Gastrointest Oncol 2022; 14:1406-1428. [PMID: 36160745 PMCID: PMC9412924 DOI: 10.4251/wjgo.v14.i8.1406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/08/2022] [Accepted: 07/17/2022] [Indexed: 02/05/2023] Open
Abstract
While the incidence of gastric cancer (GC) in general has decreased worldwide in recent decades, the incidence of diffuse cancer historically comprising poorly cohesive cells-GC (PCC-GC) and including signet ring cell cancer is rising. Literature concerning PCC-GC is scarce and unclear, mostly due to a large variety of historically used definitions and classifications. Compared to other histological subtypes of GC, PCC-GC is nevertheless characterized by a distinct set of epidemiological, histological and clinical features which require a specific diagnostic and therapeutic approach. The aim of this review was to provide an update on the definition, classification and therapeutic strategies of PCC-GC. We focus on the updated histological definition of PCC-GC, along with its implications on future treatment strategies and study design. Also, specific considerations in the diagnostic management are discussed. Finally, the impact of some recent developments in the therapeutic management of GC in general such as the recently validated taxane-based regimens (5-Fluorouracil, leucovorin, oxaliplatin and docetaxel), the use of hyperthermic intraperitoneal chemotherapy as well as pressurized intraperitoneal aerosol chemotherapy and targeted therapy have been reviewed in depth for their relative importance for PCC-GC in particular.
Collapse
Affiliation(s)
- Vincent Drubay
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- Department of Digestive Surgery, Cambrai Hospital Center and Sainte Marie, Group of Hospitals of The Catholic Institute of Lille, Cambrai 59400, France
| | - Frederiek Nuytens
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, Kortrijk 8500, Belgium
| | - Florence Renaud
- Department of Pathology, University Lille Hospital, Lille 59000, France
- CNRS, Inserm, UMR9020-U1277-CANTHER-Cancer, University Lille, CHU Lille, Lille 59000, France
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
| | - Antoine Adenis
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
- Department of Medical Oncology, Montpellier Cancer Institute, Monpellier 34000, France
- IRCM, Inserm, University of Monpellier, Monpellier 34000, France
| | - Clarisse Eveno
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- CNRS, Inserm, UMR9020-U1277-CANTHER-Cancer, University Lille, CHU Lille, Lille 59000, France
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- CNRS, Inserm, UMR9020-U1277-CANTHER-Cancer, University Lille, CHU Lille, Lille 59000, France
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
| |
Collapse
|
37
|
Tidadini F, Abba J, Quesada JL, Villeneuve L, Foote A, Baudrant M, Bonne A, Glehen O, Trilling B, Faucheron JL, Arvieux C. Assessment of postoperative pain after pressurized intraperitoneal aerosol chemotherapy (PIPAC) in the treatment of peritoneal metastasis. Int J Colorectal Dis 2022; 37:1709-1717. [PMID: 35639123 DOI: 10.1007/s00384-022-04182-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new surgical technique, for the treatment of initially unresectable peritoneal metastasis (PM). Our objective was to assess postoperative pain and morbidity. METHODS Between July 2016 and September 2020, data from 100 consecutive PIPAC procedures with oxaliplatin (PIPAC Ox) or doxorubicin-cisplatin (PIPAC C/D) in 49 patients with PM (all etiologies) were analyzed. Pain was self-assessed using a visual analog scale (VAS) of 0-10. RESULTS The median PIPAC procedures per patient were 2 [1-3]. Patients indicated greatest pain at 4 pm on the day of the procedure (D0) and on postoperative D1 at 8 am and 4 pm. Postprocedural moderate-to-severe pain (VAS 4-10) was more frequent with PIPAC Ox than with PIPAC C/D, respectively 14 (36.8%) vs 7 (13.5%); p = 0.010. Hospitalization was longer for patients with moderate-to-severe pain than for others (median 4 days [3-7] vs 3 days [2-4], p = 0.004). Multivariate analysis identified oxaliplatin as a factor associated with greater pain (OR [95% CI], 2.95 [1.10-7.89]. Opiate administration was similar after PIPAC Ox and PIPAC C/D procedures, p = 0.477. CONCLUSION PIPAC was well-tolerated, and pain was well-controlled in the majority of patients. Pain was greatest at 4 pm on D0 and 8 am and 4 pm on D1. PIPAC Ox is associated with greater pain than PIPAC C/D, independently of opiate treatment. Moderate-to-severe pain was associated with longer hospital stays.
Collapse
Affiliation(s)
- Fatah Tidadini
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France.,Lyon Center for Innovation in Cancer, EA 3738, Lyon 1 University, Lyon, France
| | - Julio Abba
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Louis Quesada
- Clinical Pharmacology Unit, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France
| | - Laurent Villeneuve
- Lyon Center for Innovation in Cancer, EA 3738, Lyon 1 University, Lyon, France
| | - Alison Foote
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Magalie Baudrant
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Aline Bonne
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Olivier Glehen
- Lyon Center for Innovation in Cancer, EA 3738, Lyon 1 University, Lyon, France
| | - Bertrand Trilling
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France.,UMR 5525, CNRS, TIMC-IMAG, University Grenoble Alpes, 38000, Grenoble, France
| | - Jean-Luc Faucheron
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France.,UMR 5525, CNRS, TIMC-IMAG, University Grenoble Alpes, 38000, Grenoble, France
| | - Catherine Arvieux
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France. .,Lyon Center for Innovation in Cancer, EA 3738, Lyon 1 University, Lyon, France.
| |
Collapse
|
38
|
Casella F, Bencivenga M, Rosati R, Fumagalli UR, Marrelli D, Pacelli F, Macrì A, Donini A, Torroni L, Pavarana M, De Manzoni G. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) in multimodal therapy for patients with oligometastatic peritoneal gastric cancer: a randomized multicenter phase III trial PIPAC VEROne. Pleura Peritoneum 2022; 7:135-141. [PMID: 36159218 PMCID: PMC9467896 DOI: 10.1515/pp-2022-0111] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/03/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objectives
Peritoneal carcinomatosis is the most frequent site of metastases in patients with gastric cancer. Current standard treatment is palliative systemic chemotherapy with very poor prognosis. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) resulted in long-term benefits in selected patients. Among patients with peritoneal carcinomatosis, a distinctive subset is oligometastatic disease which is characterized by low metastatic burden. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a recent technique of intraperitoneal chemotherapy used in combination with systemic chemotherapy with promising results.
Methods
PIPAC VER-One is a prospective, randomized, multicenter phase III clinical trial that aims to evaluate the effectiveness of the use of PIPAC in combination with systemic chemotherapy in patients with gastric cancer and synchronous positive peritoneal cytology and/or limited peritoneal metastases (peritoneal cancer index [PCI] ≤6). Patients will be randomized into two arms: arm A (control) treated with standard systemic chemotherapy and arm B (experimental) treated with a bidirectional scheme including PIPAC and systemic chemotherapy.
Results
Primary endpoint is the secondary resectability rate. Secondary endpoints are: overall survival (OS), pregression-free survival (PFS), disease-free survival (DFS), histological response assessed both on primary tumor and peritoneal lesions, quality of life (QoL), complication rate (CTCAE v5), and incremental cost-effectiveness ratios (ICER).
Conclusions
The role of PIPAC in multimodal treatment for oligometastatic gastric cancer will be investigated in this trial.
Collapse
Affiliation(s)
- Francesco Casella
- Department and of Surgical, General and Upper GI Surgery Division, Odontostomatologic, Maternal and Child Sciences , University of Verona , Verona , Italy
| | - Maria Bencivenga
- Department and of Surgical, General and Upper GI Surgery Division, Odontostomatologic, Maternal and Child Sciences , University of Verona , Verona , Italy
| | - Riccardo Rosati
- Department of Surgery , San Raffaele Hospital, San Raffaele Vita-salute University , Milan , Italy
| | | | - Daniele Marrelli
- Department of Surgery , Siena University Hospital, University of Siena , Siena , Italy
| | - Fabio Pacelli
- Surgical Unit of Peritoneum and Retroperitoneum Surgery , Fondazione Policlinico Universitario A. Gemelli, IRCCS , Rome , Italy
| | - Antonio Macrì
- Peritoneal Surface Malignancy and Soft Tissue Sarcoma Program , University of Messina , Messina , Italy
| | - Annibale Donini
- General and Emergency Surgery , Santa Maria Della Misericordia Hospital, University of Perugia , Perugia , Italy
| | - Lorena Torroni
- Department of Diagnostic and Public Health, Unit of Epidemiology and Medical Statistics , University of Verona , Verona , Italy
| | | | - Giovanni De Manzoni
- Department and of Surgical, General and Upper GI Surgery Division, Odontostomatologic, Maternal and Child Sciences , University of Verona , Verona , Italy
| |
Collapse
|
39
|
Prabhu A, Mishra D, Brandl A, Yonemura Y. Gastric Cancer With Peritoneal Metastasis-A Comprehensive Review of Current Intraperitoneal Treatment Modalities. Front Oncol 2022; 12:864647. [PMID: 35719946 PMCID: PMC9204320 DOI: 10.3389/fonc.2022.864647] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/22/2022] [Indexed: 12/24/2022] Open
Abstract
The treatment of patients with peritoneal metastasis from gastric cancer continues to evolve. With various forms of intraperitoneal drug delivery available, it is now possible to reach the sites of peritoneal metastases, which were otherwise sub-optimally covered by systemic chemotherapy, owing to the blood peritoneal barrier. We conducted a narrative review based on an extensive literature research, highlighting the current available intraperitoneal treatment options, which resulted in improved survival in well-selected patients of peritoneally metastasized gastric cancer. Intraperitoneal chemotherapy showed promising results in four different treatment modalities: prophylactic, neoadjuvant, adjuvant, and palliative. It is now possible to choose the type of intraperitoneal treatment/s in combination with systemic treatment/s, depending on patients' general condition and peritoneal disease burden, thus providing individualized treatment to these patients. Randomized controlled trials for the different treatment modalities were mainly conducted in Asia and lack further validation in the other parts of the world. Most recent application tools, such as pressurized intraperitoneal aerosol chemotherapy, seem promising and need to pass the ongoing clinical trials.
Collapse
Affiliation(s)
- Aruna Prabhu
- Department of Surgical Oncology, Thangam Cancer Center, Namakkal, India
| | - Deepti Mishra
- Department of Surgical Oncology, Thangam Cancer Center, Namakkal, India
| | - Andreas Brandl
- Digestive Unit, Champalimaud Foundation, Lisbon, Portugal
- Department of Surgery, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Yutaka Yonemura
- Department of Regional Cancer therapy, Peritoneal Surface Malignancy Centee, Kishiwada Tokushukai Hospital, Kishiwada, Japan
- Japanese/Asian School of Peritoneal Surface Oncology, Osaka, Japan
- Department of Regional Cancer therapy, Peritoneal Surface Malignancy Center, Kusatsu General Hospital, Shiga, Japan
| |
Collapse
|
40
|
Harada K, Yamashita K, Iwatsuki M, Baba H, Ajani JA. Intraperitoneal therapy for gastric cancer peritoneal carcinomatosis. Expert Rev Clin Pharmacol 2022; 15:43-49. [PMID: 35184625 DOI: 10.1080/17512433.2022.2044790] [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: 12/09/2022]
Abstract
INTRODUCTION Gastric adenocarcinoma (GAC) is one of the most aggressive malignancies worldwide and has a poor prognosis. Multidisciplinary therapies are used in its treatment, but the prognosis for GAC patients with peritoneal metastases (PM) remains poor and there is no effective established approach. AREAS COVERED This review summarizes the results of recent clinical studies and recent advances in the management, including surgery, chemotherapy, targeted therapy, and immunotherapy. In this review, keywords were searched in combination with 'peritoneal carcinomatosis' and 'gastric cancer' in PubMed, and then studies that evaluated peritoneal carcinomatosis associated with gastric cancer were identified through reading them. Several studies were quoted at second hand. Despite recent advances in therapeutic approaches such as systemic chemotherapy, immunotherapy, intraperitoneal chemotherapy, debulking surgery, thermal hyperthermic intraperitoneal chemotherapy, pressurized intraperitoneal aerosol chemotherapy, immunotherapy, and best supportive therapy, further studies are necessary. This review also summarizes molecular biology of GAC patients with PM. EXPERT OPINION Each modality is advancing and some have shown therapeutic effects, but none have become standard treatments that exhibit remarkable effects. To improve the prognosis of GAC patients with PM, large-scale clinical trials and further basic research are required.
Collapse
Affiliation(s)
- Kazuto Harada
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Kohei Yamashita
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan.,Department of Gastrointestinal Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
41
|
Sun BJ, Lee B. Review of Regional Therapies for Gastric Cancer with Peritoneal Metastases. Cancers (Basel) 2022; 14:cancers14030570. [PMID: 35158837 PMCID: PMC8833629 DOI: 10.3390/cancers14030570] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/15/2022] [Accepted: 01/19/2022] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Gastric cancer is usually diagnosed at late stages and is associated with poor five-year survival rates. Metastasis to the peritoneal cavity is common and leads to even worse outcomes. Currently, the mainstay of treatment for metastatic gastric cancer is systemic chemotherapy or supportive care. These recommendations remain despite evidence that suggests systemic therapy has poor penetration into the abdominal cavity, limiting efficacy against peritoneal disease. Newer treatments have been developed to address this problem, specifically regional therapies aimed at delivering chemotherapy directly into the peritoneal cavity to eradicate tumor cells. These novel therapies include hyperthermic intraperitoneal chemotherapy, normothermic intraperitoneal chemotherapy, and pressurized intraperitoneal aerosolized chemotherapy. Regional therapies may also be combined with surgery to remove both macroscopic and microscopic disease. Although more clinical trials are needed to evaluate its efficacy, early studies have shown promising outcomes with intraperitoneal chemotherapy. Abstract Gastric cancer carries a poor prognosis and is a leading cause of cancer-related mortality worldwide. Patients with gastric cancer who develop peritoneal metastases have an even more dismal prognosis, with median survival time measured in months. Since studies have demonstrated that systemic chemotherapy has poor penetration into the peritoneum, multimodal treatment with intraperitoneal chemotherapy has been proposed for the treatment of peritoneal metastases and has become the foundation for newer therapeutic techniques and clinical trials. These include heated intraperitoneal chemotherapy (HIPEC) with cytoreductive surgery (CRS), which involves the application of heated chemotherapy into the abdomen with or without tumor debulking surgery; normothermic intraperitoneal chemotherapy (NIPEC), in which non-heated chemotherapy can be delivered into the abdomen via a peritoneal port allowing for repeat dosing; and pressurized intraperitoneal aerosolized chemotherapy (PIPAC), a newer technique of pressurized and aerosolized chemotherapy delivered into the abdomen during laparoscopy. Early results with intraperitoneal chemotherapy have shown promise in increasing disease-free and overall survival in select patients. Additionally, there may be a palliative effect of these regional therapies. In this review, we explore and summarize these different intraperitoneal chemotherapy treatment regimens for gastric cancer with peritoneal metastases.
Collapse
|
42
|
Abstract
Peritoneal surface malignancies comprise a heterogeneous group of primary tumours, including peritoneal mesothelioma, and peritoneal metastases of other tumours, including ovarian, gastric, colorectal, appendicular or pancreatic cancers. The pathophysiology of peritoneal malignancy is complex and not fully understood. The two main hypotheses are the transformation of mesothelial cells (peritoneal primary tumour) and shedding of cells from a primary tumour with implantation of cells in the peritoneal cavity (peritoneal metastasis). Diagnosis is challenging and often requires modern imaging and interventional techniques, including surgical exploration. In the past decade, new treatments and multimodal strategies helped to improve patient survival and quality of life and the premise that peritoneal malignancies are fatal diseases has been dismissed as management strategies, including complete cytoreductive surgery embedded in perioperative systemic chemotherapy, can provide cure in selected patients. Furthermore, intraperitoneal chemotherapy has become an important part of combination treatments. Improving locoregional treatment delivery to enhance penetration to tumour nodules and reduce systemic uptake is one of the most active research areas. The current main challenges involve not only offering the best treatment option and developing intraperitoneal therapies that are equivalent to current systemic therapies but also defining the optimal treatment sequence according to primary tumour, disease extent and patient preferences. New imaging modalities, less invasive surgery, nanomedicines and targeted therapies are the basis for a new era of intraperitoneal therapy and are beginning to show encouraging outcomes.
Collapse
|
43
|
Badgwell B. Regional therapy trials in peritoneal metastases: The path to standardization of care for gastric cancer. J Surg Oncol 2021; 125:64-68. [PMID: 34897716 DOI: 10.1002/jso.26718] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/07/2021] [Indexed: 11/08/2022]
Abstract
As the peritoneum is the most common site of metastatic disease at diagnosis, disease identified at staging laparoscopy, and site of recurrence for patients with gastric cancer, intraperitoneal therapy has been an area of interest for many investigators. There are several ways to categorize the existing trials and studies. One is by indication, which includes palliative, neoadjuvant, adjuvant, and prophylactic. Another is by treatment modality which includes approaches such as hyperthermic intraperitoneal chemotherapy, pressurized intraperitoneal aerosol chemotherapy, intraperitoneal normothermic chemotherapy, and bidirectional combinations of systemic and intraperitoneal therapy. Recently completed and ongoing trials of peritoneal therapy in gastric cancer may be improving on the historically dismal survival rates for patients with carcinomatosis or disease at high risk of peritoneal recurrence. All completed randomized trials are from outside the United States, and additional studies of peritoneal therapy in Western populations are needed to clarify survival outcomes. Cooperative group trials and multi-institutional registry study efforts are ongoing to help address this clear area of unmet need.
Collapse
Affiliation(s)
- Brian Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
44
|
Kepenekian V, Péron J, You B, Bonnefoy I, Villeneuve L, Alyami M, Bakrin N, Rousset P, Benzerdjeb N, Glehen O. Non-resectable Malignant Peritoneal Mesothelioma Treated with Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) Plus Systemic Chemotherapy Could Lead to Secondary Complete Cytoreductive Surgery: A Cohort Study. Ann Surg Oncol 2021; 29:2104-2113. [PMID: 34713369 DOI: 10.1245/s10434-021-10983-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diffuse malignant peritoneal mesothelioma (DMPM) is an aggressive primary peritoneal neoplasia. At diagnosis, few patients are eligible for a recommended cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Among neoadjuvant strategies, pressurized intraperitoneal aerosol chemotherapy (PIPAC) combined with systemic chemotherapy has been recently proposed. This study evaluated this strategy in a cohort of DMPM patients. METHODS Patients with DMPM and primary or recurrent non-resectable diseases who received at least one PIPAC procedure in alternation with systemic chemotherapy were included in this retrospective study to analyze oncologic outcomes. RESULTS Overall, 26 DMPM patients were treated with at least one PIPAC, including 20 patients with no previous CRS. Of 22 patients (85%) who had symptoms, 9 had perceptible ascites. Overall, 79 PIPAC procedures were performed, with half of the patients receiving three PIPAC procedures or more. Among eight patients (31%), 10 adverse events (13% of procedures) were reported, including two severe complications, both corresponding to digestive perforations. Improvement of symptoms was reported for 32% of the patients, whereas control of ascites was noted in 46%. All but one procedure among 14 patients (54%) secondarily treated by CRS-HIPEC were considered complete resections. After a median follow-up period of 29.6 months (95% confidence interval [CI], 17.6-not reached [NR]), the median overall survival period was 12 months (95% CI 11.1-NR). The median progression-free survival (PFS) was significantly better among the patients who underwent resection than among those who did not (33.5 vs 7.4 months; hazard ratio [HR], 0.18; 95% CI 0.06-0.755; p < 0.001). CONCLUSIONS For patients with initially non-resectable DMPM, PIPAC is feasible for treatment with neoadjuvant intent and could facilitate complete secondary resection.
Collapse
Affiliation(s)
- Vahan Kepenekian
- Service de Chirurgie Digestive, Hospices Civils de Lyon, Hôpital Lyon Sud, Université Lyon-1, Pierre-Bénite, Lyon, France. .,Faculté de Médecine Lyon-Sud, Université de Lyon, Université Claude Bernard Lyon 1, EA3738 CICLY, Lyon, France.
| | - Julien Péron
- Service d'oncologie Médicale, Institut de Cancérologie des Hospices Civils de Lyon, Lyon, France.,Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Benoit You
- Faculté de Médecine Lyon-Sud, Université de Lyon, Université Claude Bernard Lyon 1, EA3738 CICLY, Lyon, France.,Service d'oncologie Médicale, Institut de Cancérologie des Hospices Civils de Lyon, Lyon, France
| | - Isabelle Bonnefoy
- Service de Chirurgie Digestive, Hospices Civils de Lyon, Hôpital Lyon Sud, Université Lyon-1, Pierre-Bénite, Lyon, France.,Faculté de Médecine Lyon-Sud, Université de Lyon, Université Claude Bernard Lyon 1, EA3738 CICLY, Lyon, France
| | - Laurent Villeneuve
- Faculté de Médecine Lyon-Sud, Université de Lyon, Université Claude Bernard Lyon 1, EA3738 CICLY, Lyon, France.,Service de Recherche et d'Epidémiologie Cliniques, Hospices Civils de Lyon, Hôpital Lyon Sud, Université Lyon-1, Lyon, France
| | - Mohammad Alyami
- Department of Surgical Oncology, King Khalid University Hospital, Najran, Saudi Arabia
| | - Naoual Bakrin
- Service de Chirurgie Digestive, Hospices Civils de Lyon, Hôpital Lyon Sud, Université Lyon-1, Pierre-Bénite, Lyon, France.,Faculté de Médecine Lyon-Sud, Université de Lyon, Université Claude Bernard Lyon 1, EA3738 CICLY, Lyon, France
| | - Pascal Rousset
- Faculté de Médecine Lyon-Sud, Université de Lyon, Université Claude Bernard Lyon 1, EA3738 CICLY, Lyon, France.,Service d'Imagerie, Hospices Civils de Lyon, Hôpital Lyon Sud, Université Lyon-1, Lyon, France
| | - Nazim Benzerdjeb
- Faculté de Médecine Lyon-Sud, Université de Lyon, Université Claude Bernard Lyon 1, EA3738 CICLY, Lyon, France.,Laboratoire d'Anatomie et Cytologie Pathologiques, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
| | - Olivier Glehen
- Service de Chirurgie Digestive, Hospices Civils de Lyon, Hôpital Lyon Sud, Université Lyon-1, Pierre-Bénite, Lyon, France.,Faculté de Médecine Lyon-Sud, Université de Lyon, Université Claude Bernard Lyon 1, EA3738 CICLY, Lyon, France
| |
Collapse
|
45
|
The Burden of Peritoneal Metastases from Gastric Cancer: A Systematic Review on the Incidence, Risk Factors and Survival. J Clin Med 2021; 10:jcm10214882. [PMID: 34768402 PMCID: PMC8584453 DOI: 10.3390/jcm10214882] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 12/22/2022] Open
Abstract
The peritoneum is a common metastatic site in gastric cancer. This systematic review provides an overview of the incidence, risk factors and survival of synchronous peritoneal metastases from gastric cancer. A systematic search was performed to identify studies wherein the incidence, risk factors and survival of gastric cancer with peritoneal metastases were investigated. Of all 38 potentially eligible studies, 17 studies were included based on the eligibility criteria. The incidence of synchronous gastric peritoneal metastases was reviewed for population-based studies (10–21%), for observational cohort studies (2–15%) and for surgical cohort studies (13–40%). Potential risk factors for synchronous gastric peritoneal metastases were younger age, non-cardia gastric cancer, female sex, signet ring cell carcinoma, diffuse type histology or linitis plastica, T4 stage, Hispanic ethnicity and more than one metastatic location. Synchronous peritoneal metastases are commonly diagnosed in patients with gastric cancer with an incidence up to 21% in recent population-based studies. Furthermore, prognosis of patients with gastric peritoneal metastases is poor with median overall survival ranging from 2 to 9 months. The high incidence and poor prognosis require intensive research on diagnostic features and effective treatment options to improve survival.
Collapse
|
46
|
Tidadini F, Abba J, Quesada JL, Baudrant M, Bonne A, Foote A, Faucheron JL, Glehen O, Villeneuve L, Arvieux C. Effect of Pressurized Intraperitoneal Aerosol Chemotherapy on the Survival Rate of Patients with Peritoneal Carcinomatosis of Gastric Origin. J Gastrointest Cancer 2021; 53:971-979. [PMID: 34677795 DOI: 10.1007/s12029-021-00698-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new surgical technique for the treatment of initially unresectable peritoneal carcinomatosis (PC). Our objective was to compare the results of PIPAC associated with systemic chemotherapy (PIPAC_CHEM) with those of systemic chemotherapy alone (ONLY_CHEM) in patients with gastric PC without metastasis other than peritoneal, and the WHO performance status < 3. METHODS This was a retrospective, single center, comparative non-randomized study. Seventeen PIPAC_CHEM patients were compared to 29 ONLY_CHEM patients. The primary endpoint was overall survival at 6 months from diagnosis of PC. RESULTS Ninety-eight patients were screened and 46 were included (PIPAC_CHEM, n = 17; ONLY_CHEM, n = 29). The PIPAC_ CHEM population was significantly younger (median 64 years [56; 68] vs 74 years [61; 79]; p = 0.0054). Median PIPAC session per patient is 2 [1-3]. Six-month survival was significantly higher in the PIPAC_CHEM group than in the ONLY_CHEM group 16/17 (94.1% [65-99.2]) vs 19/29 (65.5% [45.4-79.7]), respectively; p = 0.029. Over the entire follow-up, median survival [95% CI] was 12.8 months [7.2-34.3] with PIPAC vs 9.1 months [5.4-11.5] without, p = 0.056. At 6 months, median length of additional hospitalization was significantly less for PIPAC_CHEM (median 2 days [2-7]) than without PIPAC (median 11 days [3-21]) (p = 0.045). CONCLUSION The overall survival at 6 months after the diagnosis of carcinomatosis was significantly better for PIPAC_CHEM patients. This difference appears to continue until at least 18 months. At 6 months, days of additional hospitalization was significantly less in the PIPAC_CHEM group. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT 04,879,953.
Collapse
Affiliation(s)
- Fatah Tidadini
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France.,Lyon Center for lnnovation in Cancer- EA 3738, Lyon 1 University, Lyon, EA, France
| | - Julio Abba
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Louis Quesada
- Clinical Pharmacology Unit, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France
| | - Magalie Baudrant
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Aline Bonne
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Alison Foote
- Clinical Pharmacology Unit, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Luc Faucheron
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Olivier Glehen
- Lyon Center for lnnovation in Cancer- EA 3738, Lyon 1 University, Lyon, EA, France
| | - Laurent Villeneuve
- Lyon Center for lnnovation in Cancer- EA 3738, Lyon 1 University, Lyon, EA, France
| | - Catherine Arvieux
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France. .,Lyon Center for lnnovation in Cancer- EA 3738, Lyon 1 University, Lyon, EA, France.
| |
Collapse
|
47
|
Badgwell B. Is PIPAC a New Summit for Peritoneal Disease Treatment or are we Lost in the Snowstorm? Ann Surg Oncol 2021; 29:13-14. [PMID: 34642846 DOI: 10.1245/s10434-021-10899-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/26/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Brian Badgwell
- MD Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, TX, 77030, USA.
| |
Collapse
|
48
|
Sindayigaya R, Dogan C, Demtröder CR, Fischer B, Karam E, Buggisch JR, Tempfer CB, Lecomte T, Ouaissi M, Giger-Pabst U. Clinical Outcome for Patients Managed with Low-Dose Cisplatin and Doxorubicin Delivered as Pressurized Intraperitoneal Aerosol Chemotherapy for Unresectable Peritoneal Metastases of Gastric Cancer. Ann Surg Oncol 2021; 29:112-123. [PMID: 34611790 DOI: 10.1245/s10434-021-10860-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/04/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is increasingly used to manage gastric cancer peritoneal metastasis (GCPM). METHODS This study analyzed a prospective database of GCPM patients treated with cisplatin and doxorubicin PIPAC (PIPAC-C/D). The outcome criteria were adverse events, pathologic response [peritoneal regression grading score (PRGS)], and overall survival (OS). RESULTS The PIPAC-C/D procedure was scheduled for 144 patients with a median age of 57 years (range 22-88 years). Access to the abdominal cavity for the first PIPAC failed in 11 patients (7.7 %). A total of 296 procedures were performed for 131 patients. Of the 144 patients, 52 (36.1%) underwent one PIPAC, 32 (22.2%) underwent two PIPACs, 24 (16.7%) underwent three PIPACs, and 21 (14.6%) underwent four or more PIPACs. The overall morbidity/mortality was grade 1 for 22 patients (15.3%), grade 2 for 32 patients (22.2%), grade 3 for 7 patients (4.9%), grade 4 for no patients (0%), and grade 5 for 2 patients (1.4%). Of the 37 patients who had three or more PIPACs eligible for histopathologic response analysis, 27 (73%) had major or complete regression (PRGS 1/2). A median OS of 11 months (range 0-61 months) for the total study population and 16 months (range 2-61 months) for the patients with three or more PIPACs was observed. For 10 patients (7%) who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, the median OS was 15 months (minimum, 4 months; maximum, 27 months). Multivariate analysis showed three or more PIPACs to be an independent prognostic factor for improved OS (hazard ratio, 0.36; p < 0.0001). CONCLUSIONS Repetitive PIPAC-C/D ± systemic chemotherapy is associated with low morbidity and mortality rates. Prospective randomized trials are needed to confirm whether three or more PIPAC-C/Ds improve clinical outcome.
Collapse
Affiliation(s)
- Rémy Sindayigaya
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic and Liver Transplant Surgery, Trousseau Hospital, Chambray les Tours, France
| | - Can Dogan
- Department of Surgery and Therapy Center for Peritonealcarcinomatosis, Marien Hospital Herne, Ruhr University Bochum, Herne, Germany
| | - Cédric Remy Demtröder
- Department of Surgery and Therapy Center for Peritonealcarcinomatosis, Marien Hospital Herne, Ruhr University Bochum, Herne, Germany.,Department of General and Visceral Surgery, Therapy Center for Metabolic and Bariatric Surgery, St. Martinus Hospital Düsseldorf, Düsseldorf, Germany
| | - Britta Fischer
- Department of Surgery and Therapy Center for Peritonealcarcinomatosis, Marien Hospital Herne, Ruhr University Bochum, Herne, Germany
| | - Elias Karam
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic and Liver Transplant Surgery, Trousseau Hospital, Chambray les Tours, France
| | | | - Clemens B Tempfer
- Department of Obstetrics and Gynecology and Therapy Center for Peritoneal Carcinomatosis, Marien Hospital Herne, Ruhr-Universität Bochum, Herne, Germany
| | - Thierry Lecomte
- Department of Hepatogastroenterology and Digestive Oncology, Trousseau Hospital, Chambray les Tours, France
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic and Liver Transplant Surgery, Trousseau Hospital, Chambray les Tours, France.
| | - Urs Giger-Pabst
- Department of Surgery and Therapy Center for Peritonealcarcinomatosis, Marien Hospital Herne, Ruhr University Bochum, Herne, Germany.,Department of General, Visceral, and Transplant Surgery, University Hospital of Münster, Münster, Germany.,University of Applied Science Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
49
|
Račkauskas R, Baušys A, Lukšta M, Jurgaitis J, Paškonis M, Strupas K. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) for peritoneal malignancy: initial experience of the first program in the Baltic countries. World J Surg Oncol 2021; 19:236. [PMID: 34376191 PMCID: PMC8356452 DOI: 10.1186/s12957-021-02357-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/01/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Peritoneal malignancies include primary and metastatic cancer of the peritoneal cavity. The most common origin for peritoneal metastasis is ovarian, gastric, and colorectal cancers. Irrespective of the origin, peritoneal metastases represent the advanced disease and are associated with poor long-term outcomes. The minimally invasive approach of pressurized intraperitoneal aerosol chemotherapy (PIPAC) allows repeated applications and objective assessment of tumor response by comparing histological samples. This study aimed to investigate the initial experience with PIPAC in the Baltic region. METHODS All patients who underwent PIPAC at Vilnius University Hospital Santaros Klinikos between 2015 and 2020 were included in this retrospective study. The primary outcome of the study was overall survival (OS) in patients with peritoneal carcinomatosis treated by PIPAC. The secondary outcomes included postoperative morbidity; peritoneal carcinomatosis index (PCI) and ascites reduction after treatment by PIPAC. RESULTS In total, 15 patients underwent 34 PIPAC procedures. PIPAC-related intraoperative and postoperative morbidity occurred in 3 (8.8%) of 34 procedures. Following PIPAC, the median PCI decreased from 8 (4; 15) to 5 (1; 16) in GC patients, although, the difference failed for significance, p = 0.581. In OC patients, PCI after PIPAC remained stable. Median overall survival after PIPAC procedure was 25 (95% CI 5-44) months. Ovarian cancer patients (22; 95% CI 12-44 months) had significantly higher OS, compared to gastric cancer patients (8; 95% CI 4-16 months), p = 0.018. CONCLUSIONS PIPAC is safe and feasible for patients with gastric and ovarian cancers peritoneal metastases.
Collapse
Affiliation(s)
- Rokas Račkauskas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
| | - Augustinas Baušys
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Martynas Lukšta
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jonas Jurgaitis
- Department of Surgery, University hospital of Klaipeda, Klaipeda, Lithuania
| | - Marius Paškonis
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kęstutis Strupas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| |
Collapse
|
50
|
Park SJ, Lee EJ, Lee HS, Kim J, Park S, Ham J, Mun J, Paik H, Lim H, Seol A, Yim GW, Shim SH, Kang BC, Chang SJ, Lim W, Song G, Kim JW, Lee N, Park JW, Lee JC, Kim HS. Development of rotational intraperitoneal pressurized aerosol chemotherapy to enhance drug delivery into the peritoneum. Drug Deliv 2021; 28:1179-1187. [PMID: 34121568 PMCID: PMC8204987 DOI: 10.1080/10717544.2021.1937382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This study aims to evaluate the drug distribution, tissue concentrations, penetration depth, pharmacokinetic properties, and toxicities after rotational intraperitoneal pressurized aerosol chemotherapy (RIPAC) in pigs. Because relevant medical devices have not been introduced, we developed our prototype of pressurized intraperitoneal aerosol chemotherapy (PIPAC) and RIPAC by adding a conical pendulum motion device for rotating the nozzle. RIPAC and PIPAC were conducted using 150 ml of 1% methylene blue to evaluate the drug distribution and 3.5 mg of doxorubicin in 50 ml of 0.9% NaCl to evaluate the tissue concentrations and penetration depth, pharmacokinetic properties, and toxicities. All agents were sprayed as aerosols via the nozzle, DreamPen® (Dalim Biotech, Gangwon, South Korea), with a velocity of 5 km/h at a flow rate of 30 ml/min under a pressure of 7 bars, and capnoperitoneum of 12 mmHg was maintained for 30 min. As a result, RIPAC showed a wider distribution and stronger intensity than PIPAC. Compared with PIPAC, RIPAC demonstrated high values of the tissue concentration in the central, right upper, epigastrium, left upper, left lower, right lower, and right flank regions (median, 375.5-2124.9 vs. 161.7-1240 ng/ml; p ≤ .05), and higher values of the depth of concentrated diffusion and depth of maximal diffusion (median, 232.5-392.7 vs. 116.9-240.1 μm; 291.2-551.2 vs. 250.5-362.4 μm; p ≤ .05) in all regions except for bowels. In RIPAC, the pharmacokinetic properties reflected hemodynamic changes during capnoperitoneum, and there were no related toxicities. Conclusively, RIPAC may have the potential to enhance drug delivery into the peritoneum compared to PIPAC.
Collapse
Affiliation(s)
- Soo Jin Park
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun Ji Lee
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee Su Lee
- Interdisciplinary Program in Bioengineering, Seoul National University Graduate School, Seoul, Republic of Korea
| | - Junsik Kim
- Interdisciplinary Program in Bioengineering, Seoul National University Graduate School, Seoul, Republic of Korea
| | - Sunwoo Park
- Institute of Animal Molecular Biotechnology and Department of Biotechnology, College of Life Sciences and Biotechnology, Korea University, Seoul, Republic of Korea
| | - Jiyeon Ham
- Institute of Animal Molecular Biotechnology and Department of Biotechnology, College of Life Sciences and Biotechnology, Korea University, Seoul, Republic of Korea
| | - Jaehee Mun
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Haerin Paik
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyunji Lim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Aeran Seol
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ga Won Yim
- Department of Obstetrics and Gynecology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Beong-Cheol Kang
- Department of Experimental Animal Research, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Suk Joon Chang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Whasun Lim
- Department of Food and Nutrition, Kookmin University, Seoul, Republic of Korea
| | - Gwonhwa Song
- Institute of Animal Molecular Biotechnology and Department of Biotechnology, College of Life Sciences and Biotechnology, Korea University, Seoul, Republic of Korea
| | - Jae-Weon Kim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Nara Lee
- Department of Obstetrics & Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung Chan Lee
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Republic of Korea.,Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University, Seoul, South Korea
| | - Hee Seung Kim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Republic of Korea
| | | |
Collapse
|