Colorectal Cancer Metastases

The impact of the extent of surgery on late adverse effects following cytoreductive surgery and HIPEC

AIM

To investigate the impact of the surgical extent on late adverse effects (LAE) following cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

METHOD

A prospective cohort study including patients undergoing CRS + HIPEC due to peritoneal metastases from gastrointestinal tumour origin. From 2006 through 2019, consecutive patients treated with CRS + HIPEC were followed at 3, 6 and 12 months, and LAEs were assessed using the symptom scales and items from the European Organization for Research and Treatment of Cancer QLQ-C30 (EORTC QLQ-C30). Surgical extent was categorized into three groups (major, intermediate, minor) based on peritonectomy procedures and colorectal resections performed as part of CRS. EORTC data were analysed using a linear mixed effects regression model adjusted for age, gender, origin of tumour and comorbidity.

RESULTS

In total, 257 patients who responded to at least one questionnaire during the follow-ups were included. Only diarrhoea symptoms were positively associated with surgical extent (mean differences: major vs. minor: 8.4 (-0.5; 17.2) (p = 0.06) and major vs. intermediate: 10.9 (3.8; 18.0) (p = 0.00)). Additionally, diarrhoea symptoms persisted throughout the study period and did not change over time (mean difference 12-3 months: -3.6 (-9.1; 1.7) (p-value = 0.18)). Overall, the levels of different symptom scales (fatigue, nausea and vomiting, pain, dyspnoea, and appetite loss) significantly decreased from 3 to 12 months.

CONCLUSION

Patients undergoing extensive CRS suffer from persistent impaired gastrointestinal function in terms of diarrhoea compared patients undergoing to less extensive surgery. Attention should be directed at detecting such LAE and to guide patients accordingly.

Incomplete Cytoreduction of Colorectal Cancer Peritoneal Metastases: Survival Outcomes by a Cytoreduction Score

<b><i>Background:</i></b> The surgical management of peritoneal metastases from colorectal cancer has been a topic of controversial discussion for many decades. Peritonectomy and perioperative intraperitoneal chemotherapy added options for surgical treatment of this condition beyond palliative surgery. The most favorable outcomes are recorded when peritoneal metastases from colorectal cancer can be resected to no visible evidence of disease. <b><i>Methods:</i></b> To determine if any benefit from surgical treatment of patients with colorectal peritoneal metastases can occur from incomplete resection of peritoneal metastases, we studied patients by the completeness of cytoreduction (CC) score. The CC-3 indicated a palliative resection, CC-2 gross residual disease, and CC-1 almost complete cytoreduction but visible residual disease. The impact of clinical-, pathologic-, and treatment-related variables on the survival of the three groups was compared. <b><i>Results:</i></b> Eighty-five patients with long-term follow-up were available for study. The median age was 53 years (range 18–82). There were 60 males (70.6%). Symptomatic patients, those with bowel obstruction, and patients with positive retroperitoneal lymph nodes had significantly reduced survival. The median survival of the CC-3, CC-2, and CC-1 groups were significantly different (<i>p</i> = 0.0027). The 2-year or greater survivals of the three groups were 4.8%, 15.1%, and 38.7%, respectively. <b><i>Conclusions:</i></b> If a near complete cytoreduction combined with hyperthermic intraperitoneal chemotherapy can be performed, short-term survival benefit could be observed.

Prevention and Treatment of Peritoneal Metastases: a Comprehensive Review

Peritoneal metastases may occur from a majority of cancers that occur within the abdomen or pelvis. When cancer spread to the peritoneal surfaces is documented, a decision regarding palliation versus an aggressive approach using cytoreductive surgery (CRS) and hyperthermic perioperative intraperitoneal chemotherapy (HIPEC) must be made. This decision is dependent on a well-defined group of prognostic indicators. In addition to treatment, prevention of peritoneal metastases may be an option. The clinical and pathologic features of a primary cancer can be used to select perioperative treatments that may prevent cancer cells within the abdomen and pelvis from progressing to established peritoneal metastases. In some clinical situations with appendiceal and colorectal cancers, the clinical or histopathologic features may indicate that second-look surgery plus perioperative chemotherapy should occur. Peritoneal metastases should always be considered by the multidisciplinary team for treatment or prevention.

Peritoneal Metastases from Gastrointestinal Cancer

PURPOSE OF REVIEW

Peritoneal metastases may occur from a majority of cancers that occur within the abdomen or pelvis. When cancer spread to the peritoneal surfaces is documented, a decision regarding palliation vs. an aggressive approach using cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy must be made. The perioperative chemotherapy may be hyperthermic intraperitoneal chemotherapy (HIPEC) administered in the operating room or early postoperative intraperitoneal chemotherapy (EPIC) administered in the first 4 or 5 postoperative days.

RECENT FINDINGS

This decision is dependent on a well-defined group of prognostic indicators. In addition to treatment, the clinical and pathologic features of a primary cancer can be used to select perioperative treatments that may prevent cancer cells within the abdomen and pelvis from progressing to established peritoneal metastases. In some clinical situations with appendiceal and colorectal cancers, the clinical or histopathologic features may indicate that second-look surgery plus perioperative chemotherapy should occur. Peritoneal metastases should always be considered for treatment or prevention.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) at the Time of Primary Curative Surgery in Patients with Colorectal Cancer at High Risk for Metachronous Peritoneal Metastases

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) are maximally effective in early-stage colorectal cancer peritoneal metastases (CRC-PM); however, the use of HIPEC to treat subclinical-stage PM remains controversial. This prospective two-center study assessed adjuvant HIPEC in CRC patients at high risk for metachronous PM ( www.clinicaltrials.gov NCT02575859).

METHODS

During 2006-2012, a total of 22 patients without systemic metastases were prospectively enrolled to receive HIPEC simultaneously with curative surgery, plus adjuvant systemic chemotherapy (oxaliplatin/irinotecan-containing ± biologics), based on primary tumor-associated criteria: resected synchronous ovarian (n = 2) or minimal peritoneal (n = 6) metastases, primaries directly invading other organs (n = 4) or penetrating the visceral peritoneum (n = 10). A control group retrospectively included 44 matched (1:2) patients undergoing standard treatments and no HIPEC during the same period. The cumulative PM incidence was calculated in a competing-risks framework.

RESULTS

Patient characteristics were comparable for all groups. Median follow-up was 65.2 months [95 % confidence interval (CI) 50.9-79.5] in the HIPEC group and 34.5 months (95 % CI 21.1-47.9) in the control group. The 5-year cumulative PM incidence was 9.3 % in the HIPEC group and 42.5 % in the control group (p = 0.004). Kaplan-Meier estimated 5-year overall survival (OS) was 81.3 % in the HIPEC group versus 70.0 % in the control group (p = 0.047). No operative death occurred. Grade 3-4 [National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 4] morbidity rates were 18.2 % in the HIPEC group and 25 % in controls (p = 0.75). At multivariate analysis, HIPEC correlated to lower PM cumulative incidence [hazard ratio (HR) 0.04, 95 % CI 0.01-0.31; p = 0.002], and better OS (HR 0.25, 95 % CI 0.07-0.89; p = 0.039) and progression-free survival (HR 0.31, 95 % CI 0.11-0.85; p = 0.028).

CONCLUSION

Adjuvant HIPEC may benefit CRC patients at high-risk for peritoneal failure. These results warrant confirmation in phase III trials.

Loco-regional cancer drug therapy: present approaches and rapidly reversible hydrophobization (RRH) of therapeutic agents as the future direction

Insufficient drug uptake by solid tumors remains the major problem for systemic chemotherapy. Many studies have demonstrated anticancer drug effects to be dose-dependent, although dose-escalation studies have resulted in limited survival benefit with increased systemic toxicities. One solution to this has been the idea of loco-regional drug treatments, which offer dramatically higher drug concentrations in tumor tissues while minimizing systemic toxicity. Although loco-regional delivery has been most prominent in cancers of the liver, soft tissues and serosal peritoneal malignancies, survival benefits are very far from desirable. This review discusses the evolution of loco-regional treatments, the present approaches and offers rapidly reversible hydrophobization of drugs as the new future direction.

Conference Scene: Second Annual Workshop of the Mid-Atlantic Chapter of the American Society of Peritoneal Surface Malignancy

Second Annual Workshop of the Mid-Atlantic Chapter of the American Society of Peritoneal Surface Malignancy, Mercy Medical Center, Baltimore, MD, USA, 20–21 June 2013

The annual workshop is dedicated to the regional advancement and coordination of efforts to control the peritoneal surface component of gastrointestinal and gynecologic malignancy. It was attended by surgeons, medical oncologists, radiologists, gastroenterologists and nurses involved in clinical and laboratory research efforts to optimally manage peritoneal metastases and peritoneal mesothelioma. During the first day of the 2-day meeting, presentations were coordinated with live video transmission from the operating room at Mercy Medical Center (MD, USA). The live surgery, didactic speeches and patient presentations were displayed for open discussion in real-time. Twenty regional and global opinion leaders spoke and interacted regarding clinical and research information relevant to the rapidly developing multidisciplinary subspecialty of peritoneal surface oncology.