Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Peritoneal Metastases: A Systematic Review

Injectable 2D-MoS2-integrated Bioadhesive Hydrogel as Photothermal-Derived and Drug-Delivery Implant for Colorectal Cancer Therapy

Photothermal therapy (PTT) combined with chemotherapy using hydrogel as a delivery platform is considered a promising strategy for the treatment of advanced colorectal cancer (CRC). However, maintaining the stability of photo-absorbing agents (PTA) in the hydrogel and ensuring that the hydrogel remains anchored to the tumor tissue presents significant challenges. Herein, this work introduces an injectable 2D molybdenum disulfide (2D-MoS2)-integrated adhesive hydrogel, specifically N-(2-aminoethyl)-4-(4-(hydroxymethyl)-2-methoxy-5-nitro-sophenoxy) butanamide-linked sodium alginate-MoS2-5-fluorouracil (AlgNB/MoS2/5-FU). This hydrogel functions as a near-infrared light (NIR)-triggered photothermal and drug-delivery implant for CRC treatment. The MoS2 nanosheets maintain superior dispersibility in the hydrogel and exhibit a highly efficient NIR-triggered photothermal effect. Importantly, the aldehyde group in AlgNB also imparted tissue adhesion to the hydrogel, the adhesive hydrogel is used to infiltrate and anchor within tumor tissue. The injectable adhesive AlgNB/MoS2/5-FU hydrogel shows remarkable efficacy in inhibiting SW480 cells proliferation and promoting colorectal tumor regression by triggering PTT and delivering the 5-FU drug in both in vitro and in vivo studies. The potential synergistic mechanism of PTT and 5-FU chemotherapy may contribute to inhibiting DNA repair and enhancing a robust immune response. Therefore, this research provides valuable strategic insights for the synergistic treatment of localized CRC.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases: A pragmatic comparison of oncological outcomes in synchronous versus metachronous disease

BACKGROUND

disease burden (PCI), completeness of cytoreduction or histological features, are known to influence survival after CRS-HIPEC for colorectal peritoneal metastases (CPM). However, there is still debate about influence of CPM onset. The aim of this study is to determine the impact of CPM onset on oncological outcomes after CRS-HIPEC.

METHODS

all patients with CPM scheduled for CRS-HIPEC at one reference center between December 2007 and September 2022 were included. s-PM were defined as those diagnosed at primary disease treatment; m-PM were considered those diagnosed during follow-up. Survival outcomes and recurrence rates were compared using a pragmatic analysis.

RESULTS

125 patients with s-CPM and 170 patients with m-CPM were analyzed. Median follow-up was 58.6 and 50.6 months in s-CPM and m-CPM groups(p = 0.11). Complete cytoreduction (CCS-0/-1) rates were comparable: 84 % s-CPM vs. 88.2 % m-CPM(p = 0.190). Overall survival (OS) was significantly shorter in s-CPM: 24.7 vs. 46.6 months (p = 0.024). Conversely, median disease-free survival was similar in both groups, 10 months vs. 11 months(p = 0.155). Patients in the s-CPM group presented more pN+(p = 0.001), higher histologic grade(p = 0.007) and PCI(p = 0.04), and higher rate of concurrent liver metastases(p = 0.004). RAS/BRAF gene mutations and microsatellite instability did not differ significantly. Perioperative chemotherapy regimens and tolerance were also similar.

CONCLUSIONS

despite s-CPM being associated with impaired OS after CRS-HIPEC, the onset of PM was not found to be an independent determinant for survival. High-risk molecular and histological features strongly influence oncological outcomes after CRS-HIPEC. This is valuable data that could aid in preoperative patient selection process for CRS-HIPEC.

Textbook Outcomes Among Patients Undergoing CRS+HIPEC for Peritoneal Surface Malignancies in an Eastern European Population

BACKGROUND

The preferred treatment option for patients with limited peritoneal metastasis (PM) is cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS+HIPEC).While the textbook outcome (TO) concept has been applied to other complex surgeries, its prevalence, determinants, and impact in patients with PM remain unclear. This study sought to identify factors influencing TO among individuals with PM undergoing CRS+HIPEC in an Eastern European population.

MATERIALS AND METHODS

Between 2010 and 2023, 300 patients with PM were treated at the Department of Surgical Oncology, Medical University of Lublin. In this cohort, 155 patients were scheduled for CRS+HIPEC to achieve complete cytoreduction.

RESULTS

Overall, TO achievement in the entire cohort was 56.1%. Patients with gastrointestinal or peritoneal cancers had lower odds of achieving TO compared with individuals with ovarian cancer (51.4% vs. 68.2%; OR 0.49; 95% CI 0.24-1.03). Patients with PCI (Peritoneal Cancer Index) ≥14 had lower odds of achieving TO compared with individuals with PCI <14 (31.4% vs. 63.3%; OR 0.27; 95%CI 0.12-0.59). Achievement of completeness of cytoreduction (CCR 0/1) increased the odds of TO compared with non-completed CRS (CCR≥2, 63.5%vs.0%; OR 64.11; 95%CI 3.78-1086.72). Median overall survival (OS) for the entire cohort was 37.5 months. Achievement of TO was associated with decreased hazards of death among patients with PM undergoing CRS+HIPEC (HR 0.55; 95%CI 0.34-0.88) CONCLUSION: TO achievement improved overall survival (OS) among patients with PM undergoing CRS+HIPEC. Barriers to achieving TO included PCI ≥14, perioperative complications and incomplete cytoreduction.

Reported outcomes following cytoreductive surgery for colorectal peritoneal metastases: A systematic review to inform evidence-based practice and international consensus

AIM

Cytoreductive surgery provides a chance for long-term survival and cure in selected patients with colorectal peritoneal metastases. As clinical and academic interest in this field increases, heterogeneity in outcome reporting hinders the valid and meaningful synthesis of data into high-quality meta-analyses. The aim of this systemic review was to investigate variability in outcome reporting following cytoreductive surgery with or without intraperitoneal chemotherapy for colorectal peritoneal metastases.

METHOD

Five electronic databases [MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINAHL)] were interrogated from 2000 to October 2023 to identify all reported outcomes in the current literature. Extracted outcomes were catalogued and reviewed by a multidisciplinary working group into standardized terms and domains.

RESULTS

A total of 294 studies, from 5112 screened, were included for analysis. We extracted 2903 outcomes verbatim from included studies and catalogued them into 85 standardized outcomes across seven outcome domains. The most frequently reported domains were survival, in 274 (93%) studies, and pathological outcomes, in 232 (79%) studies. Outcomes pertaining to function and life impact were only reported in seven (2%) studies. Reported outcomes were only defined in 35% of cases, and significant variability existed between definitions.

CONCLUSION

This systematic review highlights the heterogeneity of outcome measurement and reporting following cytoreductive surgery for colorectal peritoneal metastases. Patient-reported outcomes are relatively underrepresented in the current literature. The results of this review will inform an international collaborative effort to create a core outcome set to address these issues.

Effectiveness of hyperthermic intraperitoneal chemotherapy during primary curative resection for colorectal carcinoma

PURPOSE

Peritoneal metastasis (PM) is the life-threatening cause of colorectal cancer patients (CRC). Adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) plus cytoreductive surgery exhibited promising effects in preventing recurrence and increasing the survival of CRC patients. However, the outcomes of HIPEC on treating advanced CRC with risk of PM are still controversial. Here, we retrospectively examined the impact of HIPEC on preventing PM and its overall effects on patients with locally advanced CRC who underwent primary curative resection at our center.

METHODS

We retrospectively analyzed 45 patients diagnosed with locally advanced colorectal cancer (CRC) who underwent primary curative laparoscopic surgery with proactive hyperthermic intraperitoneal chemotherapy (HIPEC), in conjunction with adjuvant systemic chemotherapy at our center between 2019 and 2022. An additional 55 patients with locally advanced CRC who underwent similar surgery and received adjuvant systemic chemotherapy but did not undergo HIPEC during the same period were selected as the control group. Disease-free survival (DFS), overall survival (OS), and PM incidence were compared between patients with and without HIPEC.

RESULTS AND CONCLUSIONS

The cumulative PM incidence was 2.2% in the HIPEC group and 14.5% in the control group(P = 0.0347). No significant adverse effects were observed in the HIPEC group. Furthermore, Kaplan-Meier survival analysis showed that the HIPEC correlated to better DFS [hazard ratio (HR) 0.4670, 95% confidence interval (CI) 0.2305-0.9462; P = 0.0345] and extended the overall survival of CRC patients [hazard ratio (HR) 0.3978, 95% confidence interval (CI) 0.1684-0.9395; P = 0.0355]. Therefore, our data supports that adjuvant HIPEC can prevent peritoneal failure in CRC patients and improve both PFS and OS survival following primary curative resection.

PIPAC Pharmacologic and Clinical Data

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) emerged as an innovative intraperitoneal chemotherapy delivery system to overcome the issue of limited efficacy of systemic therapies to induce response in peritoneal malignancies. Promising results for patients with mesothelioma peritonei and peritoneal metastasis from gastric, ovarian, colorectal, pancreatic, and hepatobiliary tumors origin are changing the landscape for patients otherwise just facing palliative treatment. Ongoing trials will shed more light on the actual benefits of PIPAC.

Development of a prediction model for recurrence in patients with colorectal peritoneal metastases undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

INTRODUCTION

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) improves survival outcomes for selected patients with colorectal peritoneal metastases (PM), but recurrence rates are high. The aim of this study was to develop a tool to predict recurrence in patients with colorectal PM that undergo CRS-HIPEC.

MATERIALS AND METHODS

For this retrospective cohort study, data of patients that underwent CRS-HIPEC for colorectal PM from four Dutch HIPEC centers were used. Exclusion criteria were perioperative systemic therapy and peritoneal cancer index (PCI) ≥20. Nine previously identified factors were considered as predictors: gender, age, primary tumor characteristics (location, nodal stage, differentiation, and mutation status), synchronous liver metastases, preoperative Carcino-Embryonal Antigen (CEA), and peritoneal cancer index (PCI). The prediction model was developed using multivariable Cox regression and validated internally using bootstrapping. The performance of the model was evaluated by discrimination and calibration.

RESULTS

In total, 408 patients were included. During the follow-up, recurrence of disease occurred in 318 patients (78%). Significant predictors of recurrence were PCI (HR 1.075, 95% CI 1.044-1.108) and primary tumor location (left sided HR 0.719, 95% CI 0.550-0.939). The prediction model for recurrence showed fair discrimination with a C-index of 0.64 (95% CI 0.62, 0.66) after internal validation. The model was well-calibrated with good agreement between the predicted and observed probabilities.

CONCLUSION

We developed a prediction tool that could aid in the prediction of recurrence in patients with colorectal PM who undergo CRS-HIPEC.

Elderly Rectal Cancer: An Updated Review

PURPOSE OF REVIEW

Treatment of rectal cancer patients of advanced age should be modulated by life expectancy and tolerance. Due to the rapid advance of this field, we aim to conduct an updated review of this topic.

RECENT FINDINGS

The field of elderly rectal cancer has advanced a lot. This review covers all the treatment aspects of elderly rectal cancer, including the prognostic factor, surgery, radiotherapy, chemotherapy, and palliative treatment. We also provide the future aspect of the management of elderly rectal cancer. The advancement of prognostic factor research, surgery, radiotherapy, chemotherapy, and palliative treatment has made the care of elderly rectal cancer patients better. The future of these fields should focus on the definition of the elderly and the application of particle therapy.

Enhanced Chemo-Immunotherapy Strategy Utilizing Injectable Thermosensitive Hydrogel for The Treatment of Diffuse Peritoneal Metastasis in Advanced Colorectal Cancer

Patients with colorectal cancer (CRC) and diffuse peritoneal metastasis (PM) are not eligible for surgical intervention. Thus, palliative treatment remains the standard of care in clinical practice. Systemic chemotherapy fails to cause drug accumulation at the lesion sites, while intraperitoneal chemotherapy (IPC) is limited by high clearance rates and associated complications. Given the poor prognosis, a customized OxP/R848@PLEL hydrogel delivery system has been devised to improve the clinical benefit of advanced CRC with diffuse PM. This system is distinguished by its simplicity, security, and efficiency. Specifically, the PLEL hydrogel exhibits excellent injectability and thermosensitivity, enabling the formation of drug depots within the abdominal cavity, rendering it an optimal carrier for IPC. Oxaliplatin (OxP), a first-line drug for advanced CRC, is cytotoxic and enhances the immunogenicity of tumors by inducing immunogenic cell death. Furthermore, OxP and resiquimod (R848) synergistically enhance the maturation of dendritic cells, promote the expansion of cytotoxic T lymphocytes, and induce the formation of central memory T cells. Moreover, R848 domesticates macrophages to an anti-tumor phenotype. OxP/R848@PLEL effectively eradicates peritoneal metastases, completely inhibits ascites production, and significantly prolongs mice lifespan. As such, it provides a promising approach to managing diffuse PM in patients with CRC without surgical indications.

Peritoneal Metastasis: A Dilemma and Challenge in the Treatment of Metastatic Colorectal Cancer

Peritoneal metastasis (PM) is a common mode of distant metastasis in colorectal cancer (CRC) and has a poorer prognosis compared to other metastatic sites. The formation of PM foci depends on the synergistic effect of multiple molecules and the modulation of various components of the tumor microenvironment. The current treatment of CRC-PM is based on systemic chemotherapy. However, recent developments in local therapeutic modalities, such as cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC), have improved the survival of these patients. This article reviews the research progress on the mechanism, characteristics, diagnosis, and treatment strategies of CRC-PM, and discusses the current challenges, so as to deepen the understanding of CRC-PM among clinicians.

Use of Prognostic Factors and Scores in Selection of Patients with Colorectal Cancer Peritoneal Metastasis (CRPM) for Cytoreductive Surgery and Intraperitoneal Chemotherapy (CRS/IPC): Results of an International Survey Among Oncologic Clinicians

BACKGROUND

No universally accepted guidelines exist for treatment of patients with colorectal cancer peritoneal metastases (CRPM) undergoing cytoreductive surgery and intraperitoneal chemotherapy (CRS/IPC). Several uncertainties remain concerning almost every aspect of this treatment modality, resulting in marked variability in patient management and likely outcomes. This survey aimed to define variations and trends in clinician decision making more clearly.

METHODS

A 41-question web-based survey was distributed electronically via the Peritoneal Surface Oncology Group International (PSOGI), the International Society for the Study of Pleura and Peritoneum (ISSPP) as well as via social media (particularly Twitter). The survey sought to address and record clinician responses regarding patient workup/assessment, selection for preoperative systemic therapy, preoperative and intraoperative selection for CRS/IPC, and consideration of prognosis and complications.

RESULTS

Complete responses were received from 60 clinicians from 45 centres in 22 countries. Upon assessment of survey responses, several interesting trends were noted in each section of the survey. Significant variability in surgeon practice and opinion were identified concerning almost every aspect of the treatment modality.

CONCLUSION

This international survey provides the most comprehensive insight into clinician decision-making trends regarding patient assessment, selection and management. This should allow areas of variability to be more clearly defined and could potentially prompt development of initiatives for achieving consensus and standardisation of care in the future.

The prognostic impact of lead times in colorectal cancer patients undergoing cytoreductive surgery and HIPEC

Background

National lead time goals have been implemented across Sweden to standardize and improve cancer patient care. However, the prognostic impact of lead times has not yet been studied in patients with colorectal cancer and peritoneal metastases scheduled for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC).

Aim

To study the correlation between lead times and overall survival and operability.

Methods

One hundred forty-eight patients with peritoneal metastases originating from colorectal cancer and scheduled for CRS + HIPEC from June 2012 to December 2019 were identified using a HIPEC register at Uppsala University Hospital. Data were collected from medical records concerning operability, overall survival, recurrence and time from diagnosis, and decision to operate to the date of surgery. Patients who had neoadjuvant therapy or no malignant cells in the resected specimens were excluded. Statistical calculations were made with the chi-squared test, Cox regression analysis, and log-rank test.

Results

The median age was 66 years (27–82). Ninety-five were women and 53 were men. One hundred six underwent CRS + HIPEC, 13 CRS only, and 29 were inoperable (open-close). No difference in overall survival was seen when comparing patients with lead times ≤ 34 days and ≥ 35 days from the decision to operate at the multidisciplinary conference to the surgery but there was a higher frequency of open-close (p = 0.023) in the group with longer lead time. Factors that impacted overall survival were open-close (p < 0.001), liver metastases (p = 0.003), and peritoneal cancer index score ≥ 20 (p < 0.001).

Conclusion

A long lead time from multidisciplinary conference to surgery has no direct impact on overall survival but can result in more cases of inoperability. In a larger cohort, this might translate into decreased survival, and efforts should therefore be made to complete preoperative work up as soon as possible and reduce overall time span. Important factors for survival are related to patient selection and extent of disease.

The Onset of In-Vivo Dehydration in Gas -Based Intraperitoneal Hyperthermia and Its Cytotoxic Effects on Colon Cancer Cells

Background

Peritoneal metastasis (PM) is an ongoing challenge in surgical oncology. Current therapeutic options, including intravenous and intraperitoneal (i.p.) chemotherapies display limited clinical efficacy, resulting in an overall poor prognosis in affected patients. Combined hyperthermia and dehydration induced by a high-flow, gas-based i.p. hyperthermic procedure could be a novel approach in PM treatment. Our study is the first to evaluate the therapeutic potential of i.p. dehydration, hyperthermia, as well as the combination of both mechanisms in an in-vivo setting.

Methods

For this study, three swine were subjected to diagnostic laparoscopy under a high-flow air stream at 48°, 49° and 50°Celsius (C). Hygrometry of the in- and outflow airstream was measured to calculate surface evaporation and i.p. dehydration. To analyze the effects of this concept, in vitro colon cancer cells (HT-29) were treated with hyperthermia and dehydration. Cytotoxicity and cell viability were measured at different time intervals. Additionally, structural changes of dehydrated cells were analyzed using scanning electron microscopy.

Results

According to our results, both dehydration and hyperthermia were cytotoxic to HT-29 cells. However, while dehydration reduced cell viability, hyperthermia did not. However, dehydration effects on cell viability were significantly increased when combined with hyperthermia (p<0.01).

Conclusions

Changes to the physiological milieu of the peritoneal cavity could significantly reduce PM. Therefore, limited dehydration of the abdominal cavity might be a feasible, additional tool in PM treatment. Further studies are required to investigate dehydration effects and their applicability in PM management.

Senescent Tumor Cells in the Peritoneal Carcinomatosis Drive Immunosenescence in the Tumor Microenvironment

More than half of all patients with colorectal cancer (CRC) develop distant metastasis and, depending on the local stage of the primary tumor, up to 48% of patients present peritoneal carcinomatosis (PC). PC is often considered as a widespread metastatic disease, which is almost resistant to current systemic therapies like chemotherapeutic and immunotherapeutic regimens. Here we could show that tumor cells of PC besides being senescent also exhibit stem cell features. To investigate these surprising findings in more detail, we established a murine model based on tumor organoids that resembles the clinical setting. In this murine orthotopic transplantation model for peritoneal carcinomatosis, we could show that the metastatic site in the peritoneum is responsible for senescence and stemness induction in tumor cells and that induction of senescence is not due to oncogene activation or therapy. In both mouse and human PC, senescence is associated with a senescence-associated secretory phenotype (SASP) influencing the tumor microenvironment (TME) of PC. SASP factors are able to induce a senescence phenotype in neighbouring cells. Here we could show that SASP leads to enhanced immunosenescence in the TME of PC. Our results provide a new immunoescape mechanism in PC explaining the resistance of PC to known chemo- and immunotherapeutic approaches. Therefore, senolytic approaches may represent a novel roadmap to target this terminal stage of CRC.