Neutropenia following Perioperative Intraperitoneal Chemotherapy

Peritoneal Mesothelioma: Systematic Review of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) Protocol Outcomes

Diffuse malignant peritoneal mesothelioma (DMPM) prognosis was improved by the locoregional treatment combining cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). HIPEC is a multiparametric treatment with multiple protocols proposed and reviewed in this work. A systematic review of medical literature was performed according to PRISMA guidelines. The search strategy used "malignant peritoneal mesothelioma" and "HIPEC" as keywords in three databases. Studies were included if reporting precisely the HIPEC regimen and the related outcomes, if comparing regimen, or if reporting national/international guidelines. The GRADE methodology was used to rate the level of evidence. Twenty-eight studies were included in this review: 1 was a meta-analysis, 18 reported cohort outcomes, 4 retrospectively compared HIPEC regimens, and 5 were guidelines. Six HIPEC regimens were found, 4 with one drug (cisplatin, mitomycine-C, carboplatin, oxaliplatin), 2 using two drugs (cisplatin-doxorubicin or cisplatin-mitomycine-C). Cisplatin, up to 250 mg/m2 over 90 min, appeared as the key HIPEC drug with a toxicity profile well controlled by the concomitant intravenous perfusion of sodium thiosulfate. Comparative studies tended to show that a bi-drug regimen led to better long-term oncologic outcomes, with cisplatin 50 mg/m2 plus doxorubicin 15 mg/m2 being safe and more efficient. This late protocol was the most widely used and recommended in 3 out of 4 international guidelines. Cisplatin was the preferred drug for HIPEC in DMPM patients. Most of the time, it was combined with doxorubicin for 90 min. A harmonization of protocols and further comparative studies are needed to optimize HIPEC regimen choice.

Side-effects of hyperthermic intraperitoneal chemotherapy in patients with gastrointestinal cancers

Background

Hyperthermic intraperitoneal chemotherapy (HIPEC) produces unwanted side-effects that are mainly caused by chemotherapeutic drugs in the treatment of gastrointestinal (GI) cancers, and these effects have not been systematically summarized. The aim of this article was to provide a comprehensive overview of the side-effects of HIPEC for GI cancers and propose practical strategies for adverse event management.

Methodology

PubMed, Web of Science, and the Cochrane Library were systematically searched for side-effects of HIPEC in GI cancers prior to October 20, 2022. A total of 79 articles were included in this review.

Results

Adverse events, such as enterocutaneous digestive fistulas, GI tract perforation, neutropenia, postoperative bleeding, ventricular tachycardia, hyperglycemia, hypocalcemia, renal impairment, encapsulating peritoneal sclerosis, scrotal ulceration, and sarcopenia were described, and their clinical management was discussed. These side-effects involve the digestive, hematopoietic, circulatory, metabolic, and urinary systems. Effective methods for adverse event management included an expert multidisciplinary team, replacing chemotherapy drugs, using Chinese medicine, and careful preoperative assessments.

Conclusion

The side-effects of HIPEC are frequent and can be minimized by several effective methods. This study proposes practical strategies for adverse event management of HIPEC to assist physicians in choosing the optimal treatment method.

Impact of Mitomycin-C-Induced Neutropenia after Hyperthermic Intraperitoneal Chemotherapy with Cytoreductive Surgery in Colorectal Cancer Patients with Peritoneal Carcinomatosis

Background

Mitomycin-C (MMC) is the most commonly used chemotherapeutic agent for hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery (CRS). However, MMC has a side effect of myelosuppression. This study aimed to evaluate the clinical manifestations and impact of MMC-induced neutropenia after CRS and HIPEC in colorectal cancer patients.

Methods

A total of 124 colorectal cancer patients who underwent CRS with HIPEC between March 2015 and January 2019 were evaluated. Patients with malignancies of non-colorectal origin, hospital stay longer than 60 days, peritoneal cancer index > 30, and complete cytoreduction score > 2 were excluded. MMC 35 mg/m² was administered for 90 min at 41–43 °C. The patients were divided into three groups: no neutropenia, mild neutropenia (grade 1–2), and severe neutropenia (grade 3–4).

Results

In total, mild and severe neutropenia occurred in 30 (24.2%) and 48 (38.7%) patients, respectively. Age and body surface area were significantly different among the neutropenia groups. Severe neutropenia developed significantly earlier than mild neutropenia (6.9 days vs. 10.4 days, p < 0.001) and also lasted significantly longer (4.6 days vs. 2.5 days, p = 0.005). The rate of major postoperative complications was significantly higher in the severe neutropenia group than in the no and mild neutropenia groups (8.3% vs. 6.7% vs. 6.5%, p = 0.015)

Conclusions

Severe neutropenia starts earlier and lasts longer than mild neutropenia after CRS and HIPEC using an MMC triple method. The higher rate of major postoperative complications in patients with severe neutropenia highlights the importance of postoperative management during the neutropenia period.

Efficacy of Adjuvant Systemic Chemotherapy Combined with Radical Surgery and Hyperthermic Intraperitoneal Chemotherapy in Gastric Cancer Treatment

Evaluation of the efficacy of the combination of radical surgery, hyperthermic intraperitoneal chemotherapy (HIPEC), and adjuvant systemic chemotherapy (ACT) in reducing gastric cancer progression in patients with resectable serosa-invasive gastric cancer in a single institution. In 2015-2016, 19 patients with gastric cancer (stage IIB-IIIC) were included in the trial. The trial protocol comprised radical surgery, HIPEC (cisplatin 50 mg/m² + doxorubicin 50 mg/m², 42 °C, 1 hour), and 1-8 cycles of ACT (oxaliplatin 100 mg/m² administered on day 1 of each cycle and oral capecitabine 1000 mg/m² (or tegafur 10-15 mg/kg) administered twice daily on days 1-14 of each cycle with an interval of 7 days between cycles). Following the ACT treatment, the patients were divided into 2 subgroups-those who underwent up to 6 ACT cycles (1-6 cycles, subgroup ≤ 6-8 patients) and those who underwent 7-8 ACT cycles (subgroup > 6-11 patients). Three-year metastasis-free survival (MFS) for the > 6 subgroup was 91 ± 9%. With a follow-up median of 17 months, 3-year MFS for the ≤ 6 subgroup was not reached - p _log-rank = 0.003. The trial showed that in managing advanced gastric cancer patients (pT4a-4bN0-3 M0) by supplementing radical surgery with ACT-enhanced hyperthermic intraperitoneal chemotherapy, ACT proved to be highly effective when administered in its full mode of 7-8 cycles compared with its truncated variant of 1-6 cycles.

Complications of Cytoreductive Surgery and HIPEC in the Treatment of Peritoneal Metastases

The combined treatment concept of cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC) has shown to be an efficient therapeutic option for selected patients with primary and secondary peritoneal carcinomatosis (PC). This strategy represents the standard of care for diseases like pseudomyxoma peritonei and peritoneal mesothelioma, and offers the best long-term results for PC from colorectal cancer. Despite these results, skepticism exists regarding this therapeutic approach partly because of its perceived high toxicity. In this article, we review the current evidence on complications that can occur after CRS and HIPEC and the risk factors associated with increased incidence of morbidity and mortality.

A comparison of hematologic toxicity profiles after heated intraperitoneal chemotherapy with oxaliplatin and mitomycin C

BACKGROUND

Although peritoneal carcinomatosis (PC) from colorectal and appendiceal tumors is consistent with metastatic disease, complete cytoreduction with hyperthermic intraperitoneal chemotherapy (HIPEC) using mitomycin C (MMC) can improve survival. A recent phase I study by our group using hyperthermic intraperitoneal oxaliplatin has demonstrated its safety and appropriate dose. Our goal in this study is to present a single institution's experience with the hematologic toxicities of the two agents.

METHODS

We performed a retrospective review of 187 patients with PC of colorectal or appendiceal origin who underwent HIPEC with MMC or oxaliplatin between October 2006 and September 2009. Hematologic toxicities were graded according to the NCI Common Terminology Criteria for Adverse Events Version 4.0.

RESULTS

Of the 187 patients, 55 had oxaliplatin-based HIPEC while 132 patients received MMC. Splenectomy was performed in 95 patients (50.8%) due to disease involvement. When comparing hematologic toxicity for MMC and oxaliplatin among the cohort of patients who underwent splenectomy, a statistically significant difference was noted in the incidence of platelet (P = .02) and neutrophil (P = .05) toxicity, with oxaliplatin having a higher incidence of grade 3 and grade 4 platelet and neutrophil toxicity respectively. However, no statistically significant difference in hematologic toxicity was noted between the two agents in patients who did not undergo splenectomy during cytoreductive surgery.

CONCLUSIONS

Oxaliplatin-based HIPEC for PC of colorectal and appendiceal origin is associated with similar white blood cell toxicity and higher platelet and neutrophil toxicity compared to MMC-based HIPEC.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in a Patient with Peritoneal Mesothelioma and HIV Infection

Background

High rates of septic complications have been associated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, which has been suggested as the treatment of choice for isolated peritoneal malignancies. Patients infected by the human immunodeficiency virus (HIV) are still considered at a high operative risk.

Method

A 58-year-old man with HIV infection and diffuse peritoneal mesothelioma underwent optimal cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Results

The patient experienced a complete clinical response to therapy with no adverse effect on disease course or markers for HIV (CD4 count, beta2-microglobulin, neopterin, p24 antigen, and viral load).

Conclusion

This report suggests that this innovative approach can be successfully performed also in this clinical setting. In selected patients who respond to all criteria, surgery is possible and is a safe and effective therapeutic option.

Incidence, risk factors, and impact of severe neutropenia after hyperthermic intraperitoneal mitomycin C

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered the standard of care for patients with peritoneal dissemination of appendiceal cancer and are increasingly being evaluated for use in patients with carcinomatosis from colon cancer. Mitomycin C (MMC) is one of the most frequently used HIPEC agents in the management of peritoneal-based gastrointestinal malignancies. This study analyzes the incidence and risk factors for developing neutropenia following MMC-HIPEC combined with CRS.

METHODS

All patients undergoing CRS and MMC-HIPEC for appendiceal cancer between January 1993 and October 2006 were retrospectively reviewed. Logistic regression was used to identify risk factors for the development of neutropenia, defined as an absolute neutrophil count (ANC) <1,000/mm(3).

RESULTS

One hundred and twenty MMC-HIPEC were performed in 117 patients with appendiceal cancer. The incidence of neutropenia was 39%. Neutropenia occurred in 57.6% of female and 21.3% of male patients (p < 0.0001). Female gender and MMC dose per body surface area (BSA) were independent risk factors for neutropenia on multivariable logistic regression [odds ratio (OR) of neutropenia in females = 3.58 (95% confidence interval, CI: 1.52, 8.43); OR for 5 unit (mg/m(2)) increase in MMC dose per BSA = 3.37 (95% CI: 1.72, 6.63)]. Neutropenia did not increase the risk of mortality, postoperative infection or length of hospital stay.

CONCLUSION

Neutropenia is a frequent complication associated with MMC-HIPEC. Female sex and MMC dose per BSA are independent risk factors for neutropenia. These differences must be considered in the management of patients undergoing MMC-HIPEC to minimize the toxicity of the procedure.

Impact of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy on Systemic Toxicity

INTRODUCTION

The purpose of this study was to analyze the postoperative systemic toxicity and procedure-related mortality (PRM) of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal surface malignancies (PSMs).

PATIENTS AND METHODS

A total of 242 (84 males/158 females) patients with PSM underwent 247 consecutive procedures. The mean age was 52 years (range 22-79). CRS was performed using peritonectomy procedures. The HIPEC technique through the closed abdomen was conducted with cisplatin (CDDP 25 mg/m(2)/l of perfusate)+mitomycin C (MMC 3.3 mg/m(2)/l perfusate) or CDDP (43 mg/l perfusate)+doxorubicin (Dx 15.25 mg/l perfusate) at 42.5 degrees C. These dosages were reduced by 30% when the patient had received systemic chemotherapy before the CRS+HIPEC. Systemic toxicities were graded according to the NCI CTCAE v3 criteria.

RESULTS

G3-5 systemic toxicity rate was 11.7 % and adverse events were bone marrow suppression, 13; nephrotoxicity, 14; neutropenic infection, 2 and pulmonary toxicity, 1. Independent risk factors for G3-5 systemic toxicity after multivariate analysis were a dose of CDDP for HIPEC of 240 mg or more (OR 2.78, CI 95% 1.20-6.45) and CDDP+Dx schedule for HIPEC (OR 2.36, CI 95% 1.02-5.45). PRM was 1.2%.

CONCLUSIONS

CRS+HIPEC presented acceptable systemic toxicity and PRM rates. Independent risk factors for systemic toxicity were the CDDP+Dx schedule and CDDP dose for HIPEC.

The controlling effect of pH on oxidation of Cr(III) by manganese oxide minerals

Oxidation of Cr(III) by three types of manganese oxide minerals (birnessite I, birnessite II, and todorokite) and effects of pH were investigated by chemical analysis, equilibrium redox, X-ray diffraction (XRD), and transmission electron microscopy. The effects of pH in the reaction systems on the oxidation of Cr(III) were similar among the three manganese oxide minerals. As pH increased from pH 2.0, the amount of Cr(III) oxidized by the tested manganese oxide minerals first increased, and then peaked at pH 3.0-3.5. While pH continually increased from 3.0 to 3.5, the amount of Cr(III) oxidized by the manganese oxide minerals sharply decreased. Until pH was higher than 5.0-5.5, the Cr(III) oxidation amounts changed to a small extent or kept stable. pH influenced the oxidation of Cr(III) mainly by altering the redox potential in the system, i.e., the concentration of H+, the species of Cr(III), and their distributions in the system. However, the surface charge of the manganese oxide minerals, subjected to the pH in the system, was not found to greatly influence the extent of the oxidation. When pH was below 5.0, oxidation of Cr(III) by the manganese oxide minerals was (or tended to be) an equilibrium reaction and was controlled thermodynamically. When pH was above 5.0-5.5, Cr(OH)3 precipitate was produced in the system and pH had little effect on the oxidation content of Cr(III).

Initiation of a program in peritoneal surface malignancy

The initiation of a Program in Peritoneal Malignancy is a long and complex process. The novelty, technically demanding nature and steep learning curve that characterize this treatment strategy calls for a carefully planned, systematic, controlled, and informed introduction is an institution, for which an Institutional Review Board approved protocol is suggested. Commitment of a surgical team and institution, education of other physician, nurses, and ancillary personnel involved in the procedure, safety precaution for patients and health care workers, and proper patient selection are important requirements for initiating the program. This manuscript provides a guide for implementation of this treatment strategy with a minimum of untoward events, reduced apprehension of medical and nursing colleagues, and a maximum benefit for patients.

Morbidity and mortality associated with intraperitoneal chemotherapy for Pseudomyxoma peritonei

BACKGROUND

Many centers include intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei. This study documented the morbidity of intraperitoneal chemotherapy in a single institution.

METHODS

A retrospective review of pseudomyxoma peritonei over a 6-year period was undertaken. Treatment, morbidity, and outcome were documented.

RESULTS

Eleven patients were identified with an average of 1.9 debulking procedures and 0.8 chemotherapy courses (0.3 complete). Intraperitoneal chemotherapy was not completed in 5 patients because of complications (56%): severe abdominal pain, seizure, neutropenia, and thrombocytopenia (the latter resulted in 1 patient's death). There was no association between incomplete chemotherapy and recurrence. Recurrence was 64% in those without chemotherapy and 44% in those with. Follow-up averaged 26 months and actual 3-year survival was 60%.

CONCLUSIONS

Intraperitoneal chemotherapeutic morbidity and mortality were 56% and 11%, respectively. Chemotherapy was associated with decreased recurrence. To optimize outcomes, multicenter prospective trials will likely be required to further refine intraperitoneal chemotherapy protocols.