Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer

Review of Imaging Peritoneal Disease and Treatment

Peritoneal disease can be classified as either benign or malignant in nature. Malignant peritoneal disease can be further considered as either primary or secondary in origin. Primary peritoneal malignancy includes peritoneal mesothelioma, serous carcinoma, and desmoplastic small round cell tumour. Peritoneal carcinomatosis is the most commonly encountered secondary malignant peritoneal disease, typically of ovarian, gastric, colorectal, pancreatic, small bowel neuroendocrine, or breast origin. Others include peritoneal lymphomatosis and sarcomatosis. Benign peritoneal pathology may mimic malignant disease. Differentiating benign from malignant peritoneal pathology can be challenging, but is critical to guide appropriate care and avoid unnecessary intervention. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) offers potentially curative treatment for patients with peritoneal carcinomatosis, pseudomyxoma peritonei, and peritoneal mesothelioma. For such patients, the radiologist provides crucial pre-operative information highlighting sites of disease involvement, particularly for sites which are challenging to assess at laparotomy or laparoscopy, including the hepatic dome, subdiaphragmatic space and mesenteric root. The radiologist is also essential to identify potential contraindications to surgery, as well as interpreting normal post-operative appearances, complications and assessing for disease recurrence.

Adenocarcinoma of the duodenal papilla with synchronous peritoneal metastases-5 years of overall survival: A case report

BACKGROUND

Ampullary adenocarcinomas are a rare disease. They can be classified anatomically or according to their histology into intestinal, pancreatobiliary, and mixed subtypes, with different subtypes having distinct prognoses and potential treatments. We report a clinical case of a patient with mixed type adenocarcinoma of the ampulla of Vater, with predominantly intestinal histology, associated with an isolated and synchronous peritoneal carcinomatosis. It is the only case reported in the literature of duodenal ampulla cancer with synchronous peritoneal metastases, with long-term survival.

CASE SUMMARY

A 53-year-old male patient with non-insulin-dependent diabetes presented with acute abdominal pain in the right hypochondrium. Images revealed dilatation of the biliary tract and the duct of Wirsung, without a clear obstructive factor. Upper gastrointestinal endoscopy revealed a tumor in the duodenal papilla. Biopsies confirmed an adenocarcinoma. In the first surgical step, a biliodigestive bypass was performed in association with resection of the carcinomatosis. Peritoneal metastases was found during the intraoperative period. Subsequently, chemotherapy with the folinic acid, fluorouracil, and oxaliplatin regimen was administered based on histology, and a favorable response was achieved. After a multidisciplinary discussion, the Whipple procedure was performed. A delayed biopsy showed disease-free margins. The patient achieved 5 years of overall survival in August 2024, and 4 years of disease-free survival in September 2024.

CONCLUSION

We conclude that an important value of this work is showing individualized treatment for a patient with cancer.

Treatment and Management of Peritoneal Spread from Colorectal Cancer Peritoneal Metastasis

Peritoneal metastases from colorectal cancer (PMCRC) present a complex treatment challenge requiring multidisciplinary expertise. Significant controversy exists regarding the optimal management of PMCRC patients. In this article, we seek to review the currently available evidence and discuss key components of patient workup, treatment, and management.

Disparities and Health Care Delivery for Patients with Peritoneal Surface Malignancy

Management of peritoneal surface malignancy (PSM) is complex and requires care at a PSM center. Despite the reported benefit of cytoreductive surgery (CRS)/ hyperthermic intraperitoneal chemotherapy (HIPEC) across PSM primaries, the uptake nationwide is low. The reasons are multifaceted and related to factors that disproportionately impact racial and ethnic minorities, rural residents, and other socially vulnerable patient populations. There are significant misperceptions of CRS/HIPEC in the treatment of PSM and the potential benefit for appropriately selected patients. Much work is needed to improve patient and provider education and to expand the reach of expert PSM management to vulnerable patients.

Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC) of Extraperitoneal Abdominal Disease, is it Appropriate?

INTRODUCTION

Cytoreductive surgery-hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) candidates often have extraperitoneal abdominal disease. Current expert peritoneal surface malignancy (PSM) guidelines recommend that the presence of extraperitoneal disease is a contraindication to CRS-HIPEC.

METHODS

We conducted a retrospective review of our institutional appendiceal and colorectal CRS-HIPEC registries. Two study cohorts were constructed: (1) cytoreduction with extraperitoneal abdominal disease, and (2) cytoreductions limited to peritoneal structures alone. The primary study outcome was survival. Subgroup analysis was based on the primary tumor and completeness of cytoreduction.

RESULTS

Overall, 864 CRS-HIPEC cases were evaluated, consisting of 578 appendiceal primaries and 286 colorectal cancers. The extraperitoneal cohort included 101 patients, with 763 patients in the non-extraperitoneal group. The median follow-up time was 13.18 years. The main analysis showed no significant differences in survival times. For overall survival (OS) there was a mean OS time of 5.87 years and a median OS time of 4.43 years for extraperitoneal cytoreductions compared with a mean of 5.90 years and a median of 4.76 years for non-extraperitoneal cytoreductions (p = 0.955). Five-year OS rates did not differ at 49.1% versus 49.5% (odds ratio [OR] 1.036, 95% confidence interval [CI] 0.671-1.597, p = 0.874). Disease-free survival (DFS) times showed a mean of 4.40 years and a median of 1.93 years for extraperitoneal cases versus a mean of 5.44 years and a median of 3.05 years for non-extraperitoneal cases (p = 0.210). Five-year DFS rates also showed no differences (OR 0.894, 95% CI 0.476-1.681, p = 0.728). No significant differences in progression-free survival (PFS)Pp times (p = 0.061) were reported. Multivariate Cox regression analysis indicated that extraperitoneal CRS was not an independent predictor of OS (hazard ratio [HR] 1.281, 95% CI 0.885-1.854, p = 0.190), DFS (HR 1.087, 95% CI 0.694-1.701, p = 0.716), or PFS (HR 0.650, 95% CI 0.243-1.738).

CONCLUSION

We conducted the largest analysis evaluating extraperitoneal cytoreductions, with no significant differences in almost all survival outcomes. We propose that the presence of extraperitoneal abdominal disease is not a contraindication to proceeding with CRS-HIPEC.

Predicting Postoperative Infection After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy with Splenectomy

BACKGROUND

Hematologic changes after splenectomy and hyperthermic intraperitoneal chemotherapy (HIPEC) can complicate postoperative assessment of infection. This study aimed to develop a machine-learning model to predict postoperative infection after cytoreductive surgery (CRS) and HIPEC with splenectomy.

METHODS

The study enrolled patients in the national TriNetX database and at the Johns Hopkins Hospital (JHH) who underwent splenectomy during CRS/HIPEC from 2010 to 2024. Demographics, comorbidities, vital signs, daily laboratory values, and documented infections were collected. The patients were divided into infected and non-infected cohorts within 14 days postoperatively. Extreme gradient boost (XGBoost) machine-learning was used to predict postoperative infection. An initial model was generated using the TriNetX dataset and externally validated in the JHH cohort.

RESULTS

From TriNetX, 1016 patients were included: 802 in the non-infected group (79%) and 214 (21%) in the postoperative infection group. The mean age was 61 ± 13 years, and 597 (56%) of the patientswere female. Most of the patients underwent CRS/HIPEC with splenectomy for appendiceal cancer (n = 590, 56%), followed by colorectal malignancy (n = 299, 29%). The remainder (n = 127, 15%) underwent CRS/HIPEC with splenectomy for gastric, pancreatic, ovarian, and small bowel malignancies or peritoneal mesothelioma. In detecting any infection, XGBoost exhibited excellent prediction accuracy (area under the receiver operating characteristic curve [AUC], 0.910 ± 0.073; F1 score, 0.915 ± 0.040) and retained high accuracy upon external validation with 96 demographically similar JHH patients (AUC, 0.823 ± 0.08; F1 score, 0.864 ± 0.03).

CONCLUSION

A novel machine-learning algorithm was developed to predict postoperative infection after CRS/HIPEC with splenectomy that could aid in the early diagnosis and initiation of treatment.

Diagnostic Advances and Novel Therapeutics in Peritoneal Metastasis

Appropriate assessment of disease burden in patients with peritoneal surface malignancy (PSM) is critical for treatment decision-making, and conventional cross-sectional imaging (computed tomography and/or MRI) often underestimates burden of disease. Advances in imaging for PSM include novel functional imaging modalities that target cells unique to the tumor microenvironment. Novel alternative methods of diagnosis and disease monitoring are also potentially applicable to management of PSM. These include forms of "liquid biopsy" targeting circulating tumor DNA. Novel regional therapies include both new therapeutic agents (immune-based and nanoparticle-based), as well as new methods of delivery such as pressurized intraperitoneal aerosolized chemotherapy.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy outcomes in peritoneal carcinomatosis: 11-year tertiary-center experience

BACKGROUND

Cytoreductive Surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are techniques developed for curative treatment of peritoneal carcinomatosis (PC). Studies have shown that CRS + HIPEC provides a survival advantage in PC, and long-term survival can be achieved in selected cases. This study aimed to evaluate CRS + HIPEC cases performed for curative purposes and to examine the prognostic factors.

METHODS

PC patients who underwent CRS + HIPEC with curative intent between January 2011 and September 2022 were included. Demographic, clinical, and pathological findings, procedure-specific parameters, complications, mortality, progression-free survival (PFS), and overall survival (OS) were analyzed.

RESULTS

Optimal cytoreduction was achieved in 70% of the patients. The median PFS for the entire series was 9.2 months, while the median OS was 20.5 months, with a 3-year OS rate of 36%. Appendiceal origin, cytoreduction score, absence of lymph node metastasis, and absence of complications were factors associated with a positive impact on both PFS and OS. In multivariate analysis, cytoreduction score emerged as the sole independent factor influencing both PFS and OS.

CONCLUSIONS

Considering the results in our series, cases of PC in which complete cytoreduction can be achieved should be evaluated for CRS + HIPEC.

Repeat Diagnostic Laparoscopy After Chemotherapy is Useful in Patient Selection for Conversion to Cytoreductive Surgery for Initially Unresectable Colorectal and Appendiceal Peritoneal Metastases: A Retrospective Cohort Study

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) enable effective management of colorectal and appendiceal peritoneal metastases (CAPM) despite high morbidity. This study aimed to evaluate the role of repeat diagnostic laparoscopy (rDL) after systemic ± intraperitoneal chemotherapy in the management of initially unresectable CAPM.

METHODS

This retrospective cohort study included 70 consecutive patients with CAPM who underwent initial diagnostic laparoscopy (iDL). Patients with inoperable or equivocal CAPM underwent chemotherapy followed by rDL to assess the treatment response and possibility of conversion to CRS and HIPEC.

RESULTS

Cytoreductive surgery was deemed feasible for 29 patients and unlikely or equivocal for 41 patients based on iDL. Of the 29 resectable patients, 24 successfully underwent CRS and HIPEC after neoadjuvant chemotherapy. Among the 41 patients initially considered unresectable, 16 were deemed operable based on rDL after chemotherapy, and CRS and HIPEC were achieved for 14 patients (conversion). The median peritoneal cancer index was significantly reduced after chemotherapy for the 14 "conversion" patients, from 16 based on iDL to 11 based on rDL (p < 0.05). The conversion rate was 34% (14/41), with a 5-year survival rate of 14%. Treatment with CRS and HIPEC was achieved for 38 of 45 patients deemed operable based on either iDL or rDL (worst-case estimated positive predictive value, 84%).

CONCLUSION

Diagnostic laparoscopy is useful in predicting the likelihood of achieving CRS for patients with CAPM. Despite inoperability based on iDL, patients should be considered for rDL after chemotherapy to assess the possibility of conversion to CRS and HIPEC.

An Organoid Model for the Therapeutic Effect of Hyperthermic Intraperitoneal Chemotherapy for Colorectal Cancer

BACKGROUND

Consensus regarding the hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer (CRC) regimen remains elusive. In this study, patient-derived tumor organoids from CRC were utilized as a preclinical model for in vitro drug testing of HIPEC regimens commonly used in clinical practice. This approach was used to facilitate the clinical formulation of HIPEC.

METHOD

Tumor tissues and corresponding clinical data were obtained from patients diagnosed with CRC at the Sixth Affiliated Hospital of Sun Yat-Sen University. Qualified samples were cultured and passaged. We aimed to assess the sensitivity of in vitro hyperthermic perfusion using five different regimens, i.e. mitomycin C, mitomycin C combined with cisplatin, mitomycin C combined with 5-fluorouracil, oxaliplatin, and oxaliplatin combined with 5-fluorouracil.

RESULTS

Tumor organoids obtained from 46 patients with CRC were cultured, and in vitro hyperthermic perfusion experiments were conducted on 42 organoids using five different regimens. The average inhibition rate of mitomycin C was 85.2% (95% confidence interval [CI] 80.4-89.9%), mitomycin C combined with cisplatin was 85.5% (95% CI 80.2-90.7%), mitomycin C combined with 5-fluorouracil was 65.6% (95% CI 59.6-71.6%), oxaliplatin was 37.9% (95% CI 31.5-44.3%), and oxaliplatin combined with 5-fluorouracil was 40.7% (95% CI 33.9-47.5%).

CONCLUSION

In vitro hyperthermic perfusion demonstrates that the inhibition rate of mitomycin C, both alone and in combination with cisplatin, surpasses that of the combination of mitomycin C with 5-fluorouracil and oxaliplatin. In clinical practice, the combination of mitomycin C and cisplatin can be regarded as the optimal choice for HIPEC in CRC.

Appendiceal adenocarcinoma-patterns of tumor spread and prognosis

INTRODUCTION

Appendiceal adenocarcinoma represents a diagnostic and therapeutic challenge since it is prone to early lymphatic and peritoneal spread. We aimed to analyze the proportion of lymph node metastases in completion right hemicolectomy specimens, risk factors for peritoneal metastases (PM), and prognosis after definitive treatment.

METHODS

Ninety-three patients with appendiceal adenocarcinoma scheduled for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) in Uppsala 2004-2020 were identified from a prospectively maintained registry. Risk factors for PM were assessed based on the presence (CT + group, n = 55) or absence (CT - group, n = 37) of visible PM at baseline CT scan. Prognostic factors were analyzed based on the actual presence (PM group, n = 66) or absence (no PM group, n = 27) of PM.

RESULTS

The median age was 60 (26-78). Forty-eight patients were women. Resection of PM at initial surgery indicated an 80 % risk of finding PM at a follow-up exploration. R1 appendectomy and perforated appendix had a similar risk for PM (24 %,26 %) which increased to 38 % if both were present. Regional lymph node metastases occurred in 31 % in the CT + group vs. 14 % in the CT - group (p = 0.005) and was associated with poor survival HR 5.16 (1.49-17.81). The 5-year OS and DFS rates were 54 % and 29 % in the PM group.

CONCLUSIONS

Patients with certain risk factors have a high likelihood of PM despite a normal CT scan, which justifies selective exploration at a HIPEC center. Regional lymph node spread supports the current practice of completion right hemicolectomy and is a significant prognostic factor.

Educational Review: Updates on Therapeutic Strategies for Gastric Cancer with Peritoneal Metastasis

Gastric cancer (GC) commonly presents in advanced stages with metastatic spread to the peritoneal cavity, and outcomes associated with gastric cancer with peritoneal metastasis (GCPM) continue to carry a dismal prognosis. Persistent challenges in the detection of peritoneal metastasis (PM) have resulted in a relative paucity of high-quality data to inform management decisions. Several consensus groups have published recommendations to guide management, including most recently the National Comprehensive Cancer Network guidelines, which now include cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) as a potential treatment modality in select patients with GCPM. Multiple clinical trials have investigated the use of CRS/HIPEC and other peritoneal-directed therapies, such as intraperitoneal chemotherapy (IPC) and pressurized intraperitoneal aerosolized chemotherapy (PIPAC). As high-volume centers work to incorporate such therapies into their practice, ongoing clinical trials are aimed at understanding their efficacy. Recent findings have improved understanding of the mechanisms and pathophysiology underlying GCPM while the discovery of novel targets offers potential for drug development and therapeutic strategies to overcome treatment resistance. This review highlights recent advancements and addresses the persistent challenges in managing GCPM while also offering a comprehensive summary of current guidelines and treatment strategies.

[Is cytoreductive surgery with HIPEC adequately funded?]

BACKGROUND

Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment concept for highly selected patients with peritoneal metastases and primary tumors (PMT). A challenge from the perspective of hospitals is the cost intensity of this promising multimodal treatment option.

RESEARCH QUESTION

Which factors influence the cost and revenue structure of CRS/HIPEC treatment in the current diagnosis-related group (DRG) system according to § 17b of the German Hospital Financing Act (KHG)?

MATERIAL AND METHODS

The database for this analysis was constituted by all patients treated with combined CRS/HIPEC at a certified tumor center between 2017 and 2021. The statistical analysis performed was descriptive, using two-sample and multisample comparisons (ANOVA) as well as linear correlation and regression analyses.

RESULTS

The total length of hospitalization for 173 patients was on average 16.1 days and the average length of stay in the intensive care unit was 2.2 days. Postoperative complications occurred in 110 (63.6%) patients. The average DRG revenue obtained was € 21,658.48. The total costs for the combined CRS/HIPC treatment amounted to an average of € 23,764.77 and were therefore on average € 2106.29 (8.86%) higher than the DRG revenue granted for the treatment. The length of stay in the intensive care unit and the total length of hospitalization correlated positively with the treatment costs and DRG revenue.

DISCUSSION

This study presents key factors influencing the cost and revenue structure of CRS/HIPEC and illustrates that this promising surgical treatment approach is relevantly underfunded by the German DRG system. A reform of the current DRG system with special consideration of highly complex oncological treatment concepts is therefore recommended.

Intraperitoneal administration of mRNA encoding interleukin-12 for immunotherapy in peritoneal carcinomatosis

Peritoneal carcinomatosis is an advanced stage of cancer with very limited treatment options. Locoregional immunotherapy is being evaluated as a way to improve efficacy and limit toxicity. This study assessed the efficacy of a cationic polymer/lipid-based transfection compound in delivering mRNA molecules intraperitoneally. Our investigation of the transfer of luciferase mRNA in murine models of peritoneal carcinomatosis revealed preferential luciferase expression in the omentum upon the intraperitoneal administration of complexed mRNAs. Macrophages were identified as key cells that capture and express the mRNA complexes, and accordingly, depletion of resident macrophages led to reduced reporter luciferase expression. To explore the therapeutic potential of this approach, mRNA complexes encoding single-chain interleukin-12 (IL12), an immunostimulatory molecule (mRNA-IL12), were investigated. mRNA-IL12-treated mice exhibited a significant survival advantage in models of peritoneal carcinomatosis and acquired immune memory, as shown upon subcutaneous rechallenge. Tumor microenvironment analyses revealed increased numbers of CD4+ and CD8+ T cells with a more proliferative phenotype, accompanied by decreased myeloid populations in the omentum. Overall, our study underscores the potential of mRNA complexes for efficient mRNA delivery, eliciting effective antitumor responses and modulating the tumor microenvironment to treat peritoneal carcinomatosis.

Efficacy and safety of subtotal pelvic peritonectomy for colorectal cancer patients with peritoneal metastasis confined to the pelvic cavity

BACKGROUND

Cytoreductive surgery has shown survival benefits for colorectal cancer (CRC) patients with peritoneal metastasis. However, the optimal extent of peritonectomy remains controversial in cases of limited peritoneal metastases. This study modified selective pelvic peritonectomy (SPP) into subtotal pelvic peritonectomy (STPP) for metastasis confined to pelvic cavity, and aimed to evaluate its feasibility, safety, and impact on survival outcomes.

MATERIALS AND METHODS

CRC patients with limited peritoneal metastasis confined to the pelvic cavity who underwent CC0 (no macroscopic residual cancer remained) resection were included from a prospectively collected database. Surgical complications, disease-free survival (DFS), and overall survival (OS) were analyzed.

RESULTS

A total of 67 patients were included (26 in the STPP group and 41 in the SPP group). Clinically, STPP was found to be feasible and without increased surgical complications or mortality rates. At a median follow-up of 33.9 months, the 3-year DFS was 65.9 % and 30.7 % in STPP and SPP groups, respectively (P= 0.002). The 3-year OS was 84.1 % and 68.5 % in STPP and SPP groups, respectively (P= 0.006). Moreover, STTP was independently associated with improved DFS (HR = 0.351, 95 % CI 0.165-0.745, P= 0.006) and OS (HR = 0.324, 95 % CI 0.116-0.902, P=0.032). Female gender was also independently associated with poor DFS (HR = 2.146, 95 % CI 1.078-4.271, P= 0.031). Among 24 female patients with remaining ovaries, 9 (37.5 %) cases developed metachronous ovarian metastasis, and of these 6 underwent a second operation.

CONCLUSIONS

Subtotal pelvic peritonectomy is associated with promising long-term outcomes in CRC patients with peritoneal metastasis confined to the pelvic cavity. Prophylactic bilateral oophorectomy should be strongly considered during cytoreductive surgery.

Perioperative management and survival outcomes following cytoreductive surgery in patients with peritoneal metastases from rectal cancer: A scoping review

BACKGROUND

Patients with rectal cancer and peritoneal metastases (PM) may have a worse prognosis and benefit from a different management than patients with colon cancer.

METHODS

A systematic literature search of MEDLINE (PubMed) and EMBASE databases was performed to identify all reported patients with rectal cancer and PM treated with cytoreductive surgery (CRS), with or without hyperthermic intraperitoneal chemotherapy (HIPEC), to investigate the proper selection criteria for this population, the optimal perioperative management, and highlight its specific oncological outcomes.

RESULTS

Twenty studies reporting on 285 patients were identified. Median age varied from 28 to 63 years, and 57.5 % of patients had synchronous disease. The use of neoadjuvant treatment was frequent, but regimens were heterogenous, consisting of radiotherapy alone, chemoradiotherapy or systemic chemotherapy. Thirty-two percent did not receive any neoadjuvant treatment. Most patients (85.6 %) received HIPEC after CRS, with mitomycin C being the most used drug. Complete cytoreduction was performed in 90.1 % of patients. Data on stoma creation and management were poorly reported. Severe complications occurred in 32.2 % of patients. Median disease-free survival ranged from 6 to 22 months, and median overall survival varied from 7 to 53.2 months.

CONCLUSION

This scoping review highlights the paucity of data available regarding the management of patients with rectal cancer and PM. It also emphasizes different issues and dilemmas regarding this specific population, especially on the use of neoadjuvant treatment, the role of HIPEC after CRS and stoma management.

Tumor agnostic ultrasmall nanoprobes for fluorescence-guided surgical resection in peritoneal metastasis

PURPOSE

Surgical excision of metastases is the only curative treatment strategy in peritoneal carcinomatosis management, and the completeness of tumor resection determines the success of the surgery. Tumor-specific fluorescence-guided probes can improve the outcomes of cytoreductive surgery and thereby prognosis. This study aimed to develop and evaluate the feasibility of fluorescently labeled ultrasmall porous silica nanoparticles (UPSN) for image-guided resection of peritoneally disseminated tumors of different origins.

METHODS

Ultrasmall fluorescent nanoprobes were synthesized and characterized for their physicochemical properties and stability. Tumor-specific uptake and biodistribution profiles were evaluated in syngeneic CT26 colorectal and KPC-689 pancreatic cancer murine models. The practicability of real-time optical UPSN-guided resection was examined in the CT26 colorectal cancer model using a surgical stereomicroscope. Quantitative measurements of tumor sensitivity and specificity were performed. Histopathological examination validated in vivo findings about tumor-specific accumulation and safety of ultrasmall fluorescent probes.

RESULTS

As-synthesized UPSNs were successfully surface modified with Cy5 or Cy3 dyes maintaining sub-15 nm size and near neutral charge which is beneficial for optimized in vivo pharmacokinetics. UPSN-Cy5 demonstrated high tumor-specific uptake and favorable biodistribution profiles in peritoneal metastasis models of CT26 and KPC tumors. Dye-conjugated UPSN enabled resection of microscopic lesions and achieved a higher tumor-to-background ratios in comparison to FDA-approved indocyanine green (ICG) dye in both models. Microscopic evaluation showed tumor localization and off-target safety profile of the UPSN-Cy5.

CONCLUSION

Ultrasmall fluorescent probes were effective in surgical resection of peritoneal metastases with high sensitivity and specificity, thus emerging as promising tumor agnostic agents for image-guided cancer surgery.

Effect of systemic FOLFOXIRI plus bevacizumab treatment of colorectal peritoneal metastasis on local and systemic immune cells

AIM

The immune system plays a crucial role in the outcome of colorectal cancer. Systemic chemotherapies modulate the immune cell composition. Little is known about these changes in peritoneal metastasized colorectal cancer. Thus, we aimed to characterize local and systemic immune cells in the course of systemic chemotherapy.

METHODS

We included in total 20 patients with peritoneal metastasized colorectal cancer in our exploratory study. Initially, we investigated the peripheral blood cell distributions before and after systemic chemotherapy in a set of 11 retrospectively collected samples. Then, a prospective clinical cohort was set up to evaluate local and systemic immune cell distribution in detail (n = 9). Tumor tissue, peritoneal fluid, and peripheral blood were collected. The main immune cell subtypes were characterized using flow cytometry and immunohistochemistry, respectively.

RESULTS

Neutrophils and the neutrophil-to-lymphocyte ratio significantly declined in response to systemic chemotherapy while circulating T cells increased (CD8+P = .015, CD4+P = .041). In peritoneal fluid, we observed a decrease of CD25+/FOXP3+/CD4+ regulatory T cells (P = .049) without loss of their ability to produce interferon gamma. T-cell infiltration in the tumor microenvironment showed a considerable variability between patients. However, the number of tumor-infiltrating CD8+ lymphocytes was not significantly changed by the application of systemic chemotherapy. Neither tumor cells nor lymphocytes or macrophages showed noteworthy expression of PD1 or PD-L1.

CONCLUSION

Our data show that immune cell distribution after systemic chemotherapy changes in peripheral blood. Interestingly, in peritoneal fluid only the inhibitory Treg population decreased and local T cells within peritoneal metastases remain unaffected. These data indicate little to no effect of systemic chemotherapy on the local immune system, supporting the need for new therapeutic options.

Controversies around the treatment of peritoneal metastases of colorectal cancer

In this editorial we examine the article by Wu et al published in the World Journal of Gastrointestinal Oncology. Surgical resection for peritoneal metastases from colorectal cancer (CRC) has been gradually accepted in the medical oncology community. A randomized trial (PRODIGE 7) on cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) failed to prove any benefit of oxaliplatin in the overall survival of patients with peritoneal metastases from colorectal origin. Nevertheless, isolated systemic chemotherapy for CRC stage IV has demonstrated a reduced response in peritoneal metastases than that obtained in other metastatic sites such as the liver. Another tool is required in those patients to achieve more local control of the disease. Surgical groups in peritoneal surgery continue to use HIPEC in their procedures, using other agents than oxaliplatin for peritoneal cavity infusion, such as mitomycin C. These patients present with complex surgical issues to manage, and consequently a large burden of complications has to be anticipated. Therefore, identifying patients who will benefit from CRS with or without HIPEC would be of great interest.

Results of complete cytoreductive strategy in patients with peritoneal metastases of colorectal origin with or without extraperitoneal metastases: A bicentric analysis

BACKGROUND

Increased survival can be achieved in patients with colorectal cancer peritoneal metastases (CRPM) treated with cytoreductive surgery. The benefit of this strategy remains uncertain when CRPM are associated with extraperitoneal metastases (EPM). The aim of this study was to compare short- and long-term outcomes of patients treated with CRS for CRPM, with or without EPM.

METHODS

This study included 413 consecutive patients who underwent CRS for CRPM: 120 with EPM (EPM+) and 293 without (EPM-). Patients with isolated ovarian metastases were included in EPM-group (n = 83).

RESULTS

EPM were mainly located to the liver (66 %,n = 79), retroperitoneal lymph nodes (33 %,n = 40); less frequently to the spleen (9 %,n = 12), lung (9 %,n = 10) or pleura (1 %,n = 1). Ovarian metastases were present in 126 patients (83 in EMP-, 43 in EPM+). Peritoneal carcinomatosis index (PCI) was similar in EPM- (8 [4-14]) and EPM+ (8 [3-13],p = 0.335) groups, as postoperative mortality (3 % vs 3 %,p = 1) and major morbidity rates (28 % vs 35 %,p = 0.223). Median overall survival (mOS) and disease-free survival were significantly higher in the EPM-group (58m vs 39m, and 16m vs 10m,p = 0.003). We highlighted 3 prognostic groups 1) EPM-with PCI<10 (mOS 93m), 2) EPM+ with PCI<10 (mOS 57m), 3) EPM-with 1015 regardless EPM (mOS 26m, p < 0.001).

CONCLUSION

Complete cytoreductive surgery seems to be feasible in patients with EPM, without increase in postoperative morbidity and mortality compared to patients without EPM. This strategy provides prolonged survival in selected patients with limited peritoneal metastases from colorectal cancer.

Advances in pharmacotherapy for the treatment of peritoneal metastases from colorectal cancer

INTRODUCTION

Patients with peritoneal metastasis (PM) from colorectal cancer (CRC) typically have a poor prognosis with historically few treatment options. Cytoreductive surgery (CRS) is the mainstay of treatment to remove macrometastases into the peritoneum, but residual micrometastases are often left behind. Systemic chemotherapy remains a cornerstone of treatment for micrometastases, but intraperitoneal therapy offers advantages including higher local dose concentration with fewer systemic side effects from treatment.

AREAS COVERED

This review covers advancements in the routes and types of pharmacotherapies for PM in CRC.

EXPERT OPINION

More evidence is needed to justify HIPEC with CRS as the standard of care treatment modality for patients with resectable PM in CRC. New therapies such as oncolytic viruses, biologics, and small-molecule inhibitors may become additional treatment modalities for PM.

Prospects of the surgical management of colorectal peritoneal metastasis

BACKGROUND

Colorectal cancer (CRC) is a common malignancy with the propensity to metastasize. Common sites of metastasis include the liver, lungs, and peritoneum, with peritoneal metastases (PMs) having the worst prognosis. Unfortunately, systemic chemotherapy is often less effective in the treatment of PMs. Therefore, removal of all visible tumor via cytoreductive surgery along with intraperitoneal (IP) therapies has been used.

METHODS

A comprehensive review of the literature was conducted using MEDLINE/PubMed and Web of Science with an end date of September 1, 2024, regarding cytoreductive surgery and heated IP chemotherapy for CRC PMs.

RESULTS

Recent studies have called into question the utility of IP chemotherapy in the treatment of CRC PMs. However, regardless of IP chemotherapy, cytoreductive surgery has demonstrated an additional survival benefit for patients with PM secondary to CRC.

DISCUSSION

This study reviews the pathophysiology of CRC PM, the current treatment paradigms, and a pathway for improving outcomes in patients with CRC PM.

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.

Staging peritoneal metastases in colorectal cancer: The correlation between MRI, surgical and histopathological peritoneal cancer index

INTRODUCTION

DW-MRI is a non-invasive way to determine the peritoneal cancer index (PCI) in colorectal cancer (CRC) patients with peritoneal metastases (PM). However, like surgeons during surgery, radiologists struggle to differentiate between PM and fibrosis. This study aimed to investigate the agreement between the PCI as determined by MRI (mriPCI), during surgery (sPCI) and histopathology examination (pPCI) in CRC patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).

MATERIALS AND METHODS

This was a single-centre, retrospective study of CRC patients with PM who were staged with DW-MRI and underwent subsequent CRS-HIPEC. All initial patients' radiological, surgical and histopathology reports were reviewed for the PCI. Histopathology was the reference standard. Primary outcome was the correlation and agreement between mriPCI and pPCI.

RESULTS

Eighty-seven patients were included. All patients had a complete macroscopic resection. Median (interquartile range) PCI for MRI, surgery, and histopathology were respectively 6.0 (2.5-9.0), 6.0 (4.0-11.0) and 6.0 (2.5-9.5). The intraclass correlation coefficient between the sPCI and pPCI was excellent 0.87 (p <0.001), and good between mriPCI and pPCI 0.77 (p <0.001) and between sPCI and mriPCI 0.70 (p <0.001).

CONCLUSION

MRI is a promising non-invasive tool to assess the PCI rather accurately.

INDEPSO-ISPSM Consensus on Peritoneal Malignancies: Management of Colorectal Peritoneal Metastases

PURPOSE

This manuscript reports the results of the Indian Network for Development of Peritoneal Surface Oncology and Indian Society of Peritoneal Surface Malignancies (INDEPSO-ISPSM) consensus that aimed to provide recommendations for some important aspects management of patients with colorectal peritoneal metastases (CPM) and address some issues unique to India.

METHODS

The modified Delphi technique was used with two rounds of voting. There were 29 questions on nine main topics-the role of cytoreductive surgery (CRS), patient selection for CRS, preoperative workup, role of systemic chemotherapy (SC), CPM with other visceral metastases, molecular profile, hyperthermic intraperitoneal chemotherapy (HIPEC) and other modalities of intraperitoneal chemotherapy (IPC), prophylactic/preventive strategies, and surveillances after CRS. A consensus was achieved if anyone option received >70 votes (strong consensus >90%).

RESULTS

Forty-eight surgical (n = 41) and gastrointestinal (n = 7) oncologists were invited; 44 agreed to participate. The response rate was 95.4% (42/44) in round 1 and 93.1% (41/44) in round 2. Overall, a consensus was achieved on 23/29 (79.3%) questions (strong consensus on 6/29 [20.6%]). The panel strongly recommended considering surgery for limited CPM with limited liver metastases (92.5%), not altering the surgical approach in patients with KRAS mutations (91.67%), and limiting the use of IPC for unresectable CPM outside clinical trials (95%). Adjuvant SC was recommended for all patients undergoing CRS (89.47%). CRS is a therapeutic option for selected patients with CPM including those with metachronous CPM (79.49) and signet ring cell cancers (76.92%). HIPEC was recommended outside clinical trials only for patients with peritoneal cancer index 11-15(80%).

CONCLUSION

The panel recommended CRS for most indications but was very selective in recommending HIPEC and IPC outside clinical trials. These recommendations should be a useful resource in clinical decision making for clinicians treating CPM in India and regions with a similar sociodemographic background.

Incidence, risk factors, and outcomes of the transition of HIPEC-induced acute kidney injury to acute kidney disease: a retrospective study

BACKGROUND

Acute kidney injury (AKI) is recognized as a common complication following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Characterized by prolonged renal function impairment, acute kidney disease (AKD) is associated with a higher risk of chronic kidney disease (CKD) and mortality.

METHODS

From January 2018 to December 2021, 158 patients undergoing CRS-HIPEC were retrospectively reviewed. Patients were separated into non-AKI, AKI, and AKD cohorts. Laboratory parameters and perioperative features were gathered to evaluate risk factors for both HIPEC-induced AKI and AKD, with the 90-day prognosis of AKD patients.

RESULTS

AKI developed in 21.5% of patients undergoing CRS-HIPEC, while 13.3% progressed to AKD. The multivariate analysis identified that ascites, GRAN%, estimated glomerular filtration rate (eGFR), and intraoperative (IO) hypotension duration were associated with the development of HIPEC-induced AKI. Higher uric acid, lessened eGFR, and prolonged IO hypotension duration were more predominant in patients proceeding with AKD. The AKD cohort presented a higher risk of 30 days of in-hospital mortality (14.3%) and CKD progression (42.8%).

CONCLUSIONS

Our study reveals a high incidence of AKI and AKI-to-AKD transition. Early identification of risk factors for HIPEC-induced AKD would assist clinicians in taking measures to mitigate the incidence.

Peritoneal Carcinomatosis in Colorectal Cancer: Review and Update of Current Clinical Data

The peritoneal metastasized colorectal cancer (pmCRC) represents a serious health problem worldwide with a special emphasis in the developed countries. Several guidelines recognize the role of multimodal therapy consisting of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of pmCRC. New data suggests that some other factors, eg, tumor biology, immune profile, neoadjuvant chemotherapy may play a predictive role for the oncological outcome of these patients.

An observational cohort of patients with colorectal peritoneal metastases or pseudomyxoma peritonei treated with CRS-HIPEC: Development and first results of the Dutch CRS-HIPEC quality registry

INTRODUCTION

To improve care for patients with colorectal peritoneal metastases (CRC-PM) or pseudomyxoma peritonei (PMP), the Dutch CRS-HIPEC quality registry was initiated in 2019. The aims are to describe the development and content of this registry and to give insight into the data collected during the first years.

MATERIALS AND METHODS

The registry is an observational cohort in the Netherlands. All patients with CRC-PM or PMP who intend to undergo cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) from 6 hospitals are included. Clinical data and outcomes (including hospital variation) were analyzed.

RESULTS

In 2019-2022, 889 patients were included in the CRS-HIPEC quality registry: 749 (84 %) with CRC-PM and 140 (16 %) with PMP. Peritoneal metastases were diagnosed synchronously in 51 % of CRC-PM patients and in 94 % of PMP patients. In patients undergoing complete CRS, the median peritoneal cancer index was 8 (IQR 4-13) for CRC-PM and 15 (IQR 6-26) for PMP. Complete cytoreduction was achieved in 639 CRC-PM patients (97 %) and 108 PMP patients (82 %). HIPEC was mainly performed with mitomycin C (CRC-PM: 94 %, PMP: 92 %). Major postoperative complications (Clavien-Dindo grade ≥3) occurred in 148 CRC-PM patients (22 %) and 30 PMP patients (23 %) with 90-day mortality rates of 2 %. In CRC-PM, differences between hospitals were observed regarding proportions of diagnostic laparoscopies/laparotomies, (neo)adjuvant treatment, ostomy formations and re-admissions.

CONCLUSION

The CRS-HIPEC quality registry provides insight into the outcomes of CRS-HIPEC and enables clinical auditing and observational cohort studies aiming to improve treatment outcomes for patients with CRC-PM and PMP.

Survival Analysis and Recurrence Patterns in 555 Patients with Colorectal Peritoneal Metastases Treated by Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

The presence at diagnosis, or development of, colorectal peritoneal metastases (CPM) is common in colorectal cancer. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) show promising results in selected patients with CPM. The current study aimed to describe oncologic outcomes of patients with CPM, focusing on recurrence patterns and risk factors for adverse events.

METHODS

We conducted a retrospective review of patients with CPM treated by CRS and HIPEC at a single institution between 2000 and 2021.

RESULTS

A total of 555 patients were included, of whom 480 (86.5%) had complete cytoreduction, with a median age of 59 years and median Peritoneal Cancer Index (PCI) of 6. Following complete cytoreduction, 5-year overall survival (OS) and disease-free survival (DFS) were 51% and 31%, respectively. In multivariable Cox regression, PCI >6 (hazard ratio [HR] 2.25), pathological node positivity (pN+; HR 1.94), and perineural invasion (HR 1.85) were associated with decreased OS, while PCI >6, pN+, and previous systemic metastases resulted in reduced DFS. Overall, 284 (62%) patients developed recurrence, of whom 97 (34%) had local recurrence (LR), 100 (35%) had systemic recurrence (SR), and 87 (31%) had combined recurrence (5-year OS: 49.3%, 46%, and 37.4%, respectively). Mutated KRAS (mKRAS) was associated with lower 5-year OS (55.8%) and DFS (27.9%) compared with wild-type KRAS (wtKRAS; 70.7% and 37.6%, respectively). In multivariable analyses, mKRAS was related to decreased OS (HR 1.82), DFS (HR 1.55), and SR (OS 1.89), but not to LR.

CONCLUSIONS

Complete cytoreduction results in good survival outcomes for patients with CPM. Burden of peritoneal disease and tumor biology are the main predictors of survival. Patients with mKRAS are a high-risk cohort, with increased probability of SR and reduced survival.

Hyperthermic intraperitoneal chemotherapy: Ideal and reality

Hyperthermic Intraperitoneal Chemoperfusion (HIPEC) is a new adjuvant therapy for the treatment of abdominal malignant tumors and metastases, which has shown great potential. The HIPEC technique can effectively kill residual lesions in the abdominal cavity through the synergistic sensitization effect of thermal chemotherapy and the circulating perfusion and washing effect of large volume perfusion fluid, thereby reducing the occurrence of malignant ascites and reducing the risk of postoperative recurrence and metastasis. However, there are still many problems in the practical operation of HIPEC, such as non-uniform distribution of perfusate temperature, inadequate perfusion due to the presence of 'dead space', incomplete cytoreductive surgery (CRS), instances of catheter obstruction during perfusate circulation, the lack of a uniform standard for selecting appropriate HIPEC techniques, occupational exposure of medical personnel during the HIPEC procedure, and the selection of HIPEC chemotherapy regimens for patients with various types of tumors. This article aims to summarize the problems encountered in the clinical practice of HIPEC, explore the problems that can be improved, and put forward some suggestions, so as to promote the further standardization and normalization of HIPEC technology.

Relevant Ongoing Clinical Trials to Investigate Local-Regional Treatment Strategies for Peritoneal Surface Malignancies

BACKGROUND AND OBJECTIVES

The multimodal therapy of peritoneal metastases of common cancers (i.e. colorectal, gastric, and ovarian), including CRS plus HIPEC, is still subject to several clinical studies.

METHODS

This paper presents the ongoing studies regarding HIPEC, as found on clinicaltrials.gov. The emphasis was set on Phase III recruiting trials, including the newest information from principal investigators who answered the call of the authors.

RESULTS

Ninety trials have been identified, and the protocols of 15 studies have been presented in detail.

CONCLUSIONS

There are interesting ongoing trials investigating the role of CRS plus HIPEC.

Systemic chemotherapy in addition to CRS-HIPEC for colorectal peritoneal metastases: A critical systematic review on the impact on overall survival

In patients with resectable colorectal peritoneal metastases, it is unclear whether systemic chemotherapy, in addition to cytoreductive surgery-hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), improves overall survival (OS). This systematic review of 12 retrospective studies involving 3721 patients aimed to summarize the available evidence. Contradictory results were found regarding the effectiveness of neoadjuvant, adjuvant, and perioperative systemic therapies on OS, with a high risk of bias. Available evidence remains inconclusive, stressing the need for prospective, randomized trials, like the ongoing Dutch CAIRO6-trial.

Inflammatory Bowel Disease in Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy

BACKGROUND

Inflammatory bowel diseases (IBDs) pose an increased risk of gastrointestinal cancer with especially worse prognosis. Cytoreductive surgery and heated intraperitoneal chemotherapy (CRS/HIPEC) improves outcomes in selected patients with colorectal peritoneal metastases. Little published data describes the outcomes of CRS/HIPEC in IBD patients.

METHODS

We performed a retrospective review of a prospectively maintained CRS/HIPEC database. Outcomes in patients with and without IBD were compared for short-term outcomes such as hospital/intensive care unit stay, blood loss/transfusions, complications, and reoperations. We also examined oncological outcomes including recurrence, overall (OS), and disease-free survival (DFS).

RESULTS

We identified 232 patients that underwent CRS/HIPEC for colorectal or small bowel adenocarcinoma, of which 10 were with IBD. Patients with IBD had lower ASA (p=0.005), less hypertension (p=0.033), and 30% small bowel primary compared to none in the non-IBD cohort (p<0.001). Otherwise, demographic and perioperative characteristics were similar between the groups. The median peritoneal cancer index (PCI) was 7 and similar between the cohorts (p=0.422). Extent of organ resections and peritonectomies performed were similar. Complications occurred in 60.3% of patients (21.2% major), similar between the groups (p=0.744 and p=0.444, respectively). Reoperation rate of 27% was similar between groups (p=0.097). The median OS in the IBD cohort was 19.6 vs 53.2 months in the non-IBD cohort (p = 0.056). The median DFS in the IBD cohort was 4.9 vs 9.4 months in the non-IBD cohort (p=0.174).

DISCUSSION

Cytoreductive surgery and heated intraperitoneal chemotherapy in patients with IBD has similar complication profile and trended towards poorer oncological outcomes as CRS/HIPEC in non-IBD patients.

Complications After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy - Can We Do Better?

The main aim of this review is to analyze postoperative complications after cytoreductive surgery and intraperitoneal chemotherapy. Although the literature in this field is ever growing, reporting on complication is not a given. Nevertheless, some main risk factors such as prior surgery, high tumor burden and the center's expertize have an impact on patient outcomes. Transparency is key, if we want to continue to improve.

Triphasic Learning Curve of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but costly procedure for select patients with peritoneal malignancies. The impact of progression along a learning curve on the cost of these procedures is unknown.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients undergoing CRS-HIPEC from 2016 to 2022 at a single quaternary center. Our study cohort was temporally divided into four equally sized volume quartiles (A, B, C, and D). We utilized cumulative sum plots and split-group analysis to characterize the institutional learning curve based on cost, operative time, length of stay, and morbidity. Multivariable linear regression was performed to estimate costs after adjusting for covariates. Bivariate analysis was performed using a Kruskal-Wallis test to compare continuous variables and a χ2 test to compare categorical variables.

RESULTS

Of 201 patients, the median age [interquartile range (IQR)] was 57 (47-65) years, 113 (56%) patients were female, 143 (71%) were white, and 107 (53%) had private insurance. Median operating room charge [US$42,639 (US$32,477-54,872), p < 0.001] varied between volume quartiles, peaking in quartile C. Stabilization was achieved for 86 cases for operating room cost, 88 cases for routine cost, 96 cases for length of stay, 103 cases for operative time, 120 cases for intensive care unit length of stay, and 150 cases for overall and serious morbidity. The actual operating room and routine costs were similar to predicted costs at the end of the study period.

CONCLUSIONS

The CRS-HIPEC learning curve is triphasic, with cost stability achieved relatively early compared with other markers of surgical proficiency.

Pressurized Intraperitoneal Aerosol Chemotherapy for Peritoneal Carcinomatosis in Colorectal Cancer Patients: A Systematic Review of the Evidence

INTRODUCTION

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) consists of the administration of aerosolized chemotherapy into the abdominal cavity of patients suffering from peritoneal carcinomatosis. Our aim was to review the evidence supporting PIPAC in patients with peritoneal carcinomatosis from colorectal cancer.

METHODS

A systematic review was performed in accordance with the 2020 PRISMA guideline. MEDLINE and CENTRAL were searched using combinations of terms including "Peritoneal carcinomatosis", "Peritoneal metastasis", "PIPAC", "Pressurized intraperitoneal aerosol chemotherapy" and "Colorectal cancer". Original studies, in English, including patients treated with PIPAC for colorectal peritoneal carcinomatosis, were considered eligible. Case reports, non-English or French language articles and secondary analyses were excluded.

RESULTS

A total of 385 articles were screened and 374 articles were excluded, leaving 11 publications for inclusion in the qualitative analysis. The included studies totalized 949 patients who received PIPAC for peritoneal carcinomatosis due to colorectal cancer. The median peritoneal carcinomatosis index (PCI) ranged from 10 to 31. In all studies, the complete PIPAC protocol was achieved with an average of two to three 3 PIPAC sessions per patient. Oxaliplatin (OX) was used as a chemotherapeutic agent in all studies and could be associated with intravenous 5-FU and leucovorin. Most post-operative adverse events were recorded as mild to moderate with no intraoperative complications. Only four studies reported a decrease in the average PCI score for 50% of the patients. Median overall survival ranged from 8 to 37.8 months. Quality of life indicators were stable between PIPAC-OX cycles with a small but not statistically significant trend of improvement of most functional scales.

CONCLUSIONS

PIPAC for peritoneal carcinomatosis from colorectal origin is feasible, safe and tolerable. Its impact on survival outcomes or quality of life remains to be demonstrated by randomized trials.

Guidelines for the Prophylaxis and Treatment of Peritoneal Metastases From Colorectal Cancer: A GRADE-Approach for Evidence Evaluation and Recommendations

Colorectal peritoneal metastases (CPM) are common in colorectal cancer patients. This article aims to provide GRADE guidelines for the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in two clinical situations: (1) To determine the value of adjuvant HIPEC for the prevention of CPM in high-risk colorectal cancer patients; (2) to determine the impact on survival of cytoreductive surgery and HIPEC followed by adjuvant systemic chemotherapy as compared to systemic chemotherapy alone in patients with CPM.

Genomic landscape defines peritoneal metastatic pattern and related target of peritoneal metastasis in colorectal cancer

The primary objective of this study is to develop a prediction model for peritoneal metastasis (PM) in colorectal cancer by integrating the genomic features of primary colorectal cancer, along with clinicopathological features. Concurrently, we aim to identify potential target implicated in the peritoneal dissemination of colorectal cancer through bioinformatics exploration and experimental validation. By analyzing the genomic landscape of primary colorectal cancer and clinicopathological features from 363 metastatic colorectal cancer patients, we identified 22 differently distributed variables, which were used for subsequent LASSO regression to construct a PM prediction model. The integrated model established by LASSO regression, which incorporated two clinicopathological variables and seven genomic variables, precisely discriminated PM cases (AUC 0.899; 95% CI 0.860-0.937) with good calibration (Hosmer-Lemeshow test p = .147). Model validation yielded AUCs of 0.898 (95% CI 0.896-0.899) and 0.704 (95% CI 0.622-0.787) internally and externally, respectively. Additionally, the peritoneal metastasis-related genomic signature (PGS), which was composed of the seven genes in the integrated model, has prognostic stratification capability for colorectal cancer. The divergent genomic landscape drives the driver genes of PM. Bioinformatic analysis concerning these driver genes indicated SERINC1 may be associated with PM. Subsequent experiments indicate that knocking down of SERINC1 functionally suppresses peritoneal dissemination, emphasizing its importance in CRCPM. In summary, the genomic landscape of primary cancer in colorectal cancer defines peritoneal metastatic pattern and reveals the potential target of SERINC1 for PM in colorectal cancer.

Comparison of EPIC Versus HIPEC in the Treatment of Colorectal Peritoneal Metastases and Appendix Tumors Using Inverse Probability of Treatment Weighting

BACKGROUND

The selection of hyperthermic intraperitoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC) for peritoneal metastases from colorectal cancer or appendiceal neoplasms following cytoreductive surgery (CRS) depends on the surgeon's discretion. This study was designed to compare postoperative and oncologic outcomes of HIPEC and EPIC using inverse probability of treatment weighting (IPTW).

METHODS

This study included 175 patients who received HIPEC or EPIC following CRS at a single tertiary university hospital between December 1999 and December 2020. Inverse probability of treatment weighting analysis was performed to control for pretreatment characteristics between the two groups. Multivariate analysis was performed to determine factors associated with postoperative and survival outcomes.

RESULTS

After IPTW, no significant differences in baseline demographics and tumor characteristics were observed between the two groups. The HIPEC group had a significantly longer operation time than the EPIC group. The EPIC group showed a significantly higher postoperative mortality rate than the HIPEC group. Operation time (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.01-1.02; p < 0.001), bowel anastomosis (OR 7.25; 95% CI 1.16-45.2; p = 0.034), neoadjuvant chemotherapy (OR 7.62; 95% CI 1.85-31.4; p = 0.005), and EPIC (OR 8.76; 95% CI 2.16-35.5; p = 0.002) were independent risk factors for major surgical complications. No association was observed between intraperitoneal chemotherapy type and major hematologic toxicity, overall survival, progression-free survival, or peritoneal progression-free survival.

CONCLUSIONS

EPIC was a risk factor for major surgical complications. Survival outcomes were similar between the two types of intraperitoneal chemotherapy.

The history of cytoreduction and HIPEC: Heating up or just blowing smoke?

Peritoneal carcinomatosis carries a grim survival prognosis with complications ranging from the physical to the psychological. Cytoreductive surgery and infusion of heated intraperitoneal chemotherapy have evolved to become a commonly used treatment option in the multi-modal management of peritoneal carcinomatosis. Here, we examine the origins of surgery over a century ago as a potential cure for peritoneal carcinomatosis and how it has evolved with our knowledge of the disease to its present state. The origin of chemotherapy is similarly described as well as its progressive application in regional therapy, guided by the ongoing development of new agents, better understanding of peritoneal physiology, and improved systemic treatment. We show how these modalities began to be used in tandem, and standardized, leading to randomized trials and better understanding of the possibilities and limitations of treatment. Finally, we discuss the current status of patient selection for cytoreduction and future directions of intraperitoneal chemotherapy.

The 2022 PSOGI International Consensus on HIPEC Regimens for Peritoneal Malignancies: HIPEC Technologies

This manuscript reports the results of an international consensus on technologies of hyperthermic intraperitoneal perioperative chemotherapy (HIPEC) performed with the following goals: To provide recommendations for the technological parameters to perform HIPEC. To identify the role of heat and its application forms in treating peritoneal metastases. To provide recommendations regarding the correct dosimetry of intraperitoneal chemotherapy drugs and their carrier solutions. To identify for each intraperitoneal chemotherapy regimen the best dosimetry and fractionation. To identify areas of future research pertaining to HIPEC technology and regimens. This consensus was performed by the Delphi technique and comprised two rounds of voting. In total, 96 of 102 eligible panelists replied to both Delphi rounds (94.1%) with a consensus of 39/51 questions on HIPEC technical aspects. Among the recommendations that met with the strongest consensus were those concerning the dose of HIPEC drug established in mg/m2, a target temperature of at least 42°C, and the use of at least three temperature probes to pursue hyperthermia. Ninety minutes as the ideal HIPEC duration seemed to make consensus. These results should be considered when designing new clinical trials in patients with peritoneal surface malignancies.

Impact of preoperative inflammatory and nutritional markers on the prognosis of patients with peritoneal metastasis of colorectal cancer

BACKGROUND

Identifying patients with peritoneal metastasis (PMs) of colorectal cancer (CRC) who will benefit from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is crucial before surgery. Inflammatory and nutritional indicators play essential roles in cancer development and metastasis.

AIM

To investigate the association of preoperative inflammatory and nutritional markers with prognosis in patients with CRC-PM.

METHODS

We included 133 patients diagnosed with CRC-PM between July 2012 and July 2018. Patients' demographics, overall survival (OS), and preoperative inflammatory and nutritional markers were evaluated. The Kaplan-Meier method and log-rank test were used to estimate differences.

RESULTS

Of the 133 patients, 94 (70.6%) had normal hemoglobin (Hb) and 54 (40.6%) had a high neutrophil-to-lymphocyte ratio (NLR). The median OS (mOS) was significantly lower for patients with high NLR (7.9 months) than for those with low NLR (25.4 months; P = 0.002). Similarly, patients with normal Hb had a longer mOS (18.5 months) than those with low Hb (6.3 months; P < 0.001). Multivariate analysis identified age, carbohydrate antigen 199 levels, NLR, Hb, and peritoneal cancer index as independent predictors of OS. Based on these findings, a nomogram was constructed, which demonstrated a good capacity for prediction, with a C-index of 0.715 (95% confidence interval: 0.684-0.740). Furthermore, the 1- and 2-year survival calibration plots showed good agreement between predicted and actual OS rates. The areas under the curve for the 1- and 2-year survival predictions of the nomogram were 0.6238 and 0.6234, respectively.

CONCLUSION

High NLR and low Hb were identified as independent predictive risk factors for poor prognosis in patients with CRC-PM. The established nomogram demonstrated high accuracy in predicting OS for patients with CRC-PM, indicating its potential as a valuable prognostic tool for this patient population.

Hyperthermic intraoperative peritoneal chemotherapy and cytoreductive surgery for people with peritoneal metastases: a systematic review and cost-effectiveness analysis

Background

We compared the relative benefits, harms and cost-effectiveness of hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery ± systemic chemotherapy versus cytoreductive surgery ± systemic chemotherapy or systemic chemotherapy alone in people with peritoneal metastases from colorectal, gastric or ovarian cancers by a systematic review, meta-analysis and model-based cost-utility analysis.

Methods

We searched MEDLINE, EMBASE, Cochrane Library and the Science Citation Index, ClinicalTrials.gov and WHO ICTRP trial registers until 14 April 2022. We included only randomised controlled trials addressing the research objectives. We used the Cochrane risk of bias tool version 2 to assess the risk of bias in randomised controlled trials. We used the random-effects model for data synthesis when applicable. For the cost-effectiveness analysis, we performed a model-based cost-utility analysis using methods recommended by The National Institute for Health and Care Excellence.

Results

The systematic review included a total of eight randomised controlled trials (seven randomised controlled trials, 955 participants included in the quantitative analysis). All comparisons other than those for stage III or greater epithelial ovarian cancer contained only one trial, indicating the paucity of randomised controlled trials that provided data. For colorectal cancer, hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy probably results in little to no difference in all-cause mortality (60.6% vs. 60.6%; hazard ratio 1.00, 95% confidence interval 0.63 to 1.58) and may increase the serious adverse event proportions compared to cytoreductive surgery ± systemic chemotherapy (25.6% vs. 15.2%; risk ratio 1.69, 95% confidence interval 1.03 to 2.77). Hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy probably decreases all-cause mortality compared to fluorouracil-based systemic chemotherapy alone (40.8% vs. 60.8%; hazard ratio 0.55, 95% confidence interval 0.32 to 0.95). For gastric cancer, there is high uncertainty about the effects of hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy versus cytoreductive surgery + systemic chemotherapy or systemic chemotherapy alone on all-cause mortality. For stage III or greater epithelial ovarian cancer undergoing interval cytoreductive surgery, hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy probably decreases all-cause mortality compared to cytoreductive surgery + systemic chemotherapy (46.3% vs. 57.4%; hazard ratio 0.73, 95% confidence interval 0.57 to 0.93). Hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy may not be cost-effective versus cytoreductive surgery + systemic chemotherapy for colorectal cancer but may be cost-effective for the remaining comparisons.

Limitations

We were unable to obtain individual participant data as planned. The limited number of randomised controlled trials for each comparison and the paucity of data on health-related quality of life mean that the recommendations may change as new evidence (from trials with a low risk of bias) emerges.

Conclusions

In people with peritoneal metastases from colorectal cancer with limited peritoneal metastases and who are likely to withstand major surgery, hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy should not be used in routine clinical practice (strong recommendation). There is considerable uncertainty as to whether hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy or cytoreductive surgery + systemic chemotherapy should be offered to patients with gastric cancer and peritoneal metastases (no recommendation). Hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy should be offered routinely to women with stage III or greater epithelial ovarian cancer and metastases confined to the abdomen requiring and likely to withstand interval cytoreductive surgery after chemotherapy (strong recommendation).

Future work

More randomised controlled trials are necessary.

Study registration

This study is registered as PROSPERO CRD42019130504.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/135/02) and is published in full in Health Technology Assessment; Vol. 28, No. 51. See the NIHR Funding and Awards website for further award information.

Venous thromboembolic events following cytoreductive surgery for lower gastrointestinal neoplasia

Introduction

Cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) represent a high-risk for venous thromboembolism (VTE) due to malignancy, prolonged surgery and immobility. We investigated the incidence of and risk factors for VTE following CRS/IPC.

Materials and methods

Data was analysed on 130 CRS/IPC performed over a 6-year period at a single centre, the Western Australian Peritonectomy Service (WAPS), on lower gastrointestinal neoplasia: pseudomyxoma peritoneii (PMP), colorectal cancer (CRC) and appendix cancer (AC). Data was analysed by univariate and multivariate logistic regression to identify risk factors for VTE.

Results

31 patients (24 %) experienced a VTE. The percentages of VTE among patients with PMP (n = 50), CRC (n = 53) and AC (n = 27) were 36 %, 17 % and 15 % respectively. 60 % of these cases were asymptomatic. The odds of VTE were higher for PMP patients than in patients with a other histopathology (OR=2.9, p = 0.01). Other significant risk factors for VTE on univariate analysis were PCI (OR=1.07, p = 0.001), pelvic dissection (OR=5.52, p = 0.001) and operation time (OR=1.36, p = 0.001).

Conclusion

This study demonstrates high rates of VTE in patients undergoing CRS/IPC. Patients with PMP have a three-fold higher risk of VTE compared to other malignancies (CRC+AC). As most VTE cases were asymptomatic, aggressive early investigation and intervention is indicated for patients undergoing CRS/IPC.

Prognostic value of liver metastases in colorectal cancer treated by systemic therapy: An ARCAD pooled analysis

BACKGROUND

The liver is the most frequent site of metastases in colorectal cancer (CRC). This study aimed to assess the response rate and survival outcomes in metastatic CRC patients with non-liver metastases (NLM) compared to those with liver metastases (LM) across different lines of treatment.

METHODS

A total of 17,924 mCRC patients included in 26 trials from the ARCAD CRC database were analyzed. The analysis was conducted based on the presence or absence of LM across different treatment groups: chemotherapy (CT) alone, CT + anti-VEGF, CT + anti-EGFR in KRAS wild-type tumors, within the first-line (1 L) and second-line (2 L), and patients enrolled in third-line (≥3 L) trials treated with trifluridine/tipiracil or regorafenib or placebo. The endpoints were overall survival (OS), progression-free survival (PFS), and overall response rate (ORR).

RESULTS

Out of the 17,924 patients, 14,066 had LM (30.6 % with only liver involvement and 69.4 % with liver and other metastatic sites), while 3858 patients had NLM. In the CT alone and CT + anti-VEGF subgroups, NLM patients showed better OS and PFS in the 1 L and 2 L settings. However, in the CT + anti-EGFR 1 L and 2 L subgroups, there was no significant difference in OS and PFS between NLM and LM patients. In the ≥ 3 L subgroups, better OS and PFS were observed in NLM patients. ORRs were higher in LM patients than in NLM patients across all cohorts treated in the 1 L and only in the anti-EGFR cohort in the 2 L.

CONCLUSION

LM is a poor prognostic factor for mCRC increasing from 1 L to ≥ 3 L except for patients in 1 L and 2 L receiving CT+anti-EGFR. These data justify using LM as a stratification factor in future trials for patients with unresectable mCRC.

ED diagnosis of peritoneal carcinomatosis

PURPOSE

The goal of our study was to better characterize new CT diagnoses of peritoneal carcinomatosis (PC) in the ED, and to evaluate how to best identify the primary lesion. Prompt identification of the source of the carcinomatosis may allow for the patient to receive early initial care from the correct clinical service.

METHODS

All new CT cases of PC-like appearance identified on CT in the ED from January 2017 through July 2020. Each report and corresponding medical record were manually reviewed. Patient demographics, presence/absence of intravenous contrast, source organ predicted by the radiologist in the CT scan report, pathologic diagnosis, and amount of ascites were tabulated. Chi-tests were used to test the statistical significance of differences between groups.

RESULTS

Of the 131 CT cases of new PC-like appearance which received workup, 108 cases had pathologically proven PC and 23 cases had no underlying malignancy yielding a positive predictive value for actual PC of 82%. The most common cause of new PC in women was gynecological (66%), and in men was of GI tract origin (57%). Concordance between radiologist prediction and final pathology was higher with intravenous contrast (58%) compared to without contrast (40%); although this difference was not statistically significant (p = 0.19). A moderate or large amount of ascites was found in more than half of GYN primaries and in adenocarcinoma of unknown primary and there was a statistically significant difference in amount of ascites between cancer primaries (p = 0.01).

CONCLUSION

A PC-like appearance on CT in the ED will likely be in patients with known malignancy, but of the new cases, there is a high PPV for it to represent new peritoneal carcinomatosis. Gynecological and GI malignancies are the most common cause in women and men, respectively, and this may help in focusing the radiologist's search pattern. Usage of intravenous contrast may help in identifying a primary lesion, and the presence of high-volume ascites should suggest a GYN primary or adenocarcinoma of unknown primary when there is no other obvious primary lesion.

Secondary cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent colorectal peritoneal metastases

Background

Secondary treatment of recurrent colorectal peritoneal metastases after previous cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is poorly investigated.

Objectives

To evaluate the overall survival outcome of secondary (repeat) CRS + HIPEC compared to palliative treatment in recurrent peritoneal disease.

Methods

Patients with colorectal peritoneal metastases treated with an index CRS + HIPEC and subsequently having recurrent peritoneal disease were identified from the prospective Swedish national HIPEC registry. Patients were divided into interventional group (secondary CRS + HIPEC) or palliative group. Multivariable logistic regression, propensity-score matching, and survival outcomes were calculated.

Results

Among 575 patients who underwent complete CRS between 2010 and 2021, 208 (36 %) were diagnosed with a subsequent recurrent peritoneal disease. Forty-two patients (20 %) were offered secondary CRS + HIPEC. Propensity-score matching of secondary interventional cases with palliative cases succeeded in 88 % (n = 37) in which female sex, lower peritoneal cancer index at index surgery, longer disease-free interval, and absence of extra-peritoneal metastases were identified as the most relevant matching covariates. Median OS from date of recurrence was 38 months (95%CI 30-58) in the interventional group and 19 months (95%CI: 15-24) in the palliative group (HR 0.35 95%CI: 0.20-0.63, p = 0.0004). Sensitivity analyses confirmed the results. As reference, the median OS from index CRS + HIPEC in the whole colorectal registry (n = 575) was 41 months (95%CI: 38-45).

Conclusion

After matching for relevant factors, the hazard ratio for death was significantly reduced in patients who were offered a secondary CRS + HIPEC procedure for recurrent peritoneal disease. Selection bias is inherent, but survival outcomes were comparable to those achieved after the initial procedure.

Adoption of an Enhanced Recovery After Surgery Protocol Increases Cost of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy and Does not Improve Outcomes

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay (LOS) and complications. The impact of ERAS protocols on the cost of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has not been studied.

PATIENTS AND METHODS

We performed a retrospective cohort analysis of patients undergoing CRS-HIPEC from 2016-2022 at a single quaternary center. Propensity score matching was used to create pre-and post-ERAS cohorts. Cost, overall and serious complications, and intensive care unit (ICU) length of stay (LOS) between the two cohorts were compared using the Mann-Whitney U-test for continuous variables and χ2 test for categorical variables.

RESULTS

Our final matched cohort consisted of 100 patients, with 50 patients in both the pre- and post-ERAS groups. After adjusting for patient complexity and inflation, the median total cost [$75,932 ($67,166-102,645) versus $92,992 ($80,720-116,710), p = 0.02] and operating room cost [$26,817 ($23,378-33,121) versus $34,434 ($28,085-$41,379), p < 0.001] were significantly higher in the post-ERAS cohort. Overall morbidity (n = 22, 44% versus n = 17, 34%, p = 0.40) and ICU length of stay [2 days (IQR 1-3) versus 2 days (IQR 1-4), p = 0.70] were similar between the two cohorts. A total cost increase of $22,393 [SE $13,047, 95% CI (-$3178 to $47,965), p = 0.086] was estimated after implementation of ERAS, with operating room cost significantly contributing to this increase [$8419, SE $1628, 95% CI ($5228-11,609), p < 0.001].

CONCLUSIONS

CRS-HIPEC ERAS protocols were associated with higher total costs due to increased operating room costs at a single institution. There was no significant difference in ICU LOS and complications after the implementation of the ERAS protocol.