Problems of success and problems of failure: recurrent disease after cytoreductive surgery and intraperitoneal chemoperfusion

Intraperitoneal chemotherapy for peritoneal surface malignancy: experience with 1,000 patients

BACKGROUND

Peritoneal dissemination of abdominal malignancy (carcinomatosis) has a clinical course marked by bowel obstruction and death; it traditionally does not respond well to systemic therapy and has been approached with nihilism. To treat carcinomatosis, we use cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A prospective database of patients has been maintained since 1992. Patients with biopsy-proven peritoneal surface disease were uniformly evaluated for, and treated with, CS and HIPEC. Patient demographics, performance status (Eastern Cooperative Oncology Group), resection status, and peritoneal surface disease were classified according to primary site. Univariate and multivariate analyses were performed. The experience was divided into quintiles and outcomes compared.

RESULTS

Between 1991 and 2013, a total of 1,000 patients underwent 1,097 HIPEC procedures. Mean age was 52.9 years and 53.1% were female. Primary tumor site was appendix in 472 (47.2%), colorectal in 248 (24.8%), mesothelioma in 72 (7.2%), ovary in 69 (6.9%), gastric in 46 (4.6%), and other in 97 (9.7%). Thirty-day mortality rate was 3.8% and median hospital stay was 8 days. Median overall survival was 29.4 months, with a 5-year survival rate of 32.5%. Factors correlating with improved survival on univariate and multivariate analysis (p ≤ 0.0001 for each) were preoperative performance status, primary tumor type, resection status, and experience quintile (p = 0.04). For the 5 quintiles, the 1- and 5-year survival rates, as well as the complete cytoreduction score (R0, R1, R2a) have increased, and transfusions, stoma creations, and complications have all decreased significantly (p < .001 for all).

CONCLUSIONS

This largest reported single-center experience with CS and HIPEC demonstrates that prognostic factors include primary site, performance status, completeness of resection, and institutional experience. The data show that outcomes have improved over time, with more complete cytoreduction and fewer serious complications, transfusions, and stomas. This was due to better patient selection and increased operative experience. Cytoreductive surgery with HIPEC represents a substantial improvement in outcomes compared with historical series, and shows that meaningful long-term survival is possible for selected carcinomatosis patients. Multi-institutional cooperative trials are needed to refine the use of CS and HIPEC.

Management of peritoneal carcinomatosis from colorectal cancer

The management of peritoneal carcinomatosis from colorectal cancer is evolving. The introduction of new chemotherapeutic and biologic agents has certainly improved the outlook for many patients with metastatic colorectal cancer. Traditionally, patients with limited hepatic or pulmonary metastases were the only candidates for metastasectomy. However, patients with metastasis localized to the peritoneum have been shown to be candidates for metastasectomy with improved clinical outcomes. Cytoreductive surgery with the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) in this cohort of patients offers the only chance for long-term survival. Complete cytoreduction in combination with HIPEC for peritoneal surface disease has been demonstrated to produce survival outcomes similar to liver resection for hepatic metastases. This review will examine recent evidence pertaining to the evolving surgical oncology paradigm for management of colorectal peritoneal carcinomatosis.

Intraperitoneal hyperthermic chemotherapy: an evolving paradigm for the treatment of peritoneal surface malignancies

Unfortunately, advanced colorectal cancer is often present at the time the disease is diagnosed. Many intra-abdominal malignancies spread throughout the peritoneal cavity, which is known as carcinomatosis. Peritoneal carcinomatosis is uniformly a terminal disease with a median survival of 6 months. Systemic chemotherapy is palliative and generally provides limited improvement in survival. Conventional surgery has typically been limited to ileostomy, colostomy or intestinal bypass procedures. Cytoreductive surgery alone has long been used to treat macroscopic disease, with limited success. However, cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy (IPHC) has evolved into a novel approach for peritoneal surface malignancy. IPHC was initially described in a canine model by Spratt. Although the first clinical series of peritoneal perfusion were small, Japanese trials, which utilized IPHC for prophylaxis in patients with gastric adenocarcinoma, Fujimoto was the first to report an improvement in survival for established gastric cracinomatosis. This early work provided the proof-of-principle for what has evolved into current management with aggressive cytoreduction and IPHC. The present review will outline the rationale, current practice and future directions of IPHC in the management of peritoneal surface malignancies.

Quality of life and nutritional assessment in peritoneal surface malignancy (PSM): recommendations for care

Quality of life (QOL) and nutritional status of patients treated for peritoneal surface malignancy are important areas for ongoing assessment. A working group of clinicians including a dietitian, physicians, and quality of life researchers was formed as part of the Fifth International Workshop on Peritoneal Surface Malignancy. The purpose of the group was to form a consensus statement on both quality of life and nutritional assessment in PSM. The relevant literature from the quality of life and nutritional assessment in peritoneal surface malignancy was reviewed and integrated to form a consensus statement. Baseline and ongoing assessment of both quality of life and nutritional status of patients undergoing cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) is recommended.

Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy: experience with 501 procedures

BACKGROUND

Peritoneal dissemination of abdominal malignancy (PSD) has a clinical course marked by bowel obstruction and death. We have been using aggressive cytoreductive surgery with intraperitoneal hyperthermic chemotherapy (IPHC) to treat PSD. The purpose of this article was to review our experience with IPHC.

STUDY DESIGN

A prospective database of patients undergoing IPHC has been maintained since 1991. Patients were uniformly evaluated and treated. Demographics, performance status, resection status, primary site, and experience quartile were compared with outcomes. Univariate and multivariate analyses were performed.

RESULTS

A total of 460 patients underwent 501 IPHC procedures. Average age was 53.0 years, and 50.4% were women. The 30-day mortality rate was 4.8%, the complication rate was 43%, and median hospital stay was 9 days. Median followup was 55.4 months, median survival was 22.2 months, and 5-year survival rate was 27.8%. Factors correlating with improved survival were performance status (p=0.0001), primary tumor (p=0.0001), resection status (p=0.0001), complications (p=0.002), previous IPHC (p=0.006), and experience quartile (p=0.031). On multivariate analysis, primary tumor site, performance status, resection status, and development of complications (p < 0.001) predicted outcomes.

CONCLUSIONS

Our experience demonstrated that preoperative criteria for better outcomes include primary tumor site and performance status. Completeness of resection and development of postoperative complications are also crucial, and outcomes have improved over time. Cytoreductive surgery and IPHC represent substantial improvements in outcomes compared with historic series and best-available systemic therapy. Longterm survival is possible for selected patients who undergo the procedure.

Appendiceal neoplasms with peritoneal dissemination: outcomes after cytoreductive surgery and intraperitoneal hyperthermic chemotherapy

BACKGROUND

Appendiceal neoplasms frequently present with peritoneal dissemination (PD) and have a clinical course marked by bowel obstruction and subsequent death. Few data have correlated outcome with appendiceal histology after cytoreductive surgery and intraperitoneal hyperthermic chemotherapy (IPHC). We have reviewed our experience with cytoreductive surgery and IPHC for PD from the appendix.

METHODS

A total of 110 cases of PD from proven appendiceal neoplasms treated with IPHC were identified from a prospectively managed database. Tumor samples were classified on pathologic review as disseminated peritoneal adenomucinosis (n = 55), peritoneal mucinous carcinomatosis (PMCA) with intermediate features (n = 18), PMCA (n = 29), or high-grade nonmucinous lesions (n = 8). A retrospective review was performed with long-term survival as the primary outcome measure.

RESULTS

A total of 116 IPHCs were performed on 110 patients for appendiceal PD between 1993 and 2004. The 1-, 3-, and 5-year survival rates for all cases were 79.9% +/- 4.1%, 59.0% +/- 5.7%, and 53.4% +/- 6.5%, respectively. When stratified by histology, disseminated peritoneal adenomucinosis and intermediate tumors had better 3-year survival rates (77% +/- 7% and 81% +/- 10%) than PMCA and high-grade nonmucinous lesions (35% +/- 10% and 15% +/- 14%; P = .0032 for test of differences between groups). Age at presentation (P = .0134), performance status (P < .0001), time between diagnosis and IPHC (P = .0011), resection status (P = .0044), and length of hyperthermic chemoperfusion (P = .0193) were independently associated with survival.

CONCLUSIONS

The data show that long-term survival is anticipated in most patients who are treated with cytoreduction and IPHC for appendiceal PD. The findings presented herein underscore the important prognostic characteristics that predict outcome after IPHC in patients with PD. In all, this work establishes a framework for the consideration of IPHC in future trials for appendiceal PD.

Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis from small bowel adenocarcinoma

INTRODUCTION

Peritoneal carcinomatosis (PC) is associated with a dismal prognosis. Small bowel adenocarcinoma is a rare etiology for PC. Due to the rarity, poor prognosis, and lack of standard treatment, we chose to review our experience with this disease process treated with cytoreductive surgery (CS) and intraperitoneal hyperthermic chemotherapy (IPHC).

METHODS

From a prospective database of IPHC patients, six patients diagnosed with PC from adenocarcinoma of the small bowel were identified. Between 1995 and 2004 these patients underwent CS and IPHC with Mitomycin C. A retrospective review was performed on these patients with mortality as the primary outcome measure.

RESULTS

Three of the six patients in this series are still alive, with a mean follow-up of 19.7 months after treatment with CS and IPHC. Three patients died of disease progression 29, 30, and 45 months after IPHC. Median survival after diagnosis of small bowel adenocarcinoma was 54 months, while median survival after CS and IPHC for PC was 30.1 months.

CONCLUSIONS

Small bowel adenocarcinoma with PC remains an unusual therapeutic challenge. Treatment with CS and IPHC is an attractive option for patients in this setting.

Intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy: current status and future directions

Natural history studies have shown that peritoneal carcinomatosis is uniformly fatal, with a median survival in the range of approximately 6 months. For more than a decade, a handful of centers have pursued aggressive intraperitoneal cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy as an alternative approach to this disease. Strict selection criteria, variation in intraperitoneal chemotherapy, and the vagaries of what represents "cytoreductive surgery" make many of our colleagues, particularly those in medical oncology, reticent to refer patients for such an aggressive therapy. This article establishes a conceptual framework for understanding the role of intraperitoneal hyperthermic chemotherapy in the treatment of peritoneal surface malignancy. This procedure continues to make advancements in the oncological community despite formidable challenges. The advancement of centers of excellence and the initiation of further phase II trials will help to define the optimal treatment approach for peritoneal carcinomatosis.