Survival and health outcomes after cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for disseminated peritoneal cancer of appendiceal origin

Quality-of-Life Outcomes for Patients Taking Opioids and Psychotropic Medications Before Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

The impact of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) on quality of life (QoL) for patients taking opioids and psychotropic medications preoperatively is unclear.

METHODS

This study retrospectively reviewed a CRS-HIPEC single-center prospectively maintained database for 2012-2016. Demographics and clinical data on opioids/psychotropic medication use were collected via chart review. The study collected QoL outcomes at baseline, then 3, 6, and 12 months postoperatively via the Center for Epidemiologic Studies Depression Scale (CES-D), Brief Pain Inventory, Functional Assessment of Cancer Therapy, and 36-Item Short-Form Health Survey. Differences in QoL between the groups were calculated using repeated measures analysis of variance regression. Descriptive statistics and Kaplan-Meier analyses were performed.

RESULTS

Of 388 patients, 44.8% were taking opioids/psychotropic medications preoperatively. At baseline, those taking opioids/psychotropic medications preoperatively versus those not taking these medications had significantly worse QoL. By 1 year postoperatively, the QoL measures did not differ significantly except for emotional functioning (e.g., no medications vs. opioids/psychotropic medications: CES-D, 5.6 vs. 10.1). Median survival did not differ significantly (opioids/psychotropic medications vs. no medications: 52.3 vs. 60.6 months; p = 0.66). At 1 year after surgery, a greater percentage of patients were taking opioids, psychotropic medications, or both than at baseline (63.2% vs. 44.8%; p < 0.001).

CONCLUSION

Despite worse baseline QoL, patients who took opioids/psychotropic medications had QoL scores 1 year postoperatively similar to the scores of those who did not except in the emotional domains. These data point to the potential utility of a timed psychosocial intervention to enhance emotional adaptation and further support the role of CRS-HIPEC in improving QoL.

Predicting Severe Complications from Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: A Data-Driven, Machine Learning Approach to Augment Clinical Judgment

BACKGROUND

CRS-HIPEC provides oncologic benefit in well-selected patients with peritoneal carcinomatosis; however, it is a morbid procedure. Decision tools for preoperative patient selection are limited. We developed a risk score to predict severity of 90 day complications for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).

PATIENTS AND METHODS

Adults who underwent CRS-HIPEC at the University of Pittsburgh Medical Center (March 2001-April 2020) were analyzed as part of this study. Primary endpoint was severe complications within 90 days following CRS-HIPEC, defined using Comprehensive Complication Index (CCI) scores as a dichotomous (determined using restricted cubic splines) and continuous variable. Data were divided into training and test sets. Several machine learning and traditional algorithms were considered.

RESULTS

For the 1959 CRS-HIPEC procedures included, CCI ranged from 0 to 100 (median 32.0). Adjusted restricted cubic splines model defined severe complications as CCI > 61. A minimum of 20 variables achieved optimal performance of any of the models. Linear regression achieved the highest area under the receiving operator characteristic curve (AUC, 0.74) and outperformed the NSQIP Surgical Risk calculator (AUC 0.80 vs. 0.66). Factors most positively associated with severe complications included peritoneal carcinomatosis index score, symptomatic status, and undergoing pancreatectomy, while American Society of Anesthesiologists 2 class, appendiceal diagnosis, and preoperative albumin were most negatively associated with severe complications.

CONCLUSIONS

This study refines our ability to predict severe complications within 90 days of discharge from a hospitalization in which CRS-HIPEC was performed. This advancement is timely and relevant given the growing interest in this procedure and may have implications for patient selection, patient and referring provider comfort, and survival.

Safety and Effectiveness of High-Precision Hyperthermic Intraperitoneal Perfusion Chemotherapy in Peritoneal Carcinomatosis: A Real-World Study

Background

Hyperthermic intraperitoneal chemotherapy (HIPEC) has been reported to effectively control peritoneal carcinomatosis (PC) in various patient populations, but there is a lack of real-world data. This study aimed to examine the safety and effectiveness of HIPEC in patients with PC in a real-world setting.

Methods

This was a retrospective study of patients with PC treated with the high-precision BR-TRG-I type HIPEC device between December 2006 and December 2016. Vital signs during HIPEC and adverse events were recorded. Effectiveness was evaluated by total objective remission rate (ORR), which was based on ascites’ remission 4 weeks after HIPEC.

Results

A total of 1,200 patients were included. There were 518 males and 682 females, with a mean age of 58.6 ± 6.5 years (range, 32–76 years). Among the patients, 93.6% of the patients (1123/1200) successfully received the three sessions of HIPEC, 158 had massive ascites. The changes of vital signs during HIPEC were within acceptable ranges, and patients only had a transient fever and abdominal distension. Regarding the HIPEC-related complications, hemorrhage was observed in seven (0.6%) patients, anastomotic leakage in four (0.5%), and intestinal obstruction in eight (0.7%). Nine (0.8%, 9/1200) patients had CTCAE grade IV bone marrow suppression, and three (0.3%, 3/1200) patients had severe renal failure (SRF), which were considered to be drug-related. The ORR of malignant ascites was 95.6% (151/158).

Conclusion

This real-world study strongly suggests that HIPEC was safe in treating PC patients with a low rate of adverse events and leads to benefits in PC patients with massive malignant ascites.

Cytoreductive surgery and HIPEC for malignant ascites from colorectal cancer - a randomized study

INTRODUCTION

The efficacy of different timings of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in controlling malignant ascites caused by peritoneal carcinomatosis of colorectal cancer (CRC) is not well defined. The study aims to investigate the clinical efficacy and safety of different timings of CRS with HIPEC for malignant ascites caused by peritoneal carcinomatosis from CRC.

MATERIALS AND METHODS

This was a preliminary randomized controlled study performed at the Intracelom Hyperthermic Perfusion Therapy Center of the Cancer Hospital of Guangzhou Medical University (China) from December 2008 to December 2016. The patients were randomized to: CRS, followed by HIPEC (CRS+HIPEC; n = 14), and ultrasound-guided HIPEC, followed by CRS 1 to 2 weeks later (HIPEC+ delayed cytoreductive surgery (dCRS) group, n = 14). The endpoints were complete remission rate of ascites, successful complete CRS rate, and overall survival.

RESULTS

Malignant ascites in all patients showed complete remission; the total effective rate was 100%. Complete CRS was not feasible in any patient. The median follow-up of the 2 groups was 41.9 and 42.3 months in the CRS+HIPEC and HIPEC+dCRS groups, respectively. Overall survival was 14.5 (95%CI: 7-19 months) and 14.3 months (95%CI: 4-21 months) (P > .05). The adverse effects of HIPEC were manageable.

CONCLUSIONS

CRS+HIPEC and HIPEC+dCRS have the same efficacy in controlling malignant ascites caused by CRC and peritoneal carcinomatosis. The timing of CRS and HIPEC does not prolong the survival of patients with peritoneal carcinomatosis from CRC, even when a complete CRS is not feasible.

Development and validation of prognostic nomograms for pseudomyxoma peritonei patients after surgery: A population-based study

BACKGROUND

The aim of study was to develop and validate nomograms for predicting overall survival (OS) and cancer-specific survival (CSS) of patients with pseudomyxoma peritonei (PMP) and compare the predictive accuracy with the American Joint Committee on Cancer (AJCC) staging system.

METHODS

Data of 4959 PMP patients who underwent surgical resection were collected between 2004 and 2015 from the Surveillance Epidemiology and End Results (SEER) database. All included patients were divided into training (n = 3307) and validation (n = 1652) cohorts. The Kaplan-Meier method and Cox proportional hazard model were applied. Nomograms were validated by discrimination and calibration. Finally, concordance index (C-index) was used to compare the predictive performance of nomograms with that of the AJCC staging system.

RESULTS

According to the univariate and multivariate analyses of training sets, both nomograms for predicting OS and CSS combining age, grade, location, N stage, M stage, and chemotherapy were identified. Nomograms predicting OS also incorporated T stage and the number of lymph nodes removed (LNR). The calibration curves showed good consistency between predicted and actual observed survival. Moreover, C-index values demonstrated that the nomograms predicting both OS and CSS were superior to the AJCC staging system in both cohorts.

CONCLUSION

We successfully developed and validated prognostic nomograms for predicting OS and CSS in PMP patients. Two nomograms were more accurate and applicable than the AJCC staging system for predicting patient survival, which may help clinicians stratify patients into different risk groups, tailor individualized treatment, and accurately predict patient survival in PMP.

The Impact of Early Recurrence on Quality of Life after Cytoreduction with HIPEC

Improved oncological outcomes after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in highly selected patients have been well documented. The extensive nature of the procedure adversely affects quality of life (QoL). The aim of this study is to longitudinally evaluate QoL following CRS/HIPEC. This is a retrospective review of a prospectively maintained database of patients with peritoneal malignancies undergoing CRS/HIPEC. Clinicopathological data, oncologic outcomes, and QoL were analyzed preoperatively and post-operatively at 2 weeks, and 1, 3, 6, and 12 months. The Functional Assessment of Cancer Therapy-Colorectal instrument was used to determine changes in QoL after CRS/HIPEC and the impact of early recurrence (<12 months) on QoL. Thirty-six patients underwent CRS/HIPEC over 36 months. The median peritoneal cancer index score was 18 and the completeness of cytoreduction-0/1 rate was 97.2 per cent. Postoperative major morbidity was 16.7 per cent with one perioperative death. Disease-free survival was 12.6 months in patients with high-grade tumors versus 31.0 months in those with low-grade tumors (P = 0.03). QoL decreased postoperatively and improved to baseline in six months. Patients with early recurrence had a decrease in global QoL compared with preoperative QoL at 6 (P < 0.03) and 12 months (P < 0.05). This correlation was not found in patients who had not recurred. Patients who undergo CRS/HIPEC have a decrease in QoL that plateaus in 3 to 6 months. Early recurrence adversely impacts QoL at 6 and 12 months. This study emphasizes the importance of patient selection for CRS/HIPEC. The expected QoL trajectory in patients at risk for early recurrence must be carefully weighed against the potential oncological benefit of CRS/HIPEC.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly: A Case-Controlled, Multicenter Study

OBJECTIVE

This study was designed to identify factors associated with morbidity and mortality in patients older than 70 years who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC).

BACKGROUND

Major surgery is associated with higher morbidity and mortality in elderly patients. For PC, CRS and HIPEC is the only current potential curative therapy, but the risks inherent to this patient population have called its benefits into question.

METHODS

We retrospectively analyzed a multi-center database from 1989 to 2015. All patients who underwent CRS and HIPEC for PC were selected and patients older than 70 years were matched 1:4 with a younger cohort according to cancer origin, peritoneal cancer index (PCI), and completeness of cytoreduction. Major morbidity and mortality were analyzed.

RESULTS

Of 2328 patients, 188 patients older than aged 70 years were matched with 704 younger patients. Patients older than aged 70 years demonstrated a higher American Society of Anesthesiologist score (≥ASA III 10.8 vs. 6.6 %, p = 0.008). There was no difference in overall 90-day morbidity (≥70: 45.7 % vs. <70: 44.5 %; p = 0.171); however, patients older than 70 years had significantly more cardiovascular complications (13.8 vs. 9.2 %, p = 0.044). Differences between the older and younger cohorts failed to reach significance for 90-day mortality (5.4 and 2.7 %, respectively; p = 0.052), and failure-to-rescue (11.6 and 6.1 %, respectively; p = 0.078). In multivariate analysis, PCI > 7 (95 % CI 1.051-5.798, p = 0.038) and HIPEC duration (95 % CI 1.106-6.235, p = 0.028) were independent factors associated with morbidity in elderly patients.

CONCLUSIONS

CRS and HIPEC appear feasible for selected patients older than aged 70 years, albeit with a higher risk of medical complications associated with increased mortality.

Impact of Major Complications on Patients' Quality of Life After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

INTRODUCTION

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an effective treatment for selected patients with peritoneal surface malignancies (PSM). Although it can have significant morbidity, perioperative mortality is low. Little is known about whether major complications after CRS/HIPEC have a lasting impact on patients' quality of life (QOL).

METHODS

We retrospectively reviewed data from a prospectively collected database on patients treated with CRS/HIPEC for PSM (2011-2014). Patients with CRS/HIPEC and 6-month QOL evaluation were included. Major perioperative complications (Clavien-Dindo grade 3/4) were the primary independent variable. QOL was evaluated using the validated EORTC QLQ-C30 score. The primary outcome was 6-month global health score. Secondary outcomes were individual functional and symptom domains.

RESULTS

Forty-two patients were analyzed. Median age was 57.5; 64 % were female. Origin of PSM was appendix (55 %), colorectal (38 %), mesothelioma (5 %), and small bowel (2 %). Fourteen patients (33 %) had major (grade 3/4) complications. Median length of stay was 16 days; patients experiencing major complications had significantly increased length of stay (35.5 vs. 13 days, p < 0.01). Major complications included intra-abdominal abscess (9.5 %), bleeding (9.5 %), symptomatic pleural effusion (7.1 %), anastomotic leaks (7.1 %), and renal failure (2.4 %). The average global health score at 6 months was 68.1. The worst-rated symptom scores at 6 months were diarrhea (39.8) and fatigue (35.4). There were no significant differences in 6-month QOL scores between patients with and without major complications, globally or in specific domains.

CONCLUSIONS

Although major complications are common after CRS/HIPEC, QOL at 6 months recovers and is similar to those without major complications.

Palliative cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion: current clinical practice or misnomer?

Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS/HIPEC) is being used more and more frequently for the management of peritoneal carcinomatosis. Despite significant improvements in oncologic outcomes and the risk of complications and mortality, CRS/HIPEC remains one of the most morbid treatments offered for advanced cancers. Consequently CRS/HIPEC is still considered controversial by many, even in the setting of cancers that are potentially curable. However, as high volume surgical oncologists become more experienced with CRS/HIPEC, the potential role of "palliative CRS/HIPEC" in the management of peritoneal carcinomatosis is being raised. Given the often limited survival benefit expected after CRS/HIPEC, understanding the impact of the treatment on quality of life (QOL) needs to be an essential part of the decision to proceed and is critical to optimizing recovery afterwards. This article reviews the potential definitions of "palliative CRS/HIPEC" in various clinical contexts and describes the current state of the QOL experience after CRS/HIPEC.

Repeated cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with recurrent peritoneal carcinomatosis

Background

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the treatment of choice for resectable peritoneal carcinomatosis (PC) and improved the survival of these patients. The situation changes if PC recurs and repeated CRS with HIPEC is considered. The patient selection and outcome of the repeated approach has not been well described. We analyzed our cohort and share the experiences.

Methods

Ninety-three CRS/HIPEC procedures, performed in 85 patients during the period 2001–2013, were examined in a retrospective analysis. Type of primary, ECOG status, peritoneal cancer index (PCI), completeness of cytoreduction (CC), duration of hospitalization, postoperative morbidity, mortality, and disease-free/overall survival were reviewed.

Results

Six patients (7 %) underwent a second CRS/HIPEC (median interval between the two procedures: 26 months, range 8–61) including two patients with mesotheliomas, one patient with ovarian adenocarcinoma, one patient with leiomyosarcoma of uterus, one patient with colon adenocarcinoma, and one patient with appendiceal adenocarcinoma. The last two patients underwent a third CRS/HIPEC, 25 and 36 months, after the second procedure. The median PCI was 14 (range, 4–26) during the first and 20 (range, 7–39) during the second CRS/HIPEC of these patients. Completeness of cytoreduction score of 0 (CC-0) was achieved in all first procedures and in 67 % of second procedures (CC-0; n = 4 and CC-1; n = 2). A CC-0 score was possible in both of the third procedures. The mean operating time was 444 min (range, 198–642) and 427 min (range, 239–617) during the first and the second procedure. Median intensive care unit (ICU) was 2 days, and hospital stay after second CRS/HIPEC was 17 days (range, 7–50). The 30-day morbidity after repeated CRS/HIPEC was 33 % (16 % for grade III–IV complications), and there was no 30-day mortality neither after the second nor after the third CRS/HIPEC. Median disease-free interval between first CRS/HIPEC and peritoneal recurrence was 17 months (range, 8–30). Median disease-free survival of 18 months (range, 4–33) was achieved after the second CRS/HIPEC. After a median follow-up of 74 months (range, 39–151), all patients are alive with disease (n = 5) or disease free (n = 1) under chemotherapy.

Conclusions

In experienced centers, repeated CRS/HIPEC can be performed with safety. Patient selection and correct timing is of particular importance in achieving control of the disease. Repeated CRS/HIPEC should be considered as treatment option for selected patients with recurrent PC.

GEM-loaded magnetic albumin nanospheres modified with cetuximab for simultaneous targeting, magnetic resonance imaging, and double-targeted thermochemotherapy of pancreatic cancer cells

Background

Targeted delivery is a promising strategy to improve the diagnostic imaging and therapeutic effect of cancers. In this paper, novel cetuximab (C225)-conjugated, gemcitabine (GEM)-containing magnetic albumin nanospheres (C225-GEM/MANs) were fabricated and applied as a theranostic nanocarrier to conduct simultaneous targeting, magnetic resonance imaging (MRI), and double-targeted thermochemotherapy against pancreatic cancer cells.

Methods

Fe₃O₄ nanoparticles (NPs) and GEM co-loaded albumin nanospheres (GEM/MANs) were prepared, and then C225 was further conjugated to synthesize C225-GEM/MANs. Their morphology, mean particle size, GEM encapsulation ratio, specific cell-binding ability, and thermal dynamic profiles were characterized. The effects of discriminating different EGFR-expressing pancreatic cancer cells (AsPC-1 and MIA PaCa-2) and monitoring cellular targeting effects were assessed by targeted MRI. Lastly, the antitumor efficiency of double/C225/magnetic-targeted and nontargeted thermochemotherapy was compared with chemotherapy alone using 3-(4, 5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) and flow cytometry (FCM) assay.

Results

When treated with targeted nanospheres, AsPC-1 cells showed a significantly less intense MRI T2 signal than MIA PaCa-2 cells, while both cells had similar signal strength when incubated with nontargeted nanospheres. T2 signal intensity was significantly lower when magnetic and C225 targeting were combined, rather than used alone. The inhibitory and apoptotic rates of each thermochemotherapy group were significantly higher than those of the chemotherapy-alone groups. Additionally, both MTT and FCM analysis verified that double-targeted thermochemotherapy had the highest targeted killing efficiency among all groups.

Conclusion

The C225-GEM/MANs can distinguish various EGFR-expressing live pancreatic cancer cells, monitor diverse cellular targeting effects using targeted MRI imaging, and efficiently mediate double-targeted thermochemotherapy against pancreatic cancer cells.

Quality of life after cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy for peritoneal carcinomatosis: A systematic review and meta-analysis

OBJECTIVE

To review the effect of cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) on health-related quality of life (HRQOL) in patients with peritoneal carcinomatosis.

BACKGROUND

CRS and HIPEC is increasingly performed with curative intent for peritoneal carcinomatosis. Significant morbidity rates are reported in the context of limited life-expectancy, necessitating accurate post-operative HRQOL outcome data.

METHODS

A systematic review of clinical studies published after January 2000 was performed using strict eligibility criteria. Key outcomes measures were post-operative HRQOL compared to pre-operative levels and reference populations. Quality appraisal and data tabulation were performed using pre-determined forms. Data were synthesised by narrative review and random-effects meta-analysis. Tau2 and I2 values and Funnel plots were analysed for consistency and bias.

RESULTS

15 studies (1583 patients) were included. HRQOL declines at the 3-4 month time-point before becoming similar or better compared to pre-operative levels at 1 year. The pooled-effects of combined post-operative functional assessment of cancer therapy and European organisation for research and treatment quality of life questionnaire scores were significantly improved from baseline on overall health status (p=0.001) and emotional health (p=0.001). Physical health (p=0.83), social health (p=0.48) and functional health (p=0.24) remain similar. HRQOL after 1 year is less clear, but benefits may persist up to 5 years especially on overall and physical health domains. Evidence is conflicted and inconclusive on HRQOL compared to reference populations. Levels of consistency and bias were acceptable.

CONCLUSIONS

CRS and HIPEC for peritoneal carcinomatosis can confer small to medium benefits for HRQOL. These results should be interpreted with in caution due to the small studies and absence of more randomised controlled trials.

Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications

BACKGROUND

Despite increasing implementation of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), there are little data on its financial implications. We analyzed hospital cost and reimbursement data within the context of insurance provider type and postoperative complications.

METHODS

Clinicopathologic variables, hospital costs, and reimbursement for all patients undergoing CRS/HIPEC at a single institution from 2009 to 2013 were analyzed.

RESULTS

A total of 64 patients underwent CRS/HIPEC. Median PCI score was 19, and average operative time was 550 min. Tumor histology included appendiceal (n = 40; 62 %), colorectal (n = 16; 25 %), goblet cell (n = 5; 8 %), and mesothelioma (n = 3; 5 %). Median length-of-stay was 13 days. Complications occurred in 42 patients (66 %), including 13 (20 %) with major (Clavien grade III-IV) complications. Payer mix included 42 private insurance and 22 Medicare/Medicaid. Financial data was available for 56 patients: average total hospital cost was $49,248 and reimbursement was $63,771, for a hospital profit of $14,523/patient. Despite similar costs between Medicare/Medicaid and private-insurance patients, Medicare/Medicaid reimbursed much less ($30,713 vs $80,747; p < 0.001), resulting in a net loss of $17,342 per patient. For private-insured patients, major complications were associated with increased cost and increased reimbursement, resulting in a net profit of $36,285, compared with a net loss of $54,274 in Medicare/Medicaid patients.

CONCLUSIONS

CRS/HIPEC is profitable in privately insured patients, even for those with major complications, but loses money in patients with Medicare/Medicaid. Under a future bundled-reimbursement system, complications will be negatively associated with profit. With these impending changes, hospitals must place emphasis on value, recalculate the reimbursement necessary for financial viability, and focus on decreasing costs and minimizing complications.

Quality of life after cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies: a systematic review

BACKGROUND

Cytoreductive Surgery (CRS) accompanied by Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a promising technique in the treatment of peritoneal metastatic disease. The complexity and the potential adverse effects of the procedure can significantly affect patients' Quality of Life (QoL). Few studies have assessed the impact of CRS + HIPEC in patients' QoL using structured and validated tools. This is a systematic review of the currently available published data, investigating the QoL after performing CRS + HIPEC for tumours of varying primary origin.

METHODS

We performed a systematic review of the studies indexed in PubMed database until July 2014, using as key phrase "quality of life" and "intraperitoneal chemotherapy", including studies using only validated questionnaires for assessing quality of life parameters.

RESULTS

20 studies were identified that matched the criteria set. The results of these studies, although of significant heterogeneity, clearly demonstrate that although overall QoL scores drop in the immediate postoperative period, at an average of 3 months post procedure they recover to 80%-100% or even exceed baseline values. Furthermore, between 6 and 12 months postoperatively, overall QoL is improved in survivors compared to pre-operative status.

CONCLUSIONS

CRS and HIPEC is feasible as a treatment modality in selected patients with peritoneal metastatic disease and can preserve or even improve patients' overall quality of life.

Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality

BACKGROUND

Cytoreductive surgery (CRS)/Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is associated with prolonged survival in selected patients with peritoneal surface disease. Yet, for elderly patients (older than 70 years of age) CRS/HIPEC is controversial, due to associated morbidity.

METHODS

A retrospective analysis of a prospective database of 950 procedures was performed. Type of malignancy, demographics, performance and resection status, hospitalization, morbidity, mortality, and survival were reviewed.

RESULTS

A total of 81 patients (median age 73, range 70-87) underwent CRS/HIPEC between 1991 and 2011. Median follow-up was 48.1 months. Complete cytoreduction was achieved in 44 %. Median survival was 31.8 months for appendiceal cancer, 41.5 for mesothelioma, 54.0 for ovarian cancer, 13.2 for colon cancer, and 7.6 for gastric cancer. The 30-day mortality was 13.6 %. The combined grade III and IV morbidity was 38 %. Median ICU and hospital stay for uncomplicated patients was 1 and 8 days, respectively. The 3-month mortality was 27.4 %. There were no deaths in the octogenarian group. In stepwise multivariate analysis, type of primary (p = 0.03), albumin (p = 0.02), and R status (p = 0.007) were predictive of survival only in the absence of complications. Splitting the data at the midpoint of surgical experience, there was a drop in 1- and 3-month mortality over time to 9.5 and 19.3 %, respectively, while the median survival increased from 11.2 (N = 39) to 46.9 months (N = 42).

CONCLUSIONS

HIPEC in the elderly is associated with a steep learning curve and considerable morbidity and mortality. However, age alone is not a contraindication for the procedure. Institutional experience and stringent patient selection are key factors for prolonged survival.

Assessment of clinical benefit and quality of life in patients undergoing cytoreduction and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for management of peritoneal metastases

Peritoneal metastasis is a significant clinical challenge; life expectancy following diagnosis is usually very short. Surgical cytoreduction with HIPEC is being used with increasing frequency in selected patients; most outcome data have shown that prolonged median survivals can be observed in selected patients. This review summarizes the published data related to outcome and quality of life after cytoreduction and HIPEC to provide insights into its use in patients with peritoneal carcinomatosis.

Extensive cytoreductive surgery for appendiceal carcinomatosis: morbidity, mortality, and survival

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) are frequently used to treat appendiceal carcinomatosis. Some patients require multivisceral resection because of the volume of disease. It is unclear whether extent of CRS impacts survival in appendiceal carcinomatosis.

METHODS

We analyzed 282 patients undergoing attempted CRS/HIPEC for appendiceal carcinomatosis. Patients were defined as having undergone Extensive CRS (n = 60) if they had >3 organ resections or >2 anastomoses; a subgroup of Extreme CRS patients (n = 10) had ≥5 organ resections and ≥3 anastomoses. Kaplan-Meier survival curves and multivariate Cox-regression models were used to identify prognostic factors affecting outcomes.

RESULTS

Relative to the comparison group, patients undergoing Extensive CRS had a higher median peritoneal carcinomatosis index, operative duration, blood loss, and length of stay. No difference in completeness of cytoreduction, severe morbidity, or 60-day mortality was evident. Subgroup analysis of 10 patients undergoing extreme CRS likewise revealed no increase in severe morbidity or mortality. Median progression-free (PFS) and overall survival (OS) were 23.5 and 74 months in the comparison group; 18.5 (p = 0.086) and 51 (p = 0.85) months in the Extensive CRS group; and 40 months and not reached in the Extreme CRS subgroup. In a multivariable analysis, extent of CRS was not independently associated with PFS or OS.

CONCLUSIONS

Extensive CRS is associated with greater OR time, blood loss, and length of stay, but is not associated with higher morbidity, mortality, or inferior oncologic outcomes in patients with appendiceal carcinomatosis.

Rhabdomyolysis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a case report

Gastric cancer with peritoneal carcinomatosis is a disease with a poor prognosis. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal perioperative chemotherapy (HIPEC) can improve prognosis, although in most cases this should still be considered as a palliative treatment. Therefore, morbidity has to be avoided at all cost as quality of life is of utmost importance. We describe the case of a 64-year-old female with an adenocarcinoma of the stomach that was initially treated with a Billroth II gastrectomy, adjuvant chemotherapy and radiotherapy. During follow-up, the diagnosis of peritoneal carcinomatosis was made, and the patient was referred for CRS and HIPEC. Postoperatively, she developed rhabdomyolysis in both gastrocnemius muscles. Renal function remained within normal limits, but ultrasonography of the lower legs suggested the presence of bilateral abscesses. Drainage with pigtail catheters was necessary for more than 1 month, significantly impairing quality of life. The objective of this case report is to heighten awareness for this complication. Rhabdomyolysis is a rare complication of CRS and HIPEC, with a significant impact on quality of life. Prevention is necessary and can be achieved by adequate surgical positioning, using the altered lithotomy position, sufficient padding and by preventing hypovolemia.

[Morbidity and mortality in a series of patients suffering from intraperitoneal neoplasia treated with peritoneal cytoreduction and hyperthermic intraperitoneal chemotherapy at the Fundación Santa Fe de Bogotá Teaching Hospital (ONCOLGroup--ATIA study)]

BACKGROUND

The procedure of radical peritonectomy followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is considered the standard treatment for peritoneal cancers.

AIMS

To evaluate various outcomes in a cohort of patients with peritoneal tumors treated with HIPEC.

METHODS

Twenty-four patients consecutively treated with radical peritonectomy plus HIPEC within the time frame of November 2007 to July 2010 were enrolled; 15 (62%) had tumors of appendicular origin, 4 (16.7%) had primary peritoneal tumors, 2 had ovarian carcinomas and there was one case of colon cancer, one carcinosarcoma and one hemangioendothelioma. Mean age was 53 years (range: 26-68) and median follow-up was 14.2 months (range: 1-32). Demographic data, histology, peritoneal cancer index (PCI), surgical procedure characteristics, recurrence-free survival (RFS), and overall survival (OS) were all evaluated. Short-term morbidity and mortality were also determined.

RESULTS

Complete cytoreduction was achieved in 18 patients (75%). Mean PCI was 15 (<10: 41% and >10: 58%), and the median (range) for surgery duration, length of stay in the Intensive Care Unit, parenteral nutritional support, and hospital stay were 12,5 (7-20) hours, 11,4 (2-74) days, 13,8 (12-65) days, and 29,1 (10-90) days, respectively. One patient (4%) died 6 months after the procedure, due to multiple associated complications. Considerable morbidity was seen in 52% of cases, including thromboembolic events (41%), catheter-related bacteremia (29%), fistulas (29%), and nephrotoxicity (25%). Six patients (25%) recurred after a median of 21 months of RFS.

CONCLUSIONS

Cytoreductive surgery plus HIPEC in well-selected patients presenting with tumors that affect the peritoneum is a procedure that can be carried out in Colombia with an adequate safety and effectiveness profile. Mortality was similar to that reported in the international literature.

Outcomes of repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal surface malignancy

BACKGROUND

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has improved the survival of patients with peritoneal surface malignancy. On recurrence, a repeat CRS/HIPEC is a treatment option.

STUDY DESIGN

A retrospective analysis of 868 CRS/HIPEC procedures was performed. Type of primary, functional status, completion of resection, hospitalization, morbidity, mortality, and survival were reviewed.

RESULTS

Sixty-two patients (7.7%) underwent a second CRS/HIPEC, including 33 patients with appendiceal primaries, 8 ovarian, 7 mesotheliomas, 4 colon cancers, and 10 various malignancies. Median follow-up was 60.8 months. Median overall survival in months was 85.3 for appendiceal cancer, 52.9 for mesothelioma, 60.1 for ovarian, and 137.4 for colon cancer. R1 resection was achieved in 43.5% after both procedures. Median survival after the second cytoreduction was 52.1 months for appendiceal cancer, 21.8 for mesothelioma, 53.9 for ovarian, and 55.7 for colon cancer. Median survival was 55.7 months for R1 resection, 20.3 months for R2a resection, and 15.5 months for R2b-R2c. Median ICU and hospital stay was 1 and 7.5 days, respectively. The 30-day morbidity after the second CRS/HIPEC was 48.4% and mortality was 3.2%. In multivariate analysis, the R status of the second CRS/HIPEC (p = 0.013) and the interval between the 2 procedures (p = 0.009) were significant in predicting improved survival.

CONCLUSIONS

In experienced tertiary centers and for selected patients, a repeat CRS/HIPEC procedure has morbidity and mortality similar to the initial cytoreduction. Survival depends primarily on the completion of the repeat cytoreduction and favorable biology of the tumor.

Patient rated outcomes and survivorship following cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CS + HIPEC)

BACKGROUND

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CS + HIPEC) is a treatment combining cytoreductive surgery with hyperthermic chemotherapy directly into the peritoneal cavity. Recipients may gain extended life when compared with best supportive care; yet results often are achieved with substantial morbidity and health-related quality of life (HRQOL) deficits. The purpose of this study was to record patient rated outcomes and the HRQOL of long-term survivors.

METHODS

One hundred and two patients living 12+ months post-treatment completed a survey including the Medical Outcomes Study 36-item Short Form Health Survey (SF-36), Functional Assessment of Cancer Therapy-Colon (FACT-C), and Pittsburgh Sleep Quality Index.

RESULTS

SF-36 Physical Component scores were significantly lower than general population norms (46.7, z= -2.943, P=0.003), while Mental Component scores were significantly higher (53.6, z=4.208, P ≤ 0.001). FACT scores were higher than general FACT normative scores. The majority (56%) of these survivors reported significant sleep quality impairment.

CONCLUSION

Although most HRQOL scores were comparable to or higher than those of the general population, long-term physical and functional deficits remain. These deficits, along with the poor sleep quality of recipients, may be improved by survivorship programs or targeted psychosocial interventions.

Survival and quality of life following cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis of colonic origin

BACKGROUND

Peritoneal carcinomatosis of colonic origin (PCC) is a life-threatening diagnosis. Cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) offers patients the prospect of long-term survival with alleviation of symptoms.

METHODS

Patients underwent HIPEC for PCC and completed questionnaires preoperatively (T1) and after surgery at 3 (T2), 6 (T3), and 12 (T4) months. Questionnaires included the Functional Assessment of Cancer Therapy-Colon (FACT-C), Brief Pain Inventory (BPI), SF-36 Medical Outcomes Study Survey (SF-36), Center for Epidemiologic Studies-Depression Scale (CES-D), and the ECOG Performance Status Rating.

RESULTS

A total of 62 patients were assessed before surgery. Median overall survival was 18 months, with 71.3 ± 6.3% survival at 1 year. Emotional well-being (P = .0007) improved after HIPEC. Social/family well-being (P = .065) and the colon subscale (P = .061) of the FACT worsened at T2, but recovered by T3. One-third to one-half of patients reported depressive symptoms over the course of the study. Pain scores increased above BL at T2, but decreased below BL at T3 and T4.

CONCLUSIONS

Emotional well being is improved after CS + HIPEC despite complications that may affect short-term recovery. Most patients remaining in the study recover to preoperative levels of functioning between 3 and 6 months after surgery. For some, survival can be attained without major decrement in QOL at 1 year. QOL concerns must be a key component in the evaluation for patients with PCC for CS and HIPEC.

Preparation and biodistribution of 188Re-labeled folate conjugated human serum albumin magnetic cisplatin nanoparticles (188Re-folate-CDDP/HSA MNPs) in vivo

BACKGROUND

The purpose of this study was to develop intraperitoneal hyperthermic therapy based on magnetic fluid hyperthermia, nanoparticle-wrapped cisplatin chemotherapy, and magnetic particles of albumin. In addition, to combine the multiple-killing effects of hyperthermal targeting therapy, chemotherapy, and radiotherapy, the albumin-nanoparticle surfaces were linked with radionuclide (188)Re-labeled folic acid ligand ((188)Re-folate-CDDP/HSA).

METHODS

Human serum albumin was labeled with (188)Re using the pre-tin method. Reaction time and optimal conditions of labeling were investigated. The particles were intravenously injected into mice, which were sacrificed at different time points. Radioactivity per gram of tissue of percent injected dose (% ID/g) was measured in vital organs. The biodistribution of (188)Re-folate-CDDP/HAS magnetic nanoparticles was assessed.

RESULTS

Optimal conditions for (188)Re-labeled folate-conjugated albumin combined with cisplatin magnetic nanoparticles were: 0.1 mL of sodium gluconate solution (0.3 mol/L), 0.1 mL of concentrated hydrochloric acid with dissolved stannous chloride (10 mg/mL), 0.04 mL of acetic acid buffer solution (pH 5, 0.2 mol/L), 30 mg of folate-conjugated albumin combined with cisplatin magnetic nanoparticles, and (188)ReO(4) eluent (0.1 mL). The rate of (188)Re-folate-CDDP-HSA magnetic nanoparticle formation exceeded 90%, and radiochemical purity exceeded 95%. The overall labeling rate was 83% in calf serum at 37°C. The major uptake tissues were the liver, kidney, intestine, and tumor after the (188)Re-folate-CDDP/HSA magnetic nanoparticles were injected into nude mice. Uptake of (188)Re-folate-CDDP/HSA magnetic nanoparticles increased gradually after injection, peaked at 8 hours with a value of 8.83 ± 1.71, and slowly decreased over 24 hours in vivo.

CONCLUSION

These results indicate that (188)Re-folate-CDDP/HSA magnetic nanoparticles can be used in radionuclide-targeted cancer therapy. Surface-modified albumin nanoparticles with folic acid ligand-labeled radionuclide ((188)Re) were successfully prepared, laying the foundation for a triple-killing effect of thermotherapy, chemotherapy, and radiation therapy.

Primary appendiceal mucinous adenocarcinoma alongside with situs inversus totalis: a unique clinical case

INTRODUCTION

Mucinous adenocarcinoma is a rare neoplasm of the gastrointestinal tract and one of the three major histological subtypes of the primary appendiceal adenocarcinoma. The most common type of presentation is that of acute appendicitis and the diagnosis is usually occurred after appendectomy. The accurate preoperative diagnosis and management of the above condition represents a real challenge when uncommon anatomic anomalies such intestinal malrotation and situs inversus take place. Situs inversus totalis with an incidence of 0.01% is an uncommon condition caused by a single autosomal recessive gene of incomplete penetration in which the major visceral organs are mirrored from their normal positions.

CASE PRESENTATION

We present an unusual case of a 59 years old, previously healthy man presented with a left lower quadrant abdominal pain, accompanied with low fever, leukocytosis, anorexia and constipation. A chest radiograph demonstrated dextrocardia with a right side positioned stomach bubble. Both preoperative US and CT scan of the abdomen and pelvis declared situs inversus, with a characteristic thickening in its wall, appendix situated in the left lower quadrant of the abdomen. These findings reached to the diagnosis of acute appendicitis with situs inversus and a standard appendicectomy was performed. Pathologic evaluation established primary mucinous adenocarcinoma of the appendix and three months afterwards the patient underwent a subsequent extended left hemicolectomy.

CONCLUSION

In conclusion, the occurrence of primary appendiceal mucinous adenocarcinoma along with situs inversus, definitely accounts as a unique clinical case. Even synchronous manifestation of primary mucinous adenocarcinoma of the appendix and situs inversus totalis represents an unusual anatomo-pathological entity, all physicians should be familiar having the knowledge to make an appropriate and accurate diagnosis that will lead to prompt and correct treatment.

A longitudinal study of the role of patient-reported outcomes on survival prediction of palliative cancer inpatients in Taiwan

GOALS OF WORK

This study explores the significance of patient-reported outcomes for predicting length of survival of palliative cancer patients.

PATIENTS AND METHODS

Patients were recruited upon admission to the inpatient palliative care unit. Weekly assessment of 180 terminal cancer patients was carried out throughout their survival time using the Medical Outcome Study 36-Item Short-Form Health Survey, the Taiwanese version of the M.D. Anderson Symptom Inventory (MDASI-T), the Karnofsky Performance Status (KPS), the Brief Pain Inventory, and the Brief Fatigue Inventory. Generalized estimating equations (GEE) were utilized to analyze whether the patient-reported outcomes predicted survival time.

MAIN RESULTS

Of all patients, 64 had one assessment, 51 had two, 25 had three, and 40 had four or more assessments, up to a maximum of eight. The univariate analysis showed that gender (P < 0.01), KPS (P < 0.01), the physical component summary score (P = 0.02), the MDASI-T total score (P < 0.01), composite fatigue severity (P < 0.01), and composite pain severity (P < 0.01) were significantly associated with length of survival. The multivariate analysis showed that gender (P < 0.01), KPS (P < 0.01), and the MDASI-T total score (P = 0.01) were significant predictors of survival time.

CONCLUSIONS

This is the first study to explore the significance of patient-related outcomes for predicting length of survival of palliative cancer patients using the GEE method. This study confirms that overall symptom severity is a significant factor in assessing the length of survival of palliative cancer patients.

Utilization and dosage pattern of echinocandins for treatment of fungal infections in US hospital practice

OBJECTIVE

With the availability of multiple echinocandins in the US, recommended dosages and dosing schedules vary by agent but actual utilization practices are unknown. The purpose of this study was to describe the utilization and dosage pattern of intravenous echinocandins for treatment of fungal infections in US hospitals.

METHODS

The Premier Perspective Database was used to describe echinocandin use in 332 US hospitals. Adult patients hospitalized from January, 2006 through June, 2007 with at least one billing record for anidulafungin (Eraxis ** ), caspofungin (Cancidas dagger ), or micafungin (Mycamine double dagger ) were included. Hospitalizations with > 1 echinocandin or >or= 1 dosage with an FDA approved indication for fungal prophylaxis were excluded. Mixed multivariable models were developed to identify factors associated with mean daily dose. ** Eraxis, a registered trade name owned by Pfizer, Inc., New York, NY, USA dagger Cancidas, a registered trade name owned by Merck & Co., Inc., Whitehouse Station, NJ, USA double dagger Mycamine, a registered trade name owned by Astellas Pharma US, Inc., Deerfield, IL, USA.

RESULTS

The number of unique patient hospitalizations was 708 for anidulafungin, 15 739 for caspofungin, and 1199 for micafungin. A single echinocandin was utilized at 88.6% of hospitals. Micafungin patients had the highest prevalence of cancer, bone marrow transplant, solid organ transplant, HIV/AIDS, fungal infection, and neutropenia. Mean day 1 dose of echinocandin therapy was 171.2 +/- 85.4 mg, 79.7 +/- 25.6 mg, and 154.3 +/- 67.3 mg; and mean day 2 onwards dose was 98.7 +/- 39.4 mg, 53.1 +/- 12.5 mg, 122.6 +/- 39.4 mg for anidulafungin, caspofungin and micafungin, respectively. Commonly used loading doses were 200 mg (55.6%) for anidulafungin, 70 mg (57.2%) for caspofungin, and 200 mg (21.2%) for micafungin. The first-day dose of echinocandin therapy (vs. subsequent days) was most strongly associated with mean daily dose.

CONCLUSIONS

In hospital practice, the mean dosages were consistent with the recommended loading and maintenance dosages for caspofungin and anidulafungin. Patients frequently received a loading dose of > 150 mg on day 1 of micafungin which was inconsistent with recommended dosing schedules. Micafungin maintenance dosages > 100 mg were also commonly used. Lack of information on reason for initiating echinocandin therapy was an important study limitation.