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Van der Speeten K, Kusamura S, Villeneuve L, Piso P, Verwaal VJ, González-Moreno S, Glehen O. The 2022 PSOGI International Consensus on HIPEC Regimens for Peritoneal Malignancies: HIPEC Technologies. Ann Surg Oncol 2024; 31:7090-7110. [PMID: 39037523 DOI: 10.1245/s10434-024-15513-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/09/2024] [Indexed: 07/23/2024]
Abstract
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.
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Affiliation(s)
- Kurt Van der Speeten
- Department of Surgical Oncology, Ziekenhuis Oost-Limburg, Genk, Belgium.
- Faculty of Life Sciences, BIOMED Research Institute, University Hasselt, Hasselt, Belgium.
| | - Shigeki Kusamura
- Department of Surgical Oncology, PSM unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laurent Villeneuve
- Department of Surgical Oncology, Centre Hospitalier Lyon-sud, Lyon, France
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Vic J Verwaal
- Peritoneal Surface Malignancy and HIPEC Institute for Regional Sundhedforskning, Syddansk University, Odense, Sweden
| | | | - Olivier Glehen
- Department of Surgical Oncology, Centre Hospitalier Lyon-sud, Lyon, France
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Rauwerdink P, Al-Toma D, Wassenaar ECE, Raicu MG, Laclé MM, Milne AN, Kuijpers KC, Huysentruyt CJR, Poelmann FB, van Ramshorst B, Elias SG, Kranenburg O, Borel Rinkes IHM, Witkamp AJ, Wiezer MJ, van Grevenstein HMU, Boerma D. Reclassification of Appendiceal Mucinous Neoplasms and Associated Pseudomyxoma Peritonei According to the Peritoneal Surface Oncology Group International Consensus: Clinicopathological Reflections of a Two-Center Cohort Study. Ann Surg Oncol 2024:10.1245/s10434-024-16254-0. [PMID: 39327362 DOI: 10.1245/s10434-024-16254-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 09/10/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND International consensus on classifications of appendiceal mucinous neoplasms (AMNs) and associated pseudomyxoma peritonei (PMP) have been carefully made but clinicopathological associations supporting decision making remain scarce. OBJECTIVE This study aimed to assess interdependence between AMNs and PMP and provide directions for clinical management. METHODS This two-center retrospective cohort study reviewed patients with PMP treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy between 2005 and 2021. The primary objective was to reassess histopathologic grade of AMNs and PMP according to the Peritoneal Surface Oncology Group International classification and to establish its interdependence. Secondary outcomes were recurrence rate, PMP grade progression, ovarian involvement, and overall survival (OS). RESULTS Of 105 patients included, 78 (74.3%) had low-grade AMNs as the primary tumor, 8 (7.6%) had high-grade AMNs, 7 (6.7%) had mucinous adenocarcinoma (MAC), 1 (0.9%) had MAC with signet ring cells (SRC), and 11 (10.5%) had unidentified tumors. Overall, 11 patients (10.5%) had no PMP, 21 (20.0%) had acellular mucin, 56 (53.3%) had low-grade PMP, 12 (11.4%) had high-grade PMP, and 5 (4.8%) had PMP-SRC. In 11 cases (13.3%), AMNs and matching PMP grade differed. Over a 16-year follow-up, recurrence occurred in 31.8%, with three cases showing histopathologically changed PMP. Ovarian involvement was observed in 43/65 females (66.2%). Median OS was 13.8 years, and 5-year OS rates were 100%, 74.4%, 44.4%, and 20% for acellular mucin, low-grade PMP, high-grade PMP and PMP-SRC, respectively (p < 0.001). CONCLUSIONS AMN histology does not always reflects its associated PMP grade, while PMP grade strongly influences survival. Ovarian involvement and recurrent PMP showing unchanged histopathological features are common.
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Affiliation(s)
- Paulien Rauwerdink
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
- Lab Translational Oncology, Division Imaging and Cancer, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Dania Al-Toma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Emma C E Wassenaar
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
- Lab Translational Oncology, Division Imaging and Cancer, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mihaela G Raicu
- Department of Pathology DNA, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Miangela M Laclé
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anya N Milne
- Department of Pathology DNA, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Karel C Kuijpers
- Department of Pathology DNA, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Clément J R Huysentruyt
- Department of Pathology, Catharina Cancer Institute - Eurofins PAMM, Eindhoven, The Netherlands
| | - Floris B Poelmann
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Bert van Ramshorst
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Sjoerd G Elias
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Onno Kranenburg
- Lab Translational Oncology, Division Imaging and Cancer, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Inne H M Borel Rinkes
- Lab Translational Oncology, Division Imaging and Cancer, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arjen J Witkamp
- Department of Surgery, Division Imaging and Cancer, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Helma M U van Grevenstein
- Department of Surgery, Division Imaging and Cancer, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Djamila Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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Rauwerdink P, van de Vlasakker VCJ, Wassenaar ECE, Rovers KP, Los M, Herbschleb KH, Creemers GJM, Thijs AMJ, Raicu MG, Huysentruyt CJR, van der Hoeven EJRJ, Nederend J, Peeters RYM, Deenen MJ, Elias SG, Fijneman RJA, Constantinides A, Kranenburg O, Burger PWA, Nienhuijs SW, Wiezer RJ, Lurvink RJ, de Hingh IHJT, Boerma D. First-line palliative systemic therapy alternated with oxaliplatin-based pressurized intraperitoneal aerosol chemotherapy for unresectable colorectal peritoneal metastases: A single-arm phase II trial (CRC-PIPAC-II). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108487. [PMID: 38905732 DOI: 10.1016/j.ejso.2024.108487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/22/2024] [Accepted: 06/12/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Palliative systemic therapy alternated with electrostatic precipitation oxaliplatin-based pressurized intraperitoneal aerosol chemotherapy (ePIPAC) has never been prospectively investigated in patients with unresectable colorectal peritoneal metastases (CPM). The CRC-PIPAC-II study aimed to assess safety, feasibility and efficacy of such bidirectional therapy. METHODS This two-center, single-arm, phase II trial enrolled chemotherapy-naïve patients to undergo three treatment cycles, consisting of systemic therapy (CAPOX, FOLFOX, FOLFIRI, or FOLFOXIRI, all with bevacizumab) and oxaliplatin-based ePIPAC (92 mg/m2) with intravenous leucovorin (20 mg/m2) and 5-fluorouracil (400 mg/m2). Primary outcome were major treatment-related adverse events. Secondary outcomes included minor events, tumor response, progression-free survival (PFS) and overall survival (OS). RESULTS Twenty patients completed 52 treatment cycles. Fifteen major events occurred in 7 patients (35 %): 5 events (33 %) related to systemic therapy; 5 (33 %) related to ePIPAC; and 5 (33 %) were biochemical events. No treatment-related deaths occurred. All patients experienced minor events, mostly abdominal pain, nausea and peripheral sensory neuropathy. After treatment, radiological, pathological, cytological, and biochemical response was observed in 0 %, 88 %, 38 %, and 31 % of patients respectively. Curative surgery was achieved in one patient. Median PFS was 10.0 months (95 % confidence interval [CI] 8.0-13.0) and median OS was 17.5 months (95 % CI 13.0-not reached). CONCLUSIONS Combining palliative systemic therapy with oxaliplatin-based ePIPAC in patients with unresectable CPM was feasible and showed an acceptable safety profile. Treatment-induced response and survival are promising, yet further research is required to determine the additional value of ePIPAC to systemic therapy.
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Affiliation(s)
| | | | | | - Koen P Rovers
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - Maartje Los
- Department of Medical Oncology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Karin H Herbschleb
- Department of Medical Oncology, St. Antonius Hospital, Nieuwegein, Netherlands
| | | | | | - Mihaela G Raicu
- Department of Pathology DNA, St. Antonius Hospital, Nieuwegein, Netherlands
| | | | | | - Joost Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, Netherlands
| | - Rifka Y M Peeters
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Maarten J Deenen
- Department of Clinical Pharmacy, Catharina Hospital, Eindhoven, Netherlands; Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Sjoerd G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Remond J A Fijneman
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Alexander Constantinides
- Lab Translational Oncology, Division Imaging and Cancer, University Medical Center Utrecht, Utrecht, Netherlands
| | - Onno Kranenburg
- Lab Translational Oncology, Division Imaging and Cancer, University Medical Center Utrecht, Utrecht, Netherlands
| | - Pim W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | | | - René J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Robin J Lurvink
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands; Department of Epidemiology, School for Oncology and Developmental Biology, GROW, Maastricht, Netherlands.
| | - Djamila Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, Netherlands.
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Kusamura S, Delhorme JB, Taibi A, Villeneuve L, Deraco M, Dico RL, Glehen O, Moran B. The 2022 PSOGI International Consensus on HIPEC Regimens for Peritoneal Malignancies: Pseudomyxoma Peritonei. Ann Surg Oncol 2024; 31:6262-6273. [PMID: 39008204 DOI: 10.1245/s10434-024-15646-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/08/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) constitutes the established standard of care for pseudomyxoma peritonei patients. However, the role of HIPEC lacks validation through randomized trials, leading to diverse proposed treatment protocols. This consensus seeks to standardize HIPEC regimens and identify research priorities for enhanced clarity. METHODS The steering committee applied the patient, intervention, comparator, and outcome method to formulate crucial clinical questions. Evaluation of evidence followed the Grading of Recommendations, Assessment, Development, and Evaluation system. Consensus on HIPEC regimens and research priorities was sought through a two-round Delphi process involving international experts. RESULTS Out of 90 eligible panelists, 71 (79%) participated in both Delphi rounds, resulting in a consensus on six out of seven questions related to HIPEC regimens. An overwhelming 84% positive consensus favored combining HIPEC with CRS, while a 70% weak positive consensus supported HIPEC after incomplete CRS. Specific HIPEC regimens also gained consensus, with 53% supporting Oxaliplatin 200 mg/m2 and 51% favoring the combination of cisplatin (CDDP) associated with mitomycin-C (MMC). High-dose MMC regimens received an 89% positive recommendation. In terms of research priorities, 61% of panelists highlighted the importance of studies comparing HIPEC regimens post CRS. The preferred regimens for such studies were the combination of CDDP/MMC and high-dose MMC. CONCLUSIONS The consensus recommends the application of HIPEC following CRS based on the available evidence. The combination of CDDP/MMC and high-dose MMC regimens are endorsed for both current clinical practice and future research efforts.
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Affiliation(s)
- Shigeki Kusamura
- Department of Surgical Oncology, PSM Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Jean-Baptiste Delhorme
- Department of General and Digestive Surgery, Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, France
| | - Abdelkader Taibi
- Department of Digestive Surgery, Dupuytren University Hospital, CNRS, XLIM, UMR 7252, Limoges, France
| | - Laurent Villeneuve
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service de Recherche et d'Epidémiologie Cliniques, Pierre-Bénite, France
- CICLY, Université Claude Bernard Lyon 1, Lyon, France
| | - Marcello Deraco
- Department of Surgical Oncology, PSM Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Rea Lo Dico
- Department of General Surgery, Emergency, and New Technologies, San Camillo Forlanini Hospital, Rome, Italy
| | - Olivier Glehen
- CICLY, Université Claude Bernard Lyon 1, Lyon, France
- Department of Surgical Oncology, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
| | - Brendan Moran
- Peritoneal Malignancy Unit, Basingstoke Hospital, Basingstoke, UK
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Winicki NM, Greer JB. Is Hyperthermic Intraperitoneal Chemotherapy Appropriate for Colon Cancer? Adv Surg 2024; 58:49-64. [PMID: 39089786 DOI: 10.1016/j.yasu.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Colorectal cancer (CRC) with peritoneal metastases is a complex disease and its management presents significant clinical challenges. In well-selected patients at experienced centers, CRS/hyperthermic intraperitoneal chemotherapy (HIPEC) can be performed with acceptable morbidity and is associated with prolonged survival. Based on the results of recent randomized controlled trials, HIPEC using oxaliplatin after CRS with shortened perfusion periods (30 minutes) is no longer recommended. There is a movement toward utilizing mitomycin C as a first-line intraperitoneal agent with extended perfusion times (90-120 minutes); however, there is currently little prospective evidence to support its widespread use.
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Affiliation(s)
- Nolan M Winicki
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Jonathan B Greer
- Division of Gastrointestinal Surgical Oncology, Peritoneal Surface Malignancy Program, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Halsted 614, Baltimore, MD 21287, USA.
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Taqi K, Lee J, Hurton S, Stockley C, Mack L, Rivard J, Temple W, Bouchard-Fortier A. Long-Term Outcomes following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis of Colorectal Origin. Curr Oncol 2024; 31:3657-3668. [PMID: 39057141 PMCID: PMC11275434 DOI: 10.3390/curroncol31070269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major treatment of colorectal peritoneal carcinomatosis (CPC). The aim was to determine the disease-free survival (DFS) and overall survival (OS) of patients undergoing CRS-HIPEC for CPC and factors associated with long-term survival (LTS). METHODS consecutive CPC patients who underwent CRS-HIPEC at a HIPEC center between 2007 and 2021 were included. Actual survival was calculated, and Cox proportional hazards models were used to identify factors associated with OS, DFS and LTS. RESULTS there were 125 patients with CPC who underwent primary CRS-HIPEC, with mean age of 54.5 years. Median follow-up was 31 months. Average intraoperative PCI was 11, and complete cytoreduction (CC-0) was achieved in 96.8%. Median OS was 41.6 months (6-196). The 2-year and 5-year OS were 68% and 24.8%, respectively, and the 2-year DFS was 28.8%. Factors associated with worse OS included pre-HIPEC systemic therapy, synchronous extraperitoneal metastasis, and PCI ≥ 20 (p < 0.05). Progression prior to CRS-HIPEC was associated with worse DFS (p < 0.05). Lower PCI, fewer complications, lower recurrence and longer DFS were associated with LTS (p < 0.05). CONCLUSION CRS and HIPEC improve OS in CPC patients but they have high disease recurrence. Outcomes depend on preoperative therapy response, extraperitoneal metastasis, and peritoneal disease burden.
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Affiliation(s)
- Kadhim Taqi
- Division of Surgical Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jay Lee
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Scott Hurton
- Division of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 0W2, Canada
| | - Cecily Stockley
- Division of Surgical Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Lloyd Mack
- Division of Surgical Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Justin Rivard
- Division of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 0W2, Canada
| | - Walley Temple
- Division of Surgical Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Antoine Bouchard-Fortier
- Division of Surgical Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
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Yrjönen A, Koskenvuo L, Haapamäki C, Lepistö A. Recurrence after cytoreductive surgery and HIPEC for pseudomyxoma peritonei: A single-center retrospective cohort study. Scand J Surg 2024; 113:140-149. [PMID: 37828760 DOI: 10.1177/14574969231200653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND AIMS Pseudomyxoma peritonei (PMP) is a rare disease characterized by progressive build-up of mucinous deposits inside the abdominal cavity. The aim of this study was to investigate the effect of disease recurrence on overall survival in patients with PMP after cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS One-hundred thirty-two consecutive PMP patients treated with CRS + HIPEC at Helsinki University Hospital between 2008 and 2017 were included. The impact of clinicopathological and treatment-related characteristics on recurrence and overall survival was evaluated. RESULTS The median follow-up time in the study was 5.04 (range = 0.05-11.60) years. In 121 (91.7%) patients, the disease was classified as low grade and 11 (8.3%) had high-grade disease. In the low-grade group, 26 (21.5%) patients developed a recurrence during follow-up compared to 6 (54.5%) patients in the high-grade group. In the low-grade group, cumulative survival was 98.2%, 91.4%, and 91.4% at 3, 6, and 8 years, respectively. In the high-grade group, cumulative survival was 90.0% and 78.8% at 3 and 6 years, respectively. In patients with recurrent disease, the cumulative survival was 100%, 84.6%, and 84.6% at 3, 6, and 8 years in the low-grade category and 80.0% and 60.0% at 3 and 6 years in the high-grade category, respectively. In the low-grade group, a statistically significant correlation with recurrence but not with overall survival was identified with peritoneal cancer index (PCI), carcinoembryonic antigen (CEA), and the number of affected regions. CONCLUSION The recurrence of low-grade PMP does not significantly affect overall survival of patients. Disease extent may not be a prognostic indicator after curative CRS and HIPEC in low-grade PMP.
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Affiliation(s)
- Antti Yrjönen
- Jorvi Hospital, Ambulatory Surgery Unit, Karvasmäentie 8, Espoo 02740 Finland
| | - Laura Koskenvuo
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Carola Haapamäki
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anna Lepistö
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Dietz MV, Hannink G, Said I, van der Zant FA, van de Vlasakker VCJ, Brandt-Kerkhof ARM, Verhoef C, Bremers AJA, de Wilt JHW, Hemmer PHJ, de Hingh IHJT, de Reuver PR, Madsen EVE. Development of a prediction model for recurrence in patients with colorectal peritoneal metastases undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108294. [PMID: 38583215 DOI: 10.1016/j.ejso.2024.108294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/07/2024] [Accepted: 03/20/2024] [Indexed: 04/09/2024]
Abstract
INTRODUCTION Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) improves survival outcomes for selected patients with colorectal peritoneal metastases (PM), but recurrence rates are high. The aim of this study was to develop a tool to predict recurrence in patients with colorectal PM that undergo CRS-HIPEC. MATERIALS AND METHODS For this retrospective cohort study, data of patients that underwent CRS-HIPEC for colorectal PM from four Dutch HIPEC centers were used. Exclusion criteria were perioperative systemic therapy and peritoneal cancer index (PCI) ≥20. Nine previously identified factors were considered as predictors: gender, age, primary tumor characteristics (location, nodal stage, differentiation, and mutation status), synchronous liver metastases, preoperative Carcino-Embryonal Antigen (CEA), and peritoneal cancer index (PCI). The prediction model was developed using multivariable Cox regression and validated internally using bootstrapping. The performance of the model was evaluated by discrimination and calibration. RESULTS In total, 408 patients were included. During the follow-up, recurrence of disease occurred in 318 patients (78%). Significant predictors of recurrence were PCI (HR 1.075, 95% CI 1.044-1.108) and primary tumor location (left sided HR 0.719, 95% CI 0.550-0.939). The prediction model for recurrence showed fair discrimination with a C-index of 0.64 (95% CI 0.62, 0.66) after internal validation. The model was well-calibrated with good agreement between the predicted and observed probabilities. CONCLUSION We developed a prediction tool that could aid in the prediction of recurrence in patients with colorectal PM who undergo CRS-HIPEC.
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Affiliation(s)
- Michelle V Dietz
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ibrahim Said
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Femke A van der Zant
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Andreas J A Bremers
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Patrick H J Hemmer
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eva V E Madsen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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Varinelli L, Battistessa D, Guaglio M, Zanutto S, Illescas O, Lorenc EJ, Pisati F, Kusamura S, Cattaneo L, Sabella G, Milione M, Perbellini A, Noci S, Paolino C, Kuhn E, Galassi M, Cavalleri T, Deraco M, Gariboldi M, Baratti D. Colorectal carcinoma peritoneal metastases-derived organoids: results and perspective of a model for tailoring hyperthermic intraperitoneal chemotherapy from bench-to-bedside. J Exp Clin Cancer Res 2024; 43:132. [PMID: 38698446 PMCID: PMC11064374 DOI: 10.1186/s13046-024-03052-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/19/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Peritoneal metastases from colorectal cancer (CRCPM) are related to poor prognosis. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been reported to improve survival, but peritoneal recurrence rates are still high and there is no consensus on the drug of choice for HIPEC. The aim of this study was to use patient derived organoids (PDO) to build a relevant CRCPM model to improve HIPEC efficacy in a comprehensive bench-to-bedside strategy. METHODS Oxaliplatin (L-OHP), cisplatin (CDDP), mitomycin-c (MMC) and doxorubicin (DOX) were used to mimic HIPEC on twelve PDO lines derived from twelve CRCPM patients, using clinically relevant concentrations. After chemotherapeutic interventions, cell viability was assessed with a luminescent assay, and the obtained dose-response curves were used to determine the half-maximal inhibitory concentrations. Also, induction of apoptosis by different HIPEC interventions on PDOs was studied by evaluating CASPASE3 cleavage. RESULTS Response to drug treatments varied considerably among PDOs. The two schemes with better response at clinically relevant concentrations included MMC alone or combined with CDDP. L-OHP showed relative efficacy only when administered at low concentrations over a long perfusion period. PDOs showed that the short course/high dose L-OHP scheme did not appear to be an effective choice for HIPEC in CRCPM. HIPEC administered under hyperthermia conditions enhanced the effect of chemotherapy drugs against cancer cells, affecting PDO viability and apoptosis. Finally, PDO co-cultured with cancer-associated fibroblast impacted HIPEC treatments by increasing PDO viability and reducing CASPASES activity. CONCLUSIONS Our study suggests that PDOs could be a reliable in vitro model to evaluate HIPEC schemes at individual-patient level and to develop more effective treatment strategies for CRCPM.
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Affiliation(s)
- Luca Varinelli
- Department of Experimental Oncology, Molecular Epigenomics Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Davide Battistessa
- Department of Experimental Oncology, Molecular Epigenomics Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Marcello Guaglio
- Peritoneal Surface Malignancies Unit, Colorectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Susanna Zanutto
- Department of Experimental Oncology, Molecular Epigenomics Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Oscar Illescas
- Department of Experimental Oncology, Molecular Epigenomics Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Ewelina J Lorenc
- Department of Experimental Oncology, Molecular Epigenomics Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Federica Pisati
- Cogentech Ltd. Benefit Corporation With a Sole Shareholder, Via Adamello 16, Milan, 20139, Italy
| | - Shigeki Kusamura
- Peritoneal Surface Malignancies Unit, Colorectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Laura Cattaneo
- Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale Dei Tumori Di Milano, Via G. Venezian 1, Milan, 20133, Italy
| | - Giovanna Sabella
- Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale Dei Tumori Di Milano, Via G. Venezian 1, Milan, 20133, Italy
| | - Massimo Milione
- Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale Dei Tumori Di Milano, Via G. Venezian 1, Milan, 20133, Italy
| | - Alessia Perbellini
- Department of Experimental Oncology, Molecular Epigenomics Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Sara Noci
- Department of Experimental Oncology, Molecular Epigenomics Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Cinzia Paolino
- Department of Experimental Oncology, Molecular Epigenomics Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Elisabetta Kuhn
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, 20122, Italy
- Pathology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, 20122, Italy
| | - Margherita Galassi
- Centrale Produzione Farmaci, Hospital Pharmacy, Fondazione IRCCS Istituto Nazionale Dei Tumori Di Milano, Via G. Venezian 1, Milan, 20133, Italy
| | - Tommaso Cavalleri
- Peritoneal Surface Malignancies Unit, Colorectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancies Unit, Colorectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy.
| | - Manuela Gariboldi
- Department of Experimental Oncology, Molecular Epigenomics Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
| | - Dario Baratti
- Peritoneal Surface Malignancies Unit, Colorectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, Milan, 20133, Italy
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10
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Zheng Y, Zhang J, Chen C, Gong Z, Wang Z, Deng Q, Yu S, Hu Y, Liu Y, Cao H, Xiao Q, Wang J, Ding K, Sun L. Prophylactic hyperthermic intraperitoneal chemotherapy in T4 colorectal cancer: Can it improve the oncologic prognosis? - A propensity score matching study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107958. [PMID: 38219698 DOI: 10.1016/j.ejso.2024.107958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/08/2023] [Accepted: 01/08/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND Some studies show that cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) may improve overall survival and is a possible curative treatment for selected colorectal cancer (CRC) patients with restricted peritoneal metastasis (PM). The value of HIPEC in preventing PM of CRC is still controversial. MATERIALS AND METHODS In this retrospective propensity score matching (PSM) cohort study, all patients with cT4N0-2M0 undergoing treatment at a single institution in China (2014-2018) were reviewed. The 3-year disease-free survival (DFS) was set as the primary outcome, and the 3-year PM rate was also analyzed. RESULTS 220 patients were included in this study for analysis. After 1:3 PSM: HIPEC (n = 45) and No HIPEC (n = 135). Through analysis, it was found that prophylactic HIPEC correlated to better DFS [hazard ratio (HR) 0.43, 95 % confidence interval (CI) 0.19-0.95; p = 0.037], and N2 stage correlated to worse DFS [HR 1.97, 95 % CI 1.09-3.56; p = 0.025]. For laparoscopic surgery subgroup analyses, 3-year PM rate of patients with laparoscopic surgery was 13.8 % in No HIPEC group, and 2.6 % in HIPEC group (p = 0.070). Besides, no post-operative death occurred, the anastomotic leakage rate was 2.2 % in HIPEC group and 0.7 % in the control group (p = 0.439). CONCLUSIONS Prophylactic HIPEC may improve the prognosis in patients with cT4N0-1M0 CRC, but not in cT4N2M0 CRC, and it does not significantly increase surgery-related complications. Laparoscopic surgery followed by HIPEC for T4 stage CRC may not increase risk of PM.
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Affiliation(s)
- Yuyan Zheng
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China
| | - Jingjing Zhang
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China
| | - Chao Chen
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China
| | - Zhiyuan Gong
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China
| | - Zhanhuai Wang
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China
| | - Qun Deng
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China
| | - Shaojun Yu
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China
| | - Yeting Hu
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China
| | - Yue Liu
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China
| | - Hongfeng Cao
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China
| | - Qian Xiao
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China; Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, Hangzhou, Zhejiang, China
| | - Jian Wang
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China; Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, Hangzhou, Zhejiang, China
| | - Kefeng Ding
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China; Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, Hangzhou, Zhejiang, China.
| | - Lifeng Sun
- Zhejiang University School of Medicine Second Affiliated Hospital, Colorectal Surgery, Hangzhou, Zhejiang, China; Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, Hangzhou, Zhejiang, China.
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11
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Willemse JRJ, Lahaye MJ, Kok NFM, Grotenhuis BA, Aalbers AGJ, Beets GL, Rijsemus C, Maas M, van Golen LW, Beets-Tan RGH, Lambregts DMJ. Whole-body MRI with diffusion-weighted imaging as an adjunct to 18 F-fluorodeoxyglucose positron emission tomography and CT in patients with suspected recurrent colorectal cancer. Colorectal Dis 2024; 26:290-299. [PMID: 38145899 DOI: 10.1111/codi.16840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 12/27/2023]
Abstract
AIM The aim was to explore how findings of whole-body MRI including diffusion-weighted imaging (DW-MRI) compared to the routine diagnostic workup with CT and/or 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT in patients with suspected recurrent colorectal cancer (CRC). METHOD This was an exploratory retrospective analysis of 55 patients with a clinical suspicion of recurrent CRC who underwent DW-MRI following CT and/or FDG-PET/CT. Two readers in consensus interpreted all clinical imaging reports and converted each described lesion into a confidence score (1 = definitely benign to 5 = definitely malignant). DW-MRI findings were compared to the most recent previous CT or PET/CT. Any discrepant or additional DW-MRI findings were documented and compared with histology and/or clinical follow-up (if available). RESULTS Whole-body MRI including diffusion-weighted imaging (DW-MRI) resulted in discrepant/additional findings in 26/55 (47%) cases; 23/37 (62%) compared to previous CT and 3/18 (17%) compared to previous PET/CT. These included 10 cases where DW-MRI converted previously inconclusive CT (n = 8) or PET/CT (n = 2) findings into a conclusive diagnosis, one where it contradicted a previous CT diagnosis of recurrence, five where DW-MRI diagnosed recurrent disease not previously reported on CT and 10 cases where DW-MRI detected additional lesions compared to CT (n = 9) or PET/CT (n = 1). Eighty-eight per cent of cases with discrepant/additional findings concerned patients with recurrent/metachronous peritoneal metastases. In total, DW-MRI resulted in 42 discrepant/additional lesions; the DW-MRI diagnosis was correct in 76% of these lesions and incorrect (false positive) in 7%. In the remaining 17%, no standard of reference was available. CONCLUSIONS This explorative study suggests that DW-MRI may be of added value to patients with a clinical suspicion for recurrent CRC, in particular to identify patients with peritoneal metastases. DW-MRI mainly has potential as a 'problem-solver' in patients with inconclusive or negative findings on previous imaging (in particular CT) and to detect additional disease sites in patients already diagnosed with recurrent disease.
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Affiliation(s)
- Jeroen R J Willemse
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Max J Lahaye
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Niels F M Kok
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Brechtje A Grotenhuis
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Arend G J Aalbers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Geerard L Beets
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Charlotte Rijsemus
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Monique Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Larissa W van Golen
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Doenja M J Lambregts
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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12
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Graf W, Ghanipour L, Birgisson H, Cashin PH. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Metastases from Colorectal Cancer-An Overview of Current Status and Future Perspectives. Cancers (Basel) 2024; 16:284. [PMID: 38254775 PMCID: PMC10813964 DOI: 10.3390/cancers16020284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Peritoneal metastases (PM) are observed in approximately 8% of patients diagnosed with colorectal cancer, either synchronously or metachronously during follow-up. PM often manifests as the sole site of metastasis. PM is associated with a poor prognosis and typically shows resistance to systemic chemotherapy. Consequently, there has been a search for alternative treatment strategies. This review focuses on the global evolution of the combined approach involving cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for the management of PM. It encompasses accepted clinical guidelines, principles for patient selection, surgical and physiological considerations, biomarkers, pharmacological protocols, and treatment outcomes. Additionally, it integrates the relevant literature and findings from previous studies. The role of CRS and HIPEC, in conjunction with other therapies such as neoadjuvant and adjuvant chemotherapy, is discussed, along with the management of patients presenting with oligometastatic disease. Furthermore, potential avenues for future development in this field are explored.
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Affiliation(s)
- Wilhelm Graf
- Uppsala Sweden and Department of Surgery, Institution of Surgical Sciences, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden; (L.G.); (H.B.); (P.H.C.)
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13
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Dhiman A, Kothary V, Witmer HDD, Bregio C, Sood D, Ong CT, Polite B, Eng OS, Shergill A, Turaga KK. Role of Tumor-informed Personalized Circulating Tumor DNA Assay in Informing Recurrence in Patients With Peritoneal Metastases From Colorectal and High-grade Appendix Cancer Undergoing Curative-intent Surgery. Ann Surg 2023; 278:925-931. [PMID: 36994703 DOI: 10.1097/sla.0000000000005856] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To investigate the role of a personalized, tumor-informed circulating tumor DNA (ctDNA) assay in informing recurrence in patients with peritoneal metastases (PM) from colorectal (CRC) and high-grade appendix (HGA) cancer after curative cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). BACKGROUND Over 50% of patients with CRC/HGA-PM recur after optimal CRS-HIPEC. The limited sensitivity of axial imaging and diagnostic biomarkers is a significant cause of delay in the detection of recurrence and initiation of further therapies. Plasma ctDNA has a promising role in monitoring response to treatment and/or recurrence after primary cancer resection. METHODS Patients with CRC/HGA-PM who underwent curative CRS-HIPEC and serial postresection ctDNA assessments were included. Patients with rising postoperative ctDNA levels were compared with those with stable, undetectable ctDNA levels. Primary outcomes were the percentage of patients with recurrence and disease-free survival (DFS). Secondary outcomes were overall survival, ctDNA sensitivity, lead time, and performance of ctDNA compared with carcinoembryonic antigen. RESULTS One hundred thirty serial postresection ctDNA assessments [median 4, interquartile range (IQR), 3 to 5] were performed in 33 patients (n = 13 CRC, n = 20 HGA) who underwent completeness of cytoreduction-0/1 CRS with a median follow-up of 13 months. Of the 19 patients with rising ctDNA levels, 90% recurred versus 21% in the stable ctDNA group (n = 14, < 0.001). Median DFS in the rising ctDNA cohort was 11 months (IQR, 6 to 12) and not reached in the stable ( P = 0.01). A rising ctDNA level was the most significant factor associated with DFS (hazard ratio: 3.67, 95% CI: 1.06-12.66, P = 0.03). The sensitivity and specificity of rising ctDNA levels in predicting recurrence were 85% and 84.6%, respectively. The median ctDNA lead time was 3 months (IQR, 1 to 4). Carcinoembryonic antigen was less sensitive (50%) than ctDNA. CONCLUSIONS This study supports the clinical validity of serial ctDNA assessment as a strong prognostic biomarker in informing recurrence in patients with CRC/HGA-PM undergoing curative resection. It also holds promises for informing future clinical trial designs and further research.
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Affiliation(s)
- Ankit Dhiman
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, IL
| | - Vishesh Kothary
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
| | - Hunter D D Witmer
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, IL
| | - Celyn Bregio
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Divya Sood
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, IL
| | - Cecilia T Ong
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, IL
| | - Blase Polite
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
| | - Oliver S Eng
- Division of Surgical Oncology, Department of Surgery, University of California, Irvine, Orange, CA
| | - Ardaman Shergill
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
| | - Kiran K Turaga
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, IL
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14
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Sedighim S, Khan A, Li AY, Tajik F, Radhakrishnan VK, Eng O, Turaga K, Senthil M. Adoption of cytoreductive surgery in the management of peritoneal malignancies-Global trends. J Surg Oncol 2023; 128:1021-1031. [PMID: 37818906 DOI: 10.1002/jso.27448] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 10/13/2023]
Abstract
Cytoreductive surgery (CRS) has now been accepted as an integral component in the management of gastrointestinal and gynecological cancers with peritoneal metastases. Since the adoption of CRS is influenced by access to advanced medical facilities, trained multidisciplinary teams, and funding, there is wide variability in incorporation of CRS into routine clinical practice between high- versus low- and middle-income countries. This review highlights the global trends in the adoption of CRS for peritoneal malignancies with a specific focus on the establishment of CRS programs and barriers to incorporate CRS into routine clinical care in low- and middle-income countries.
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Affiliation(s)
- Shaina Sedighim
- Department of Surgery, University of California, Irvine, California, USA
| | - Aaqil Khan
- Department of Surgery, University of California, Irvine, California, USA
- School of Medicine, University of California, Irvine, California, USA
| | - Amy Y Li
- Division of Surgical Oncology, Department of Surgery, University of California Irvine Medical Center, Orange, California, USA
| | - Fatemeh Tajik
- Department of Surgery, University of California, Irvine, California, USA
| | | | - Oliver Eng
- Division of Surgical Oncology, Department of Surgery, University of California Irvine Medical Center, Orange, California, USA
| | - Kiran Turaga
- Division of Surgical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Maheswari Senthil
- Department of Surgery, University of California, Irvine, California, USA
- Division of Surgical Oncology, Department of Surgery, University of California Irvine Medical Center, Orange, California, USA
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15
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Zhong Y, Yang K, Qin X, Luo R, Wang H. Impact of Molecular Status on Cytoreductive Surgery for Peritoneal Metastases from Colorectal Cancer. Clin Colon Rectal Surg 2023; 36:415-422. [PMID: 37795471 PMCID: PMC10547537 DOI: 10.1055/s-0043-1767705] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Colorectal cancer peritoneal metastases (CRC-PM) are present in 5 to 15% of instances of CRC, and the overall survival (OS) of patients with CRC-PM is much lower than that of patients with other isolated metastatic locations. In recent years, the introduction of cytoreductive surgery (CRS) in conjunction with hyperthermic intraperitoneal chemotherapy has resulted in a significant improvement in CRC-PM patients' OS. Despite this, a significant proportion of CRS patients continue to suffer complications of grades III to V or even die during the perioperative period. Early diagnosis, optimization of patient selection criteria, and refining of individualized combination therapy are necessary for these patients. In this review, we evaluate studies examining the relationship between molecular status and CRS in CRC-PM. Our objective is to gain a comprehensive understanding of how the altered molecular status of CRC-PM impacts CRS, which could increase the likelihood of tailored therapy in the future.
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Affiliation(s)
- Yun Zhong
- Department of Colorectal Surgery, Sun Yat-sen University, The Sixth Affiliated Hospital, Guangzhou, China
- Department of General Surgery, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Material Conversion and Evaluation Engineering Technology Research Center of Guangdong Province, Guangzhou, China
- Institute of Biomedical Innovation and Laboratory of Regenerative Medicine and Biomaterials, Guangzhou, China
| | - Keli Yang
- Department of Colorectal Surgery, Sun Yat-sen University, The Sixth Affiliated Hospital, Guangzhou, China
- Department of General Surgery, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Material Conversion and Evaluation Engineering Technology Research Center of Guangdong Province, Guangzhou, China
- Institute of Biomedical Innovation and Laboratory of Regenerative Medicine and Biomaterials, Guangzhou, China
| | - Xiusen Qin
- Department of Colorectal Surgery, Sun Yat-sen University, The Sixth Affiliated Hospital, Guangzhou, China
- Department of General Surgery, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Material Conversion and Evaluation Engineering Technology Research Center of Guangdong Province, Guangzhou, China
- Institute of Biomedical Innovation and Laboratory of Regenerative Medicine and Biomaterials, Guangzhou, China
| | - Rui Luo
- Department of Colorectal Surgery, Sun Yat-sen University, The Sixth Affiliated Hospital, Guangzhou, China
- Department of General Surgery, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Material Conversion and Evaluation Engineering Technology Research Center of Guangdong Province, Guangzhou, China
- Institute of Biomedical Innovation and Laboratory of Regenerative Medicine and Biomaterials, Guangzhou, China
| | - Hui Wang
- Department of Colorectal Surgery, Sun Yat-sen University, The Sixth Affiliated Hospital, Guangzhou, China
- Department of General Surgery, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Material Conversion and Evaluation Engineering Technology Research Center of Guangdong Province, Guangzhou, China
- Institute of Biomedical Innovation and Laboratory of Regenerative Medicine and Biomaterials, Guangzhou, China
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Nguyen QA, Chou WH, Hsieh MC, Chang CM, Luo WT, Tai YT, Chang WC. Genetic alterations in peritoneal metastatic tumors predicted the outcomes for hyperthermic intraperitoneal chemotherapy. Front Oncol 2023; 13:1054406. [PMID: 37182141 PMCID: PMC10170308 DOI: 10.3389/fonc.2023.1054406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 03/27/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered for patients with peritoneal metastasis (PM). However, patients selection that relies on conventional prognostic factors is not yet optimal. In this study, we performed whole exome sequencing (WES) to establish tumor molecular characteristics and expect to identify prognosis profiles for PM management. Methods In this study, blood and tumor samples were collected from patients with PM before HIPEC. Tumor molecular signatures were determined using WES. Patient cohort was divided into responders and non-responders according to 12-month progression-free survival (PFS). Genomic characteristics between the two cohorts were compared to study potential targets. Results In total, 15 patients with PM were enrolled in this study. Driver genes and enriched pathways were identified from WES results. AGAP5 mutation was found in all responders. This mutation was significantly associated with better OS (p = 0.00652). Conclusions We identified prognostic markers that might be useful to facilitate decision-making before CRS/HIPEC.
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Affiliation(s)
- Quynh-Anh Nguyen
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Wan-Hsuan Chou
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Mao-Chih Hsieh
- Department of General Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Che-Mai Chang
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Wei-Tzu Luo
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Yu-Ting Tai
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wei-Chiao Chang
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
- Master Program in Clinical Genomics and Proteomics, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Integrative Research Center for Critical Care, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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17
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Strijker D, Meijerink WJHJ, van Heusden-Schotalbers LAG, van den Berg MGA, van Asseldonk MJMD, Drager LD, de Wilt JHW, van Laarhoven KJHM, van den Heuvel B. Multimodal Prehabilitation in Patients Undergoing Complex Colorectal Surgery, Liver Resection, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): A Pilot Study on Feasibility and Potential Efficacy. Cancers (Basel) 2023; 15:cancers15061870. [PMID: 36980756 PMCID: PMC10047129 DOI: 10.3390/cancers15061870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/10/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Surgery for complex primary and metastatic colorectal cancer (CRC), such as liver resection and hyperthermic intraperitoneal chemotherapy (HIPEC), in academic settings has led to improved survival but is associated with complications up to 75%. Prehabilitation has been shown to prevent complications in non-academic hospitals. This pilot study aimed to determine the feasibility and potential efficacy of a multimodal prehabilitation program in patients undergoing surgery in an academic hospital for complex primary and metastatic CRC. METHODS All patients awaiting complex colorectal surgery, liver resection, or HIPEC from July 2019 until January 2020 were considered potentially eligible. Feasibility was measured by accrual rate, completion rate, adherence to the program, satisfaction, and safety. To determine potential efficacy, postoperative outcomes were compared with a historical control group. RESULTS Sixteen out of twenty-five eligible patients (64%) commenced prehabilitation, and fourteen patients fully completed the intervention (88%). The adherence rate was 69%, as 11 patients completed >80% of prescribed supervised trainings. No adverse events occurred, and all patients expressed satisfaction with the program. The complication rate was significantly lower in the prehabilitation group (37.5%) than the control group (70.2%, p = 0.020). There was no difference in the type of complications. CONCLUSION This pilot study illustrates that multimodal prehabilitation is feasible in the majority of patients undergoing complex colorectal cancer, liver resection, and HIPEC in an academic setting.
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Affiliation(s)
- Dieuwke Strijker
- Department of Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | | | | | - Manon G A van den Berg
- Department of Gastroenterology and Hepatology-Dietetics and Intestinal Failure, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | - Monique J M D van Asseldonk
- Department of Gastroenterology and Hepatology-Dietetics and Intestinal Failure, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | - Luuk D Drager
- Department of Operating Rooms, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | | | - Baukje van den Heuvel
- Department of Operating Rooms, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
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18
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Bakkers C, Rovers KP, Rijken A, Simkens GAAM, Bonhof CS, Nienhuijs SW, Burger JWA, Creemers GJM, Brandt-Kerkhof ARM, Tuynman JB, Aalbers AGJ, Wiezer MJ, de Reuver PR, van Grevenstein WMU, Hemmer PHJ, Punt CJA, Tanis PJ, Mols F, de Hingh IHJT. Perioperative Systemic Therapy Versus Cytoreductive Surgery and HIPEC Alone for Resectable Colorectal Peritoneal Metastases: Patient-Reported Outcomes of a Randomized Phase II Trial. Ann Surg Oncol 2023; 30:2678-2688. [PMID: 36754943 PMCID: PMC10085918 DOI: 10.1245/s10434-023-13116-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/02/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND As part of a randomized phase II trial in patients with isolated resectable colorectal peritoneal metastases (CPMs), the present study compared patient-reported outcomes (PROs) of patients treated with perioperative systemic therapy versus cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) alone. Also, PROs of patients receiving perioperative systemic therapy were explored. PATIENTS AND METHODS Eligible patients were randomized to perioperative systemic therapy (experimental) or CRS-HIPEC alone (control). PROs were assessed using EORTC QLQ-C30, QLQ-CR29, and EQ-5D-5L questionnaires at baseline, after neoadjuvant treatment (experimental), and at 3 and 6 months postoperatively. Linear mixed modeling was used to compare five predefined PROs (visual analog scale, global health status, physical functioning, fatigue, C30 summary score) between arms and to longitudinally analyze PROs in the experimental arm. RESULTS Of 79 analyzed patients, 37 (47%) received perioperative systemic therapy. All predefined PROs were comparable between arms at all timepoints and returned to baseline at 3 or 6 months postoperatively. The experimental arm had worsening of fatigue [mean difference (MD) + 14, p = 0.001], loss of appetite (MD + 15, p = 0.003), hair loss (MD + 18, p < 0.001), and loss of taste (MD + 27, p < 0.001) after neoadjuvant treatment. Except for loss of appetite, these PROs returned to baseline at 3 or 6 months postoperatively. CONCLUSIONS In patients with resectable CPM randomized to perioperative systemic therapy or CRS-HIPEC alone, PROs were comparable between arms and returned to baseline postoperatively. Together with the trial's previously reported feasibility and safety data, these findings show acceptable tolerability of perioperative systemic therapy in this setting.
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Affiliation(s)
- C Bakkers
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - K P Rovers
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - A Rijken
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - G A A M Simkens
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - C S Bonhof
- Center of Research on Psychological and Somatic Disorders, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - S W Nienhuijs
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - G J M Creemers
- Department of Medical Oncology, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - A R M Brandt-Kerkhof
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam University Medical Centers, VUMC, Amsterdam, The Netherlands
| | - A G J Aalbers
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - M J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - P R de Reuver
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - P H J Hemmer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - C J A Punt
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - F Mols
- Center of Research on Psychological and Somatic Disorders, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands. .,GROW - School for Oncology and Development Biology, Maastricht University, Maastricht, The Netherlands.
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19
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Peerenboom R, Dhiman A, Witmer HDD, Spurr LF, Polite B, Eng OS, Shergill A, Turaga KK. PI3K Pathway Alterations in Peritoneal Metastases are Associated with Earlier Recurrence in Patients with Colorectal Cancer Undergoing Optimal Cytoreductive Surgery. Ann Surg Oncol 2023; 30:3114-3122. [PMID: 36637640 DOI: 10.1245/s10434-022-12784-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/24/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Colorectal cancer with peritoneal metastasis (CRC-PM) represents a biologically heterogeneous disease; yet little is known regarding the impact of tumor biology on survival outcomes following optimal cytoreductive surgery (CRS). We analyzed the frequency of alterations in cancer signaling pathways in patients with CRC-PM and their impact on recurrence-free survival (RFS) following optimal CRS. METHODS Thirty-five consecutive CRC-PM patients who underwent optimal CRS/HIPEC and next generation sequencing of peritoneal metastases were included in the study. Alterations in eight cancer-related signaling pathways were analyzed: Wnt/APC, p53, RTK-RAS, PI3K, TGF-B, Notch, Myc, and cell cycle. The association of pathway alterations with RFS and OS following optimal cytoreduction was estimated using Cox proportional hazard modeling. RESULTS The most frequently altered pathways were Wnt/APC (63%), p53 (63%), RTK-RAS (60%), and PI3K (23%). Among optimally cytoreduced patients with CRC-PM, PI3K pathway alterations were an independent predictor of worse RFS (hazard ratio 3.2, 95% confidence interval CI 1.3-8.3, p = 0.01) with a clinically meaningful impact on median months to recurrence (5 vs. 13 months, p = 0.02). Alterations in p53, Wnt, and RTK-RAS pathways were not significantly associated with a difference in RFS following CRS. Alterations in the four pathways were not associated with differences in OS following CRS (median OS was 50 (interquartile range 23-80) months). CONCLUSIONS In patients with CRC-PM, PI3K pathway alterations are associated with earlier recurrence following optimal CRS, which may represent a distinct molecular subtype. This novel finding can tailor clinical trials by using PIK3CA-directed interventions to reduce risk of recurrence after optimal CRS.
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Affiliation(s)
- Rayne Peerenboom
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Ankit Dhiman
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Hunter D D Witmer
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Liam F Spurr
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.,Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Blase Polite
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Oliver S Eng
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Ardaman Shergill
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Kiran K Turaga
- Department of Surgery, Yale University School of Medicine, 310 Cedar Street FMB 130J, New Haven, CT, 06510, USA.
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20
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Foster JM, Zhang C, Rehman S, Sharma P, Alexander HR. The contemporary management of peritoneal metastasis: A journey from the cold past of treatment futility to a warm present and a bright future. CA Cancer J Clin 2023; 73:49-71. [PMID: 35969103 DOI: 10.3322/caac.21749] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/12/2022] [Accepted: 06/15/2022] [Indexed: 01/17/2023] Open
Abstract
Peritoneal metastasis (PM) is often regarded as a less frequent pattern of spread; however, collectively across all spectra of primary tumors, the consequences of PM impact a large population of patients annually. Unlike other modes of metastasis, symptoms at presentation or during the treatment course are common, representing an additional challenge in the management of PM. Early efforts with chemotherapy and incomplete surgical interventions transiently improved symptoms, but durable symptom control and survival extension were rare, which established a perspective of treatment futility for PM through most of the 20th century. Notably, the continued development of better systemic therapy combinations, optimization of cytoreductive surgery (CRS), and rigorous investigation of combining regional therapy-specifically hyperthermic intraperitoneal chemotherapy-with CRS, have resulted in more effective multimodal treatment options for patients with PM. In this article, the authors provide a comprehensive review of the data establishing the contemporary approach for tumors with a high frequency of PM, including appendix, colorectal, mesothelioma, and gastric cancers. The authors also explore the emerging role of adding hyperthermic intraperitoneal chemotherapy to the well established paradigm of CRS and systemic therapy for advanced ovarian cancer, as well as the recent clinical trials identifying the efficacy of poly(adenosine diphosphate ribose) polymerase maintenance therapy. Finally, recent data are included that explore the role of precision medicine technology in PM management that, in the future, may help further improve patient selection, identify the best systemic therapy regimens, detect actionable mutations, and identify new targets for drug development.
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Affiliation(s)
- Jason M Foster
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Chunmeng Zhang
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Shahyan Rehman
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey
| | - Prateek Sharma
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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21
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van der Zant FA, Kooijman BJL, Hentzen JEKR, Helfrich W, Ploeg EM, van Ginkel RJ, van Leeuwen BL, Been LB, Klaase JM, Hemmer PHJ, van der Hilst CS, Kruijff S. Impact of cumulative complications on 1-year treatment-related healthcare costs in patients with colorectal peritoneal metastases undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. BJS Open 2022; 6:6758035. [PMID: 36218348 PMCID: PMC9552551 DOI: 10.1093/bjsopen/zrac109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/27/2022] [Accepted: 08/01/2022] [Indexed: 11/12/2022] Open
Abstract
Background The aim of this study was to evaluate the impact of all minor and major complications on treatment-related healthcare costs in patients who undergo cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of colorectal peritoneal metastases (PMs). Method Patients with histologically proven colorectal PMs who underwent CRS + HIPEC from March 2006 to October 2019 in a tertiary referral centre were retrospectively identified from a prospectively maintained database. Patients were divided into six subgroups according to the severity of the complications, which were scored using the comprehensive complication index (CCI) (CCI 0–9.9, CCI 10–19.9, CCI 20–29.9, CCI 30–39.9, CCI 40–49.9, and CCI 50 or higher). Treatment-related healthcare costs up to 1 year after CRS + HIPEC were obtained from the financial department. Differences in costs and survival outcomes were compared using the chi-squared test and Kruskal–Wallis H test. Results A total of 142 patients were included (CCI 0–9.9, 53 patients; CCI 10–19.9, 0 patients; CCI 20–29.9, 45 patients; CCI 30–39.9, 14 patients; CCI 40–49, 9 patients; and CCI 50 or higher, 21 patients). Median (interquartile range) treatment-related healthcare costs increased significantly and exponentially for the CCI 30–39, CCI 40–49, and CCI 50 or higher groups (€48 993 (€44 262–€84 805); €57 167 (€43 047–€67 591); and €82 219 (€55 487–€145 314) respectively) compared with those for the CCI 0–9.9 and CCI 20–29.9 groups (€33 856 (€24 433–€40 779) and €40 621 (€31 501–€58 761) respectively, P < 0.010). Conclusion Treatment-related healthcare costs increase exponentially as more complications develop among patients who undergo CRS + HIPEC for the treatment of colorectal PMs. Anastomotic leakages after CRS + HIPEC lead to an increase of 295 per cent of treatment-related healthcare costs.
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Affiliation(s)
- Femke A van der Zant
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bob J L Kooijman
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Wijnand Helfrich
- Department of Surgery, Laboratory for Translational Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Emily M Ploeg
- Department of Surgery, Laboratory for Translational Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert J van Ginkel
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lukas B Been
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joost M Klaase
- Department of Surgery, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick H J Hemmer
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christian S van der Hilst
- Department of Surgery, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Schelto Kruijff
- Correspondence to: Schelto Kruijff, Department of Surgical Oncology, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands (e-mail: )
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22
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Adamina M, Warlaumont M, Berger MD, Däster S, Delaloye R, Digklia A, Gloor B, Fritsch R, Koeberle D, Koessler T, Lehmann K, Müller P, Peterli R, Ris F, Steffen T, Weisshaupt CS, Hübner M. Comprehensive Treatment Algorithms of the Swiss Peritoneal Cancer Group for Peritoneal Cancer of Gastrointestinal Origin. Cancers (Basel) 2022; 14:4275. [PMID: 36077810 PMCID: PMC9454505 DOI: 10.3390/cancers14174275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Peritoneal cancer (PC) is a dire finding, yet in selected patients, long-term survival is possible. Complete cytoreductive surgery (CRS) together with combination immunochemotherapy is essential to achieve cure. Hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC) are increasingly added to the multimodal treatment. The Swiss Peritoneal Cancer Group (SPCG) is an interdisciplinary group of expert clinicians. It has developed comprehensive treatment algorithms for patients with PC from pseudomyxoma peritonei, peritoneal mesothelioma, gastric, and colorectal origin. They include multimodal neoadjuvant treatment, surgical resection, and palliative care. The indication for and results of CRS HIPEC and PIPAC are discussed in light of the current literature. Institutional volume and clinical expertise required to achieve best outcomes are underlined, while inclusion of patients considered for CRS HIPEC and PIPAC in a clinical registry is strongly advised. The present recommendations are in line with current international guidelines and provide the first comprehensive treatment proposal for patients with PC including intraperitoneal chemotherapy. The SPCG comprehensive treatment algorithms provide evidence-based guidance for the multimodal care of patients with PC of gastrointestinal origin that were endorsed by all Swiss clinicians routinely involved in the multimodal care of these challenging patients.
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Affiliation(s)
- Michel Adamina
- Klinik für Viszeral- und Thoraxchirurgie, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Maxime Warlaumont
- Chirurgie Digestive et Cancérologique, CHU de Lille, CH de Cambrai, 59000 Lille, France
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, 1011 Lausanne, Switzerland
| | - Martin D. Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Silvio Däster
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, 4031 Basel, Switzerland
| | - Raphaël Delaloye
- Department of Medical Oncology, University Hospital Basel, 4031 Basel, Switzerland
| | - Antonia Digklia
- Department of Oncology, Lausanne University Hospital CHUV, University of Lausanne, 1011 Lausanne, Switzerland
| | - Beat Gloor
- Department of Visceral Surgery and Medicine, Inselspital, University Bern, 3010 Bern, Switzerland
| | - Ralph Fritsch
- Department of Medical Oncology and Hematology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Dieter Koeberle
- Department of Medical Oncology and Hematology, St. Claraspital, 4002 Basel, Switzerland
- Faculty of Medicine, University of Bern, 3012 Bern, Switzerland
| | - Thibaud Koessler
- Department of Oncology, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Phaedra Müller
- Klinik für Viszeral- und Thoraxchirurgie, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
| | - Ralph Peterli
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, 4031 Basel, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - Thomas Steffen
- Klinik für Allgemein-, Viszeral-, Endokrine und Transplantationschirurgie, Kantonsspital St. Gallen, 9000 St. Gallen, Switzerland
| | | | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, 1011 Lausanne, Switzerland
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23
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Kyang LS, Dewhurst SL, See VA, Alzahrani NA, Morris DL. Outcomes and prognostic factors of cytoreductive surgery and perioperative intraperitoneal chemotherapy in high-volume peritoneal carcinomatosis. Int J Hyperthermia 2022; 39:1106-1114. [PMID: 35993246 DOI: 10.1080/02656736.2022.2112625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The management of patients with extensive appendiceal mucinous neoplasms and mesothelioma is controversial. Our aims were to analyze overall survival (OS), disease-free survival (DFS) and independent prognostic factors associated with high peritoneal cancer index (PCI) status in patients who underwent cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC). METHODS A prospectively-maintained database for patients with appendiceal neoplasms and mesothelioma undergoing CRS/PIC from year 1996 to 2018 was retrospectively analyzed. Patients who achieved complete cytoreduction were stratified into limited (PCI < 30) and extensive (PCI ≥ 30) disease groups. RESULTS 260 female and 235 male patients were identified. The 5-year survival for low-grade appendiceal mucinous neoplasms (LAMN) was significantly higher in the low PCI group (96.2% vs. 63.5%, p < 0.001). There was no difference in the OS across both groups in high-grade appendiceal mucinous neoplasms (HAMN) (63 vs. 69 months; p = 0.942) and mesothelioma (72 vs. 42 months; p = 0.058). Overall mortality was 2%. Grade III/IV complications were significantly higher in extensive disease (68% vs. 36.6%, p < 0.001). On multivariate analysis, use of EPIC and blood transfusion (>8 units) were independent positive and negative prognostic factors, respectively, associated with OS. Meanwhile, use of EPIC conferred benefit in DFS while increased blood transfusion (>8 units) and elevated preoperative CA125 were predictive of a poor DFS. CONCLUSION Long-term survivals following CRS/PIC are achievable with acceptable mortality and higher morbidity rates in extensive appendiceal mucinous neoplasms and mesothelioma. High PCI status does not preclude treatment with CRS/PIC.
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Affiliation(s)
- Lee S Kyang
- Department of Surgery, St George Hospital & University of New South Wales, Sydney, Australia
| | - Suzannah L Dewhurst
- Department of Surgery, St George Hospital & University of New South Wales, Sydney, Australia
| | - Valerie A See
- Department of Surgery, St George Hospital & University of New South Wales, Sydney, Australia
| | - Nayef A Alzahrani
- Department of Surgery, National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - David L Morris
- Department of Surgery, St George Hospital & University of New South Wales, Sydney, Australia
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24
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Mor E, Shemla S, Assaf D, Laks S, Benvenisti H, Hazzan D, Shiber M, Shacham-Shmueli E, Margalit O, Halpern N, Boursi B, Beller T, Perelson D, Purim O, Zippel D, Ben-Yaacov A, Nissan A, Adileh M. Natural History and Management of Small-Bowel Obstruction in Patients After Cytoreductive Surgery and Intraperitoneal Chemotherapy. Ann Surg Oncol 2022; 29:8566-8579. [PMID: 35941342 DOI: 10.1245/s10434-022-12370-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 07/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Small-bowel obstruction (SBO) after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a common complication associated with re-admission that may alter patients' outcomes. Our aim was to characterize and investigate the impact of bowel obstruction on patients' prognosis. METHODS This was a retrospective analysis of patients with SBO after CRS/HIPEC (n = 392). We analyzed patients' demographics, operative and perioperative details, SBO re-admission data, and long-term oncological outcomes. RESULTS Out of 366 patients, 73 (19.9%) were re-admitted with SBO. The cause was adhesive in 42 (57.5%) and malignant (MBO) in 31 (42.5%). The median time to obstruction was 7.7 months (range, 0.5-60.9). Surgical intervention was required in 21/73 (28.7%) patients. Obstruction eventually resolved (spontaneous or by surgical intervention) in 56/73 (76.7%) patients. Univariant analysis identified intraperitoneal chemotherapy agents: mitomycin C (MMC) (HR 3.2, p = 0.003), cisplatin (HR 0.3, p = 0.03), and doxorubicin (HR 0.25, p = 0.018) to be associated with obstruction-free survival (OFS). Postoperative complications such as surgical site infection (SSI), (HR 2.2, p = 0.001) and collection (HR 2.07, p = 0.015) were associated with worse OFS. Multivariate analysis maintained MMC (HR 2.9, p = 0.006), SSI (HR 1.19, p = 0.001), and intra-abdominal collection (HR 2.19, p = 0.009) as independently associated with OFS. While disease-free survival was similar between the groups, overall survival (OS) was better in the non-obstruction group compared with the obstruction group (p = 0.03). CONCLUSIONS SBO after CRS/HIPEC is common and complex in management. Although conservative management was successful in most patients, surgery was required more frequently in patients with MBO. Patients with SBO demonstrate decreased survival.
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Affiliation(s)
- Eyal Mor
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Shanie Shemla
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Dan Assaf
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Shachar Laks
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Haggai Benvenisti
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - David Hazzan
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Mai Shiber
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Einat Shacham-Shmueli
- The Department of Oncology, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Ofer Margalit
- The Department of Oncology, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Naama Halpern
- The Department of Oncology, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Ben Boursi
- The Department of Oncology, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Tamar Beller
- The Department of Oncology, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Daria Perelson
- The Department of Anesthesiology, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Ofer Purim
- The Department of Oncology, Assuta Ashdod Public Hospital, Affiliated with the Faculty of Health and Science, Ben-Gurion University, Beer-Sheba, Israel, Ashdod, Israel
| | - Douglas Zippel
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Almog Ben-Yaacov
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Aviram Nissan
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Mohammad Adileh
- The Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel.
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Li J, Wang AR, Chen XD, Zhang YX, Pan H, Li SQ. Effect of hyperthermic intraperitoneal chemotherapy in combination with cytoreductive surgery on the prognosis of patients with colorectal cancer peritoneal metastasis: a systematic review and meta-analysis. World J Surg Oncol 2022; 20:200. [PMID: 35701802 PMCID: PMC9195265 DOI: 10.1186/s12957-022-02666-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/28/2022] [Indexed: 11/30/2022] Open
Abstract
Background Peritoneal metastasis often occurs in patients with colorectal cancer peritoneal metastasis, and the prognosis is poor. A large body of evidence highlights the beneficial effects of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) on survival, but to date, there is little consensus on the optimal treatment strategy for patients with colorectal cancer peritoneal metastasis. The purpose of this study is to evaluate the impact of CRS + HIPEC on survival and provide reference for the treatment of patients with colorectal cancer peritoneal metastasis. Methods This systematic review and meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The PubMed, Embase, Cochrane, Web of Knowledge, and ClinicalTrials.gov databases were screened from inception of the review to March 11, 2022. Ten studies were included in qualitative and quantitative analysis. Results A total of 3200 patients were enrolled in the study, including 788 patients in the CRS and HIPEC groups and 2412 patients in the control group, of which 3 were randomized controlled trials and 7 were cohort studies. The 3 randomized controlled studies were of high quality, and the quality scores of the 7 cohort studies were all 7 or above, indicating high quality. The results showed that the OS of CRS + HIPEC group was higher than that of control group (HR: 0.53, 95% CI: 0.38–0.73; P < 0.00001, I2 = 82.9%); the heterogeneity of the studies was large. The subgroup analysis showed that the OS of CRS and HIPEC group was higher than that of PC group (HR: 0.37, 95% CI: 0.30–0.47; P = 0.215, I2 = 31%) and higher than that in CRS group (HR: 0.73, 95% CI: 0.49–1.07; P = 0.163, I2 = 44.8%); the heterogeneity of the studies was low. In the OPEN group, the OS of THE CRS and HIPEC groups was higher than that in the control group (HR: 0.51, 95% CI: 0.38–0.70; P = 0.353, I2 = 3.9%); OPEN group showed lower heterogeneity. The OS of 60–100-min group was higher than that in the control group (HR: 0.65, 95% CI: 0.49–0.88; P = 0.172, I2 = 37.4%); the heterogeneity of the studies was low. Sensitivity analysis showed that there was no significant difference in the results of the combined analysis after each study was deleted. The results of publication bias showed that the P-value of Egger and Begg tests was 0.078 > 0.05, indicating that there is no publication bias. Conclusions CRS + HIPEC can improve the survival rate of patients with colorectal cancer peritoneal metastasis
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Affiliation(s)
- Ji Li
- General Surgery, Chongqing Western Hospital, Chongqing, 400051, China
| | - An-Ran Wang
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400042, China
| | - Xiao-Dong Chen
- General Surgery, Chongqing Western Hospital, Chongqing, 400051, China
| | - Yu-Xin Zhang
- General Surgery, Chongqing Western Hospital, Chongqing, 400051, China
| | - Hong Pan
- General Surgery, Chongqing Western Hospital, Chongqing, 400051, China
| | - Shi-Qiang Li
- General Surgery, Chongqing Western Hospital, Chongqing, 400051, China.
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Dietz MV, van Kooten JP, van Vugt JLA, Brandt-Kerkhof ARM, Verhoef C, Madsen EVE. The Impact of Low Skeletal Muscle Mass on Short- and Long-Term Outcomes After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2022; 29:5830-5841. [PMID: 35650370 PMCID: PMC9356922 DOI: 10.1245/s10434-022-11941-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/10/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a potentially curative treatment for peritoneal metastases from colorectal cancer (CRC) or pseudomyxoma peritonei (PMP). Because of the considerable morbidity of this treatment, optimal patient selection is key. This study aimed to assess the impact of low skeletal muscle mass (SMM) on outcomes after CRS-HIPEC. METHODS Patients who underwent CRS-HIPEC between 2014 and 2020 at a tertiary center were included. SMM was measured on computed tomography by means of the L3 muscle index. Postoperative complications and survival outcomes were compared between groups by use of logistic regression and Kaplan-Meier survival analyses. RESULTS Of 284 included patients, 149 had low SMM. Occurrence of severe postoperative complications did not differ between groups (28.9% for patients with low vs. 34.1% for patients with normal SMM). Low SMM was not associated with postoperative complications (p = 0.344). For CRC patients, no significant differences were observed in disease-free (DFS) or overall survival (OS) between patients with low (median DFS 7 months [IQR 4-14], median OS 33 months [IQR 14-NR]) and patients with normal SMM (median DFS 8 months [IQR 5-20], median OS 35 months [IQR 18-NR]). Regarding PMP, survival outcomes did not significantly differ between groups (3-year DFS 47.3% for patients with low SMM vs. 54.5% for patients with normal SMM, p = 0.676; 3-year OS 70.8% vs. 90.9% respectively, p = 0.172). CONCLUSIONS Low SMM could not be identified as a predictor of severe complications or survival outcomes after CRS-HIPEC.
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Affiliation(s)
- Michelle V Dietz
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Job P van Kooten
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jeroen L A van Vugt
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Eva V E Madsen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Unusual site of pseudomyxoma peritonei recurrence after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a case report of intraluminal disease manifestation in the small bowel. World J Surg Oncol 2022; 20:147. [PMID: 35538541 PMCID: PMC9088063 DOI: 10.1186/s12957-022-02613-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pseudomyxoma peritonei (PMP) is an uncommon clinical condition characterized by the presence of mucinous ascites, mainly induced by perforated appendiceal mucinous neoplasms (AMN). The peritoneal surface of the small bowel is usually spared from disease manifestation due to peristaltic movements. Mucinous tumours can disseminate as PMP on the entire peritoneum, but are rarely intraluminal. For the first time in literature, we report a case of intraluminal PMP involving the ileum. CASE PRESENTATION A 75-year-old male was treated for perforated AMN and disseminated PMP with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. During follow-up, the patient developed intraperitoneal recurrence together with intraluminal depositions in the ileum, both disease manifestations with identical KRAS and SMAD4 mutations. Hereafter, the patient was treated with palliative care. CONCLUSION This case illustrates the variation in the biological and clinical behaviour of this rare disease. Clinicians should be aware of unusual tumour distribution patterns of PMP, including the presence of mucinous tumour within the small bowel.
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Dietz MV, van Kooten JP, Said I, Brandt-Kerkhof ARM, Verhoef C, Bremers AJA, de Wilt JHW, de Reuver PR, Madsen EVE. Survival Outcomes After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy in Patients with Synchronous Versus Metachronous Onset of Peritoneal Metastases of Colorectal Carcinoma. Ann Surg Oncol 2022; 29:6566-6576. [PMID: 35513588 PMCID: PMC9492568 DOI: 10.1245/s10434-022-11805-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/04/2022] [Indexed: 12/14/2022]
Abstract
Background Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment option for peritoneal metastases (PM) from colorectal carcinoma (CRC). Because of considerable morbidity, optimal patient selection is essential. This study was designed to determine the impact of the onset of PM (synchronous vs. metachronous) on survival outcomes after CRS-HIPEC. Methods Patients undergoing CRS-HIPEC for colorectal PM in two academic centers in the Netherlands between 2010 and 2020 were eligible for inclusion. Patients were classified as synchronous (s-PM, i.e., diagnosis at time of presentation, staging, or primary surgery) or metachronous onset (m-PM, i.e., diagnosis during follow-up) of colorectal PM. Survival outcomes were compared between groups by Kaplan–Meier survival and Cox regression analyses. Results Of 390 included patients, 179 (45.9%) had synchronous onset of colorectal PM. These patients more often presented with higher TN-stage and poor differentiation/signet cell histology. Treatment with perioperative chemotherapy was more common in s-PM patients. m-PM patients experienced more serious postoperative complications (Clavien-Dindo ≥ III). There was no significant difference in disease-free survival (DFS) between s-PM (median 9 months, interquartile range [IQR] 5–15) and m-PM patients (median 8 months, IQR 5–17). Overall survival (OS) was significantly shorter for s-PM (median 28 months, IQR 11–48) versus m-PM patients (median 33 months, IQR 18–66, p = 0.049). Synchronous onset of PM was not independently associated with OS in a multivariable analysis. Conclusions Synchronous onset of colorectal PM was associated with poor tumor characteristics and more advanced disease, but was not an independent predictor of survival outcomes after CRS-HIPEC.
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Affiliation(s)
- Michelle V Dietz
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Job P van Kooten
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ibrahim Said
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Andreas J A Bremers
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva V E Madsen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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29
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Said I, Ubink I, Ewalds RSG, Arkesteijn JGT, Verheul HMW, de Wilt JHW, Dekker HM, Bremers AJA, de Reuver PR. In Patients Undergoing CRS/HIPEC for Colorectal Adenocarcinoma with Peritoneal Metastases, Presence of Ascites on Computed Tomography Imaging is not a Prognostic Marker for Survival. Ann Surg Oncol 2022; 29:5256-5262. [PMID: 35430666 PMCID: PMC9246798 DOI: 10.1245/s10434-022-11718-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/16/2022] [Indexed: 11/18/2022]
Abstract
Abstract
Background
Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a potentially curative treatment for patients with colorectal peritoneal metastases (CRPM). Patient selection is key to optimizing outcomes after CRS/HIPEC. The aim of this study was to determine the prognostic value of ascites diagnosed on preoperative imaging.
Methods
A prospective database of patients eligible for CRS/HIPEC between 2010 and 2020 was retrospectively analyzed. The presence of ascites, postoperative complications, overall survival (OS), disease-free survival (DFS), and completeness of cytoreduction were assessed. Univariable and multivariable logistic regression was performed to identify independent predictors for outcome.
Results
Of the 235 included patients, 177 (75%) underwent CRS/HIPEC while 58 (25%) were not eligible for CRS/HIPEC. In 42 of the 177 patients (24%) who underwent CRS/HIPEC, ascites was present on preoperative computed tomography (CT) imaging. Peritoneal Cancer Index (PCI) score was significantly higher in patients with preoperative ascites compared with patients without (11 [range 2–30] vs. 9 [range 0–28], respectively; p = 0.011) and complete cytoreduction was more often achieved in patients without ascites (96.3% vs. 85.7%; p = 0.007). There was no significant difference in median DFS and OS after CRS/HIPEC between patients with and without ascites {10 months (95% confidence interval [CI] 7.1–12.9) vs. 9 months (95% CI 7.2–10.8), and 25 months (95% 9.4–40.6) vs. 27 months (95% CI 22.4–31.6), respectively}.
Conclusions
Ascites on preoperative imaging was not associated with worse survival in CRS/HIPEC patients with CRPM. Therefore, excluding patients from CRS/HIPEC based merely on the presence of ascites is not advisable.
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Affiliation(s)
- Ibrahim Said
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
| | - Inge Ubink
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Roos S G Ewalds
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Johanna G T Arkesteijn
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, Radboudumc, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Helena M Dekker
- Department of Medical Imaging, Radboudumc, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Andreas J A Bremers
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Philip R de Reuver
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Learning Curve of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy – an Analysis of Critical Perioperative and Surgical Outcomes among 155 Peritoneal Surface Malignancy Patients Treated at a Tertiary Care Cancer Centre. Clin Oncol (R Coll Radiol) 2022; 34:e305-e311. [DOI: 10.1016/j.clon.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/15/2022] [Accepted: 03/02/2022] [Indexed: 11/22/2022]
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Lundbech M, Krag AE, Iversen LH, Hvas AM. Postoperative bleeding and venous thromboembolism in colorectal cancer patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:17-33. [PMID: 34626208 DOI: 10.1007/s00384-021-04021-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has improved survival for selected patients with peritoneal metastases from colorectal cancer. Previous studies report conflicting rates of postoperative bleeding and venous thromboembolism (VTE) after CRS + HIPEC. The aim of the present study was to systematically review the literature and to estimate the overall 30-day incidence of postoperative bleeding and the overall 90-day incidence of VTE after CRS + HIPEC. METHODS Studies were identified in PubMed, Embase, and Web of Science on 29 April 2021. Data were extracted for a qualitative synthesis and to estimate an overall mean incidence in the meta-analysis. RESULTS Fourteen studies with a total of 3268 patients were included in the systematic review. Postoperative bleeding incidence rates within 30 days ranged from 1.7 to 8.3% with an overall 30-day postoperative bleeding incidence with [95% CI] at 4.2 [2.6;6.2]%. VTE incidence rates within 90 days ranged from 0.2 to 13.6% with an overall 90-day VTE incidence with [95% CI] at 2.7 [1;5.2]% after CRS + HIPEC. CONCLUSION This systematic review and meta-analysis indicate a low risk for postoperative bleeding within 30 days and VTE within 90 days after CRS + HIPEC for peritoneal metastases from colorectal cancer.
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Affiliation(s)
- Mikkel Lundbech
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Engel Krag
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Lene Hjerrild Iversen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Parikh MS, Johnson P, Romanes JP, Freitag HE, Spring ME, Garcia-Henriquez N, Monson JRT. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Peritoneal Metastases: A Systematic Review. Dis Colon Rectum 2022; 65:16-26. [PMID: 34636780 DOI: 10.1097/dcr.0000000000002315] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Combined treatment modality of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is emerging as an alternative option for colorectal peritoneal metastases, but there is ambiguity regarding patient selection, treatment protocols, and efficacy. OBJECTIVE To elaborate on the patient characteristics, hyperthermic intraperitoneal chemotherapy protocol and health outcomes in colorectal peritoneal metastases patients undergoing a combination of hyperthermic intraperitoneal chemotherapy and cytoreductive surgery and provide guidance for future studies. DATA SOURCES A Medline search for English language studies published between 2004 and 2019. STUDY SELECTION Medical subject headings and key terms, including: hyperthermic intraperitoneal chemotherapy, colorectal peritoneal metastases, colorectal cancer and combinations thereof as per guidelines. MAIN OUTCOME MEASURES Overall survival, disease-free survival, and morbidity and mortality rates. RESULTS Of the 26 included studies, 42% were published between 2016 and 2019. More than half of the studies were retrospective in nature and conducted in tertiary specialized centers outside of the United States. The median age range was 44 to 62 years. Mitomycin C-based therapy was seen in 50% of studies. Mean weighted median disease-free survival for 11 studies was 15 months (9 to 36 months). Median OS ranged from 12 to 63 months, with an average of 33.6 months among 20 studies. Overall morbidity varied from 11% to 56%, with a weighted mean of 29% in 18 studies. Mortality ranged from 0 to 34%, with a weighted mean of 4% in 15 studies. LIMITATIONS Despite careful study selection, variability in methodology of the included studies can limit review findings. CONCLUSION Due to study heterogeneity, and a recent large, randomized trial showing no overall benefit, use of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in colorectal peritoneal metastases patients is highly controversial. Further standardized controlled studies can help uniformly define and build consensus among the medical community on patient eligibility and the optimal hyperthermic intraperitoneal chemotherapy techniques. PROSPERO Registered on March 3, 2020, CRD42020146942.
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Affiliation(s)
- Manasi S Parikh
- Center for Colon and Rectal Cancer, Surgical Health Outcomes Consortium, AdventHealth Orlando, Orlando, Florida
| | - Paul Johnson
- Center for Colon and Rectal Cancer, Surgical Health Outcomes Consortium, AdventHealth Orlando, Orlando, Florida
| | | | - Harvey E Freitag
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mary E Spring
- Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida
| | - Norbert Garcia-Henriquez
- Center for Colon and Rectal Cancer, Surgical Health Outcomes Consortium, AdventHealth Orlando, Orlando, Florida
| | - John R T Monson
- Center for Colon and Rectal Cancer, Surgical Health Outcomes Consortium, AdventHealth Orlando, Orlando, Florida
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Peritoneal metastases found in routinely resected specimens after cytoreductive surgery and heated intraperitoneal chemotherapy. Eur J Surg Oncol 2021; 48:795-802. [PMID: 35012833 DOI: 10.1016/j.ejso.2021.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/07/2021] [Accepted: 12/19/2021] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Peritoneal metastases (PM) originating from colorectal cancer (CRC) and pseudomyxoma peritonei (PMP) can be treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Certain sites in the peritoneal cavity are prone to contain PM and are, therefore, routinely resected. The aim of this study is to investigate the frequency of disease in CRS specimens routinely resected. Secondly, to investigate if the risk of finding PM in routinely resected specimen is associated with involvement of anatomic related peritoneal areas. MATERIALS AND METHODS This study investigated 433 patients diagnosed with PMP (n = 119) or PM from CRC (n = 314) and operated with CRS + HIPEC between June 2006 and November 2020 at a national center. Baseline data were prospectively registered. Pathology reports were reviewed for the presence of metastases in the routinely resected umbilicus, ligamentum teres hepatis, ovaries and greater omentum. Tumor extent was estimated using the Dutch region count. RESULTS PM was found in 14.7% of umbilical resections, in 17.4% of the resected ligamentum teres hepatis, in 48.2% of the resected ovaries and in 49.5% of the greater omentum specimens. We found an association between macroscopic disease involvement of the nearest region and risk of PM found in the related resections. Seven of 31 women with no macroscopically visible disease in the pelvis had PM diagnosed in the resected ovaries. CONCLUSIONS A substantial proportion of routine resections held histologic verified PM. Our results may advocate for a routinely performed resection of the umbilicus, ligamentum teres hepatis, ovaries and greater omentum.
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Fagih SN, Baghdadi RM, Banjer AY, Ismail AA, Addas MA, Shabkah AA, Trabulsi NH. Scrotal Necrosis Following Heated Intra-peritoneal Chemotherapy: Case Report and Review of the Literature. Cureus 2021; 13:e20638. [PMID: 34976544 PMCID: PMC8712224 DOI: 10.7759/cureus.20638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/20/2022] Open
Abstract
Scrotal necrosis is a rare occurrence that is scarcely reported among patients having undergone heated intra-peritoneal chemotherapy (HIPEC) procedures. Due to anatomic factors and the thermally enhanced cytotoxicity of chemotherapeutic agents, this complication can have debilitating post-operative effects. We herein highlight the presentation of scrotal necrosis in a patient who underwent HIPEC procedure for peritoneal metastasis secondary to colorectal carcinoma, and how it contrasts to previously documented cases of a similar nature. Furthermore, we describe a successful management strategy that consisted of conservative measures followed by surgical debridement and primary repair, and enabled the patient to experience significant functional and cosmetic improvement.
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35
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Mangieri CW, Moaven O, Valenzuela CD, Erali RA, Votanopoulos KI, Shen P, Levine EA. Utility of hyperthermic intraperitoneal chemotherapy in cases of incomplete cytoreductive surgery. J Surg Oncol 2021; 125:703-711. [PMID: 34841542 DOI: 10.1002/jso.26759] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Hyperthermic intraperitoneal chemotherapy (HIPEC) during cytoreductive surgery (CRS) is typically reserved for a complete or optimal cytoreduction. There is the potential for therapeutic effect of HIPEC with an incomplete cytoreduction, particularly for near optimal cytoreductions. METHODS Retrospective review of incomplete cytoreductions (R2b, R2c) for appendiceal and colorectal primaries. Primary endpoints were overall survival (OS) and progression-free survival (PFS). Subgroup analysis for primary etiology and specific cytoreductive score. RESULTS A total of 121 cases of incomplete CRS, 74 CRS alone, and 47 CRS-HIPEC. For the entire study group there was a survival benefit with HIPEC. OS and PFS were 2.3 versus 1.4 (p = 0.001) and 1.6 versus 0.7 (p < 0.0001) respectively for cases with and without HIPEC. Subgroup analysis of appendiceal neoplasms, 43 CRS-HIPEC and 50 CRS alone, found HIPEC benefit persisted; OS and PFS were 2.4 versus 1.5 (p = 0.016) and 1.7 versus 0.8 (p < 0.0001), respectively for cases with and without HIPEC. Benefit most pronounced in low-grade cases with doubling of the OS and PFS (p = 0.004). With colorectal primary cases, 10 CRS-HIPEC and 18 CRS alone, no difference in OS and PFS. When stratifying out by cytoreduction scores, R2b and R2c, HIPEC only provided a benefit for R2b cases; OS and PFS for R2b cases were 2.28 versus 1.01 (p = 0.011) and 1.67 versus 0.75 (p = 0.001), respectively for cases with and without HIPEC. CONCLUSION HIPEC has utility for incomplete cytoreductions with appendiceal neoplasms, greatest effect with low-grade appendiceal neoplasms. HIPEC is only beneficial for near optimal cytoreductions (R2b).
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Affiliation(s)
- Christopher W Mangieri
- Division of Surgical Oncology, Surgical Oncology Section, Wake Forest Baptist Health Medical Center, Winston-Salem, North Carolina, USA
| | - Omeed Moaven
- Department of Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Cristian D Valenzuela
- Division of Surgical Oncology, Surgical Oncology Section, Wake Forest Baptist Health Medical Center, Winston-Salem, North Carolina, USA
| | - Richard A Erali
- Division of Surgical Oncology, Surgical Oncology Section, Wake Forest Baptist Health Medical Center, Winston-Salem, North Carolina, USA
| | - Konstantinos I Votanopoulos
- Division of Surgical Oncology, Surgical Oncology Section, Wake Forest Baptist Health Medical Center, Winston-Salem, North Carolina, USA
| | - Perry Shen
- Division of Surgical Oncology, Surgical Oncology Section, Wake Forest Baptist Health Medical Center, Winston-Salem, North Carolina, USA
| | - Edward A Levine
- Division of Surgical Oncology, Surgical Oncology Section, Wake Forest Baptist Health Medical Center, Winston-Salem, North Carolina, USA
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Pelvic exenteration, cytoreductive surgery, and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancy: experience and outcomes from an exenterative and peritonectomy unit. Langenbecks Arch Surg 2021; 406:2807-2815. [PMID: 34495403 DOI: 10.1007/s00423-021-02323-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Pelvic exenteration (PE) for locally advanced pelvic malignancy is well established, though high rates of morbidity and mortality exist. Such a complication profile has often deterred the surgical community from offering exenteration in combination with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). We aimed to evaluate the perioperative outcomes following pelvic exenteration when combined with CRS and HIPEC for peritoneal surface malignancy (PSM) in a tertiary referral centre. METHODS A review of a prospectively maintained PSM database from June 2015 to December 2020 at a tertiary referral institution was performed. Patients who underwent CRS, PE, and HIPEC were matched with patients who underwent PE alone. Primary endpoints were perioperative morbidity and mortality. RESULTS From June 2015 to December 2020, 20 patients required PE as part of their CRS and HIPEC for PSM. The majority of patients were female (n = 16, 80%) with a median age of 52 (range 21-70). Colorectal cancer was the predominant pathology (n = 12, 60%). Median PCI was 11.5 (range 3-39). CC0 and R0 resections were achieved in all patients. CRS, PE, and HIPEC and PE-alone groups were well matched for clinicopathological variables. There was no difference in perioperative major morbidity (HIPEC: 30% vs PE: 15% p = 0.256) and mortality (HIPEC: 0 vs PE: 5% p = 0.311) between groups. Median follow-up was 17.5 months (range 7-68). Eight patients (40%) died from disease-related issues during the study period. CONCLUSION An aggressive surgical strategy with complete resection is feasible and safe in select patients with complex PSM involving the pelvis.
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Somashekhar SP, Rohit KC, Ramya Y, Zaveri SS, Ahuja V, Namachivayam AK, Ashwin KR. Bowel Anastomosis After or Before HIPEC: A Comparative Study in Patients Undergoing CRS+HIPEC for Peritoneal Surface Malignancy. Ann Surg Oncol 2021; 29:214-223. [PMID: 34462817 DOI: 10.1245/s10434-021-10661-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anastomotic leak after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) remains a dreaded complication. There is no consensus statement regarding the optimal timing for bowel anastomoses to perform after or before HIPEC. METHODS Patients who underwent CRS+HIPEC and had at least one bowel anastomosis were retrospectively analyzed to evaluate if timing of anastomosis done after or before HIPEC had an impact on bowel complication rates (anastomotic leak and perforation). RESULTS From 2013 to 2019, 214 of 370 patients underwent CRS+HIPEC and had at least one bowel anastomosis. Of these 214 patients, 104 and 110 patients had anastomosis after and before HIPEC, respectively. A total of 324 anastomoses were performed, with a mean of 0.87 anastomoses per patient (range 1-4). The incidence of anastomotic leaks was comparable between the pre- and post-HIPEC groups (3.6% vs. 4.8%; p > 0.05), as was the bowel complication rate (7.6% vs. 7.2%). After multivariate analysis, prior surgical score >1 (odds ratio [OR] 4.3), recurrent cancers (OR 7.4), and more than two anastomosis (OR 3.8) were considered independent risk factors for bowel complications. CONCLUSION Anastomosis of the bowel performed after or before HIPEC does not affect bowel complication rates (leak/perforation). Higher prior surgical score, surgery for recurrent cancers, and more than two bowel anastomosis are independent risk factors for predicting bowel complications. Prehabilitation, standardization of steps, immediate attention and repair of serosal tears, and thorough inspection of the bowel before closure helps to decrease bowel complications. The timing of anastomosis can be at the discretion of the surgeon.
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Affiliation(s)
- S P Somashekhar
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India
| | - Kumar C Rohit
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India.
| | - Yethadka Ramya
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India
| | - Shabber S Zaveri
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India
| | - Vijay Ahuja
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India
| | | | - K R Ashwin
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India
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Verwaal VJ, Funder JA, Sørensen MM, Iversen LH. The impact of postoperative complications following cytoreductive surgery combined with oxaliplatin based heated intraperitoneal chemotherapy. Eur J Surg Oncol 2021; 48:183-187. [PMID: 34474946 DOI: 10.1016/j.ejso.2021.08.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 07/15/2021] [Accepted: 08/20/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) has become the mainstream treatment for peritoneal metastases of colorectal origin. This extensive treatment is known for its increased morbidity rate. In this study, the impact of postoperative complications on survival was evaluated in a high-volume centre. PATIENTS AND METHOD Between November 2016 through October 2018, all 106 patients with peritoneal metastases of colorectal origin treated with CRS + HIPEC with oxaliplatin were evaluated. Data on patient characteristics, Peritoneal Carcinomatosis Index (PCI), operative procedure, post-operative complications (Clavien-Dindo classification grade III or higher) and survival were collected. In-hospital postoperative complications were analysed for their association with patient characteristics, tumour load (PCI), and operative procedure with logistic regression analyses. Survival was analysed with the Cox regression analysis. RESULTS Of 106 patients, 78% had an un-eventful in-hospital recovery. Of those patients who experienced complications, 52% patients had one complication and 48% had more than one. The median follow-up time was 33.8 months. Median survival was 22.4 months (95% CI 12.2-NR) for patients who experienced complications and not reached for those who did not. Survival was significantly associated with complications (HR 2.2, 95% CI 1.2-4.0) as well as with PCI (HR 1.1, 95% CI 1.1-1.2) in univariate analyses. A stepwise Cox regression analysis showed both PCI and complications had an independent negative impact on survival. CONCLUSION Postoperative complications, independently of tumour load, led to reduced survival in patients with peritoneal metastases of colorectal origin when treated with CRS + HIPEC with oxaliplatin.
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Affiliation(s)
- Victor Jilbert Verwaal
- Department of Surgery, Aarhus University Hospital, Denmark; Hospital of Southwestern Jutland, University of Southern Denmark, Esbjerg, Denmark
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García-Fadrique A, Estevan Estevan R, Sabater Ortí L. Quality Standards for Surgery of Colorectal Peritoneal Metastasis After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2021; 29:188-202. [PMID: 34435297 DOI: 10.1245/s10434-021-10642-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/27/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The standardization of surgical outcomes throughout surgical procedures is mandatory. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) should provide proficient oncological and surgical outcomes. STUDY DESIGN The aim of this study was to identify clinically relevant quality indicators and their quality standard, and to determine their acceptable quality limit. A systematic review on cytoreductive results from 2000 to 2018 was performed focusing on clinical guidelines, consensus conferences, and publications. After the selection of quality indicators, a systematic review of indexed references was performed in order to calculate the quality standard for each indicator. STUDY SELECTION Unicentric/multicentric series, comparative studies, and clinical trials. Studies were to include outcomes after cytoreduction of colorectal origin and series with more than 50 patients. Quality indicators with at least 10 series were mandatory and objective measurements were also mandatory for inclusion. MAIN OUTCOME MEASUREMENTS Quality indicators selected were 1- to 5-year survival, overall disease-free survival, 1- to 5-year disease-free survival, complete surgical resection, duration of surgery, length of stay, overall morbimortality, major morbidity, re-intervention, postoperative hemorrhage, intestinal fistula, anastomotic leakage, wound infection, postoperative medical complications, overall recurrence, and failure to rescue. RESULTS The most relevant quality indicators and critical quality limits were overall disease-free survival and 5-year overall disease-free survival (14 months and <10 months, and 14% and <4%, respectively), completeness of surgical resection (89% and <80%, respectively), overall mortality (3% and >8%, respectively), overall morbidity (47% and >63%, respectively), failure to rescue (12% and <30%, respectively), reintervention (13 and <22%, respectively), anastomotic leakage (6% and <13%, respectively), and overall recurrence (60% and <74%, respectively). CONCLUSION This is the first study to assess quality standards in CRS + HIPEC for colorectal peritoneal metastases. The current data are of particular relevance for future studies to control the variability of this surgery.
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Affiliation(s)
| | | | - Luis Sabater Ortí
- Hospital Clínico Universitario, Department of Surgery, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
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Lepsenyi M, Algethami N, Al-Haidari AA, Algaber A, Syk I, Rahman M, Thorlacius H. CXCL2-CXCR2 axis mediates αV integrin-dependent peritoneal metastasis of colon cancer cells. Clin Exp Metastasis 2021; 38:401-410. [PMID: 34115261 PMCID: PMC8318971 DOI: 10.1007/s10585-021-10103-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 05/14/2021] [Indexed: 01/10/2023]
Abstract
Peritoneal metastasis is an insidious aspect of colorectal cancer. The aim of the present study was to define mechanisms regulating colon cancer cell adhesion and spread to peritoneal wounds after abdominal surgery. Mice was laparotomized and injected intraperitoneally with CT-26 colon carcinoma cells and metastatic noduli in the peritoneal cavity was quantified after treatment with a CXCR2 antagonist or integrin-αV-antibody. CT-26 cells expressed cell surface chemokine receptors CXCR2, CXCR3, CXCR4 and CXCR5. Stimulation with the CXCR2 ligand, CXCL2, dose-dependently increased proliferation and migration of CT-26 cells in vitro. The CXCR2 antagonist, SB225002, dose-dependently decreased CXCL2-induced proliferation and migration of colon cancer cells in vitro. Intraperitoneal administration of CT-26 colon cancer cells resulted in wide-spread growth of metastatic nodules at the peritoneal surface of laparotomized animals. Laparotomy increased gene expression of CXCL2 at the incisional line. Pretreatment with CXCR2 antagonist reduced metastatic nodules by 70%. Moreover, stimulation with CXCL2 increased CT-26 cell adhesion to extracellular matrix (ECM) proteins in a CXCR2-dependent manner. CT-26 cells expressed the αV, β1 and β3 integrin subunits and immunoneutralization of αV abolished CXCL2-triggered adhesion of CT-26 to vitronectin, fibronectin and fibrinogen. Finally, inhibition of the αV integrin significantly attenuated the number of carcinomatosis nodules by 69% in laparotomized mice. These results were validated by use of the human colon cancer cell line HT-29 in vitro. Our data show that colon cancer cell adhesion and growth on peritoneal wound sites is mediated by a CXCL2-CXCR2 signaling axis and αV integrin-dependent adhesion to ECM proteins.
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Affiliation(s)
- Mattias Lepsenyi
- Section of Surgery, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, 20502, Malmö, Sweden
| | - Nader Algethami
- Section of Surgery, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, 20502, Malmö, Sweden
| | - Amr A Al-Haidari
- Section of Surgery, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, 20502, Malmö, Sweden
| | - Anwar Algaber
- Section of Surgery, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, 20502, Malmö, Sweden
| | - Ingvar Syk
- Section of Surgery, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, 20502, Malmö, Sweden
| | - Milladur Rahman
- Section of Surgery, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, 20502, Malmö, Sweden
| | - Henrik Thorlacius
- Section of Surgery, Department of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, 20502, Malmö, Sweden.
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Faviana P, Boldrini L, Musco B, Ferrari M, Greco A, Fornaro L, Masi G, Forfori F, Ricci S, Brogi A, Basolo F, Falcone A, Gadducci A, Lippolis PV. Management of Peritoneal Carcinomatosis With Cytoreductive Surgery Combined With Intraperitoneal Chemohyperthermia at a Novel Italian Center. In Vivo 2021; 34:2061-2066. [PMID: 32606183 DOI: 10.21873/invivo.12008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Peritoneal carcinomatosis (PC) is a common manifestation of many gastrointestinal (GI) malignancies and is an advanced stage that is often associated with disseminated disease. Considerable progress has been made to achieve safe elimination of macroscopic disease using cytoreductive surgery (CRS) and more recently in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of microscopic disease or disease with minimal volume. The aim of this study was to assess the effects of such procedures on the quality of life (QoL), the long-term benefit and the functional status of the treated patients. PATIENTS AND METHODS Data from patients who underwent CRS-HIPEC for peritoneal metastasis (PM) at our center from November 2016 to November 2018 were analyzed retrospectively. The drugs administered were mitomycin and cisplatin. Quality of life (QoL) was assessed using the Euroquol-5D-5L and National Comprehensive Cancer Network Functional Assessment of Cancer Therapy-Breast Cancer Symptom Index v2 questionnaires before CRS-HIPEC, and 1, 3 and 6 months after were administered. RESULTS In our series, the survival efficacy of CRS plus HIPEC was confirmed in the treatment of primary and secondary peritoneal pathologies, particularly in ovarian cancer, although larger studies are needed to investigate its role in the pathology of gastric, colonic and rectal cancer. The QoL data were promising, with essentially stable values between the preoperative and the 1-month follow-up, but with incremental benefits from the second to the third month.
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Affiliation(s)
- Pinuccia Faviana
- Department of Surgical, Medical, Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Laura Boldrini
- Department of Surgical, Medical, Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Barbara Musco
- Department of General Surgery, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Mauro Ferrari
- Department of General Surgery, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Alfonso Greco
- Department of General Surgery, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Lorenzo Fornaro
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gianluca Masi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesco Forfori
- Department of Surgical, Medical, Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Sergio Ricci
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Augusto Brogi
- Department of Surgical, Medical, Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Fulvio Basolo
- Department of Surgical, Medical, Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Alfredo Falcone
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Angelo Gadducci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Synchronous Liver Resection, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Liver and Peritoneal Metastases: A Systematic Review and Meta-analysis. Dis Colon Rectum 2021; 64:754-764. [PMID: 33742615 DOI: 10.1097/dcr.0000000000002027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Synchronous liver resection, cytoreductive surgery, and hyperthermic intraperitoneal chemotherapy for colorectal liver and peritoneal metastases have traditionally been contraindicated. More recent clinical practice has begun to promote this aggressive treatment in select patients. OBJECTIVE This study aimed to investigate the perioperative and oncological outcomes of patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, with and without liver resection, in the management of metastatic colorectal cancer. DATA SOURCES Medline, Embase, and Cochrane Library databases were searched up to July 2020. STUDY SELECTION Cohort studies comparing outcomes following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with and without liver resection for metastatic colorectal cancer were reviewed. No randomized controlled trials were available. INTERVENTION Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with or without synchronous liver resection were compared. MAIN OUTCOME MEASURES The primary outcome measures were perioperative mortality and major morbidity. Secondary outcomes included 3- and 5-year overall survival and 1- and 3-year disease-free survival. RESULTS Fourteen studies fitted the inclusion criteria, with 8 studies included in the meta-analysis. On pooled analysis, there was no significant difference in perioperative morbidity and mortality between the two groups. Patients that underwent concomitant liver resection had worse 1- and 3-year disease-free survival and 3- and 5-year overall survival. LIMITATIONS Only a limited number of studies were available, with a moderate degree of heterogeneity. CONCLUSIONS The addition of synchronous liver resection to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for the treatment of resectable metastatic colorectal cancer was not associated with increased perioperative major morbidity and mortality in comparison with cytoreduction and hyperthermic intraperitoneal chemotherapy alone. However, the presence of liver metastases was associated with inferior disease-free and overall survival. These data support the continued practice of liver resection, cytoreductive surgery, and hyperthermic intraperitoneal chemotherapy in the management of select patients with such stage IV disease.
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Rovers KP, Bakkers C, Nienhuijs SW, Burger JWA, Creemers GJM, Thijs AMJ, Brandt-Kerkhof ARM, Madsen EVE, van Meerten E, Tuynman JB, Kusters M, Versteeg KS, Aalbers AGJ, Kok NFM, Buffart TE, Wiezer MJ, Boerma D, Los M, de Reuver PR, Bremers AJA, Verheul HMW, Kruijff S, de Groot DJA, Witkamp AJ, van Grevenstein WMU, Koopman M, Nederend J, Lahaye MJ, Kranenburg O, Fijneman RJA, van 't Erve I, Snaebjornsson P, Hemmer PHJ, Dijkgraaf MGW, Punt CJA, Tanis PJ, de Hingh IHJT. Perioperative Systemic Therapy vs Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Alone for Resectable Colorectal Peritoneal Metastases: A Phase 2 Randomized Clinical Trial. JAMA Surg 2021; 156:710-720. [PMID: 34009291 DOI: 10.1001/jamasurg.2021.1642] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance To date, no randomized clinical trials have investigated perioperative systemic therapy relative to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) alone for resectable colorectal peritoneal metastases (CPM). Objective To assess the feasibility and safety of perioperative systemic therapy in patients with resectable CPM and the response of CPM to neoadjuvant treatment. Design, Setting, and Participants An open-label, parallel-group phase 2 randomized clinical trial in all 9 Dutch tertiary centers for the surgical treatment of CPM enrolled participants between June 15, 2017, and January 9, 2019. Participants were patients with pathologically proven isolated resectable CPM who did not receive systemic therapy within 6 months before enrollment. Interventions Randomization to perioperative systemic therapy or CRS-HIPEC alone. Perioperative systemic therapy comprised either four 3-week neoadjuvant and adjuvant cycles of CAPOX (capecitabine and oxaliplatin), six 2-week neoadjuvant and adjuvant cycles of FOLFOX (fluorouracil, leucovorin, and oxaliplatin), or six 2-week neoadjuvant cycles of FOLFIRI (fluorouracil, leucovorin, and irinotecan) and either four 3-week adjuvant cycles of capecitabine or six 2-week adjuvant cycles of fluorouracil with leucovorin. Bevacizumab was added to the first 3 (CAPOX) or 4 (FOLFOX/FOLFIRI) neoadjuvant cycles. Main Outcomes and Measures Proportions of macroscopic complete CRS-HIPEC and Clavien-Dindo grade 3 or higher postoperative morbidity. Key secondary outcomes were centrally assessed rates of objective radiologic and major pathologic response of CPM to neoadjuvant treatment. Analyses were done modified intention-to-treat in patients starting neoadjuvant treatment (experimental arm) or undergoing upfront surgery (control arm). Results In 79 patients included in the analysis (43 [54%] men; mean [SD] age, 62 [10] years), experimental (n = 37) and control (n = 42) arms did not differ significantly regarding the proportions of macroscopic complete CRS-HIPEC (33 of 37 [89%] vs 36 of 42 [86%] patients; risk ratio, 1.04; 95% CI, 0.88-1.23; P = .74) and Clavien-Dindo grade 3 or higher postoperative morbidity (8 of 37 [22%] vs 14 of 42 [33%] patients; risk ratio, 0.65; 95% CI, 0.31-1.37; P = .25). No treatment-related deaths occurred. Objective radiologic and major pathologic response rates of CPM to neoadjuvant treatment were 28% (9 of 32 evaluable patients) and 38% (13 of 34 evaluable patients), respectively. Conclusions and Relevance In this randomized phase 2 trial in patients diagnosed with resectable CPM, perioperative systemic therapy seemed feasible, safe, and able to induce response of CPM, justifying a phase 3 trial. Trial Registration ClinicalTrials.gov Identifier: NCT02758951.
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Affiliation(s)
- Koen P Rovers
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Checca Bakkers
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Simon W Nienhuijs
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Geert-Jan M Creemers
- Department of Medical Oncology, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Anna M J Thijs
- Department of Medical Oncology, Catharina Cancer Institute, Eindhoven, the Netherlands
| | | | - Eva V E Madsen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Esther van Meerten
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Miranda Kusters
- Department of Surgery, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Kathelijn S Versteeg
- Department of Medical Oncology, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Arend G J Aalbers
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Niels F M Kok
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Tineke E Buffart
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marinus J Wiezer
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Djamila Boerma
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Maartje Los
- Department of Medical Oncology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andreas J A Bremers
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Derk Jan A de Groot
- Department of Medical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Arjen J Witkamp
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Max J Lahaye
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Onno Kranenburg
- Cancer Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Remond J A Fijneman
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Iris van 't Erve
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Patrick H J Hemmer
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Cornelis J A Punt
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
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The impact of PRODIGE 7 on the current worldwide practice of CRS-HIPEC for colorectal peritoneal metastases: A web-based survey and 2021 statement by Peritoneal Surface Oncology Group International (PSOGI). Eur J Surg Oncol 2021; 47:2888-2892. [PMID: 34020808 DOI: 10.1016/j.ejso.2021.05.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/09/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The PRODIGE 7-trial investigated the additional value of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) to cytoreductive surgery (CRS) for patients with colorectal peritoneal metastases (CPM). The results of PRODIGE 7 were presented at the 2018 ASCO meeting showing that 30 min oxaliplatin-based HIPEC did not improve overall survival. The current study investigated the impact of PRODIGE 7 on the worldwide practice of CRS and HIPEC. MATERIALS AND METHODS CRS-HIPEC experts from 19 countries were invited through the Peritoneal Surface Oncology Group International (PSOGI) to complete an online survey concerning the current CRS-HIPEC practice in their hospital and country, and were asked to appraise the effect of PRODIGE 7. RESULTS The survey was completed by 18/19 experts. Although their personal opinions of CRS-HIPEC were barely influenced by PRODIGE 7, they reported a substantial impact on daily practice. This included a switch towards Mitomycin-C based HIPEC-regimens and prolongation of HIPEC perfusion time, a reduction in the number of referrals from non-HIPEC centers, a reduction in national consensus, the removal of HIPEC from national guidelines, and a reduced reimbursement rate. CONCLUSION The PRODIGE 7 has had a major impact on the practice of CRS-HIPEC for CPM worldwide. HIPEC remains an attractive option with potential for control and eradication of disease and further studies into the optimal HIPEC-regimen are urgently needed. Meanwhile, given the complexity of the treatment of patients with CPM, and the proven benefits of optimal CRS, referral of patients with potentially resectable CPM to expert centers is recommended whilst the precise role of HIPEC is further evaluated.
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Quénet F, Roca L, de Forges H, Gléhen O, Goéré D. Limitations of the PRODIGE 7 trial - Authors' reply. Lancet Oncol 2021; 22:e179-e180. [PMID: 33932377 DOI: 10.1016/s1470-2045(21)00192-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 01/06/2023]
Affiliation(s)
- François Quénet
- Department of Surgical Oncology, Institut du Cancer de Montpellier, University of Montpellier, Montpellier 34298, France.
| | - Lise Roca
- Biometrics Unit, Institut du Cancer de Montpellier, University of Montpellier, Montpellier 34298, France
| | - Hélène de Forges
- Department of Clinical Research and Innovation, Institut du Cancer de Montpellier, University of Montpellier, Montpellier 34298, France
| | - Olivier Gléhen
- Department of Digestive Surgery, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Diane Goéré
- Department of Digestive Surgery Hôpital Saint Louis, Paris, France
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Ray MD, Dhall K. Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in the management of peritoneal surface malignancies - An evidence-based review. Curr Probl Cancer 2021; 45:100737. [PMID: 34116836 DOI: 10.1016/j.currproblcancer.2021.100737] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 02/27/2021] [Accepted: 03/15/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Traditionally, peritoneal surface malignancies (PSM) were considered terminal diseases because of their advanced nature, therefore, systemic chemotherapy was given with palliative intent only. As a result, very poor survival outcomes were observed. But with the introduction of complete Cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC), the scenario has changed dramatically. METHODOLOGY An objective electronic database search was performed in Pubmed, NLM Catalog, Google scholar, Bookshelf, and Pubmed Central published in the time period from 2000 till 2020. All the randomized studies were included. In the absence of randomized studies, both prospective and retrospective studies were included. The outcomes of HIPEC were measured in terms of median survival, disease-free survival, overall survival, complications and drug toxicities. RESULTS CRS and HIPEC are considered the standard of care for PMP and MPM even in the absence of level 1 evidence due to lack of an effective alternative treatment. In colorectal and gastric cancer, several phase-three trials are showing overall survival benefit in selected cases while there is a prophylactic and palliative role of HIPEC in gastric cancer. Three reported phase 3 trials showed positive results in ovarian cancer. In peritoneal sarcomatosis, the role of HIPEC is yet to be proven. CONCLUSION The patient selection is the key to the successful outcomes after HIPEC. HIPEC should be performed by the experienced surgeons in specialized centres with a strong critical care and intensive care support to reduce the morbidity and mortality. Ongoing trials and future directions will prove to be an indispensable arm in the oncological armamentarium.
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Affiliation(s)
- Mukur Dipi Ray
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Kunal Dhall
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India.
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Outcomes following synchronous liver resection, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal liver and peritoneal metastases: A bi-institutional study. Surg Oncol 2021; 37:101553. [PMID: 33839444 DOI: 10.1016/j.suronc.2021.101553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/04/2021] [Accepted: 03/26/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE Synchronous liver resection, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal liver (CRLM) and peritoneal metastases (CRPM) has traditionally been contraindicated. However, latest practice promotes specialist, multidisciplinary-led consideration for select patients. This study aimed to evaluate the perioperative and oncological outcomes of synchronous resection in the management of CRLM and CRPM from two tertiary referral centres. METHOD This bi-institutional, retrospective, cohort study included patients undergoing simultaneous liver resection, CRS and HIPEC for metastatic colorectal cancer from 2013 to 2020. Patients treated with ablative liver techniques, staged operative approaches and extra abdominal disease were excluded. Overall survival (OS) and disease-free survival (DFS) rates were assessed. Univariate and multivariate analyses identified variables associated with survival and major morbidity (Clavien-Dindo grade III/IV). RESULTS Twenty-three patients were included. The median peritoneal carcinomatosis index (PCI) was 9 (range 0-22). There were two major liver resections and 21 minor resections. CC-0 resections were achieved in all patients. Major morbidity occurred in 7 patients. There were no deaths at 90 days. PCI was independently associated with morbidity (p = 0.04). PCI >10 (p = 0.069), major morbidity (p = 0.083) and presence of KRAS mutation (p = 0.052) approached significance for poor OS. Median follow up was 21 months (4-54 months). Median OS was 37 months, 3-year survival 54%, and median DFS 18 months. CONCLUSION Synchronous liver resection, cytoreductive surgery and HIPEC is feasible in selected patients with low-volume CRPM and CRLM. Increasing PCI is associated with postoperative major morbidity, and should be considered during operative planning.
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de Boer NL, Brandt-Kerkhof ARM, Madsen EVE, Doukas M, Verhoef C, Burger JWA. The Accuracy of the Surgical Peritoneal Cancer Index in Patients with Peritoneal Metastases of Colorectal Cancer. Dig Surg 2021; 38:205-211. [PMID: 33657551 DOI: 10.1159/000513353] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 11/15/2020] [Indexed: 12/10/2022]
Abstract
INTRODUCTION The peritoneal cancer index (PCI) is one of the most important prognostic factors in patients with peritoneal metastases from colorectal cancer undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). The PCI is determined during laparotomy by 2 experienced surgeons and plays a major role in the decision to proceed with CRS-HIPEC. The primary objective of this study was to determine the accuracy of the surgical PCI (sPCI) by comparing it with the PCI confirmed by the pathologist (pPCI). METHODS All consecutive patients who underwent CRS-HIPEC for colorectal peritoneal metastases between February 2015 and June 2018 were identified. Relevant patient- and tumor-related characteristics were collected. RESULTS In total, 119 patients were included, 60 males (50.4%). The median age was 64 (IQR 55-71). The median sPCI (sPCI = 11, IQR 6-16) was significantly higher than the median pPCI (pPCI = 8, IQR 3-13, p < 0.001). The total pPCI was lower than the total sPCI in 80 patients (67.2%). In 21 patients (17.6%), the sPCI was overestimated with ≥5 points. Small lesions are more likely to be negative. In patients that underwent resection of their primary tumor prior to CRS-HIPEC, the difference between the sPCI and pPCI was significantly larger (p < 0.05). CONCLUSIONS Surgical calculation of the PCI often results in overestimation. Far-reaching consequences are tied to the macroscopic evaluation of the sPCI, but this evaluation seems not very reliable.
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Affiliation(s)
- Nadine L de Boer
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands,
| | | | - Eva V E Madsen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jacobus W A Burger
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.,Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
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Ramanathan R, Choudry H, Jones H, Girgis M, Gooding W, Kalinski P, Bartlett DL. Phase II Trial of Adjuvant Dendritic Cell Vaccine in Combination with Celecoxib, Interferon-α, and Rintatolimod in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Metastases. Ann Surg Oncol 2021; 28:4637-4646. [PMID: 33400000 PMCID: PMC7784622 DOI: 10.1245/s10434-020-09464-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/25/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Peritoneal metastases portend poor prognosis in the setting of standard chemotherapy. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) improves outcomes, but relapse is common. We report a phase II trial evaluating the safety and efficacy of adjuvant αDC1 vaccination with chemokine modulation (CKM) after CRS/HIPEC. METHODS Patients undergoing CRS/HIPEC for appendiceal cancer, colorectal cancer, or peritoneal mesothelioma were enrolled. In addition to standard adjuvant chemotherapy, patients received intranodal and intradermal injections of autologous tumor-loaded αDC1 vaccine. After each vaccine booster, patients received CKM over 4 days, consisting of celecoxib, interferon (IFN)-α, and rintatolimod. RESULTS Forty-six patients underwent CRS/HIPEC followed by αDC1 treatment, including 24 appendiceal primaries, 20 colorectal, and 2 mesotheliomas. DC maturation was successful, with 97% expressing HLA-DR and CD86. Tumor cell recovery from peritoneal tumors was challenging, resulting in only 17% of patients receiving the target dose of αDC1. The αDC1 and CKM regimen was well tolerated. CKM successfully modulated serum inflammatory cytokine and chemokine levels. Median progression-free survival (PFS) for appendiceal primaries was 50.4, 34.2, and 8.9 months for grade 1, 2, and 3 tumors, respectively, while median PFS for colorectal cancer was 20.5 and 8.9 months for moderately and poorly differentiated tumors, respectively. CONCLUSIONS Adjuvant autologous tumor antigen-loaded αDC1 vaccine and CKM is well tolerated. The mucinous nature of peritoneal metastases limits the feasibility of obtaining adequate autologous tumor cells. The improvement in median PFS did not meet our predefined thresholds, leading us to conclude that αDC1 vaccination is not appropriate for patients undergoing CRS/HIPEC for peritoneal metastases.
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Affiliation(s)
- Rajesh Ramanathan
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Surgery, Banner MD Anderson Cancer Center, Phoenix, AZ, USA
| | - Haroon Choudry
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Heather Jones
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Girgis
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Surgery, UCLA Health, Los Angeles, CA, USA
| | - William Gooding
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pawel Kalinski
- Medical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - David L Bartlett
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. .,Department of Surgery, AHN Cancer Institute, Pittsburgh, PA, USA.
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Kranenburg O, van der Speeten K, de Hingh I. Peritoneal Metastases From Colorectal Cancer: Defining and Addressing the Challenges. Front Oncol 2021; 11:650098. [PMID: 33816304 PMCID: PMC8010649 DOI: 10.3389/fonc.2021.650098] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/15/2021] [Indexed: 12/19/2022] Open
Abstract
The presence of peritoneal metastases (PM) in patients with colorectal cancer (CRC) is associated with an extremely poor prognosis. The diagnosis of PM is challenging, resulting in an underestimation of their true incidence. While surgery can be curative in a small percentage of patients, effective treatment for non-operable PM is lacking, and clinical and pre-clinical studies are relatively sparse. Here we have defined the major clinical challenges in the areas of risk assessment, detection, and treatment. Recent developments in the field include the application of organoid technology, which has generated highly relevant pre-clinical PM models, the application of diffusion-weighted MRI, which has greatly improved PM detection, and the design of small clinical proof-of-concept studies, which allows the efficient testing of new treatment strategies. Together, these developments set the stage for starting to address the clinical challenges. To help structure these efforts, a translational research framework is presented, in which clinical trial design is based on the insight gained from direct tissue analyses and pre-clinical (organoid) models derived from CRC patients with PM. This feed-forward approach, in which a thorough understanding of the disease drives innovation in its clinical management, has the potential to improve outcome in the years to come.
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Affiliation(s)
- Onno Kranenburg
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, Netherlands
- Utrecht platform for Organoid Technology, Utrecht University, Utrecht, Netherlands
- *Correspondence: Onno Kranenburg
| | - Kurt van der Speeten
- Department of Surgical Oncology, Faculty of Medicine, Biomedical Research Institute (BIOMED) Research Institute, Hospital Oost-Limburg, Belgium and University Hasselt, Diepenbeek, Belgium
| | - Ignace de Hingh
- Department of Surgery, Research School for Oncology and Developmental Biology, Catharina Hospital Eindhoven, The Netherlands and Maastricht University, Maastricht, Netherlands
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