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Ramos Arias G, Sindayigaya R, Ouaissi M, Buggisch JR, Schmeding M, Giger-Pabst U, Zieren J. Safety and Feasibility of High-Pressure/High-Dose Pressurized Intraperitoneal Aerosol Chemotherapy (HP/HD-PIPAC) for Primary and Metastatic Peritoneal Surface Malignancies. Ann Surg Oncol 2023; 30:2497-2505. [PMID: 36400887 DOI: 10.1245/s10434-022-12698-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/04/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the feasibility and perioperative safety of high-pressure/high-dose pressurized intraperitoneal aerosol chemotherapy (HP/HD-PIPAC) to manage peritoneal surface malignancies (PSM). METHODS Retrospective analysis of a prospective database of about 130 consecutive patients scheduled for HP/HD-PIPACs for PSM. Doxorubicin plus cisplatin (PIPAC-C/D) or oxaliplatin (PIPAC-Ox) were nebulized into a constant capnoperitoneum of 20 mmHg at doses of 6, 30, or 120 mg/m2 of body surface area (BSA). Outcome criteria were perioperative complications (Clavien-Dindo). RESULTS The median age of patients was 62 years (range 9-82), and the primary tumor site was of colorectal (CRC), upper gastrointestinal tract (UGI), unknown primary (CUP), malignant epithelioid mesothelioma of the peritoneum (MPM), hepato-pancreatic-biliary tract (HPB), and other origin in 30 (23.1%), 27 (20.8%), 16 (12.3%), 16 (12.3%), 6 (4.6%), and 35 (26.9%) patients, respectively. Abdominal access failed for a first, second, third, and fourth or more HP/HD-PIPAC in 12/130 (9.2%), 4/64 (6.3%), 6/40 (15.0%), and 2/33 (6.1%) patients. A total of 243 procedures were performed in 118 patients. No intraoperative complications related to increased capnoperitoneal pressure occurred, but an intraoperative bleeding complication was observed in 1/243 (0.4%) patients. The overall rate of postoperative procedure-related complications was 19.3% (47/243), while 15.3% (37/243), 1.6% (6/243), 1.6% (1/243), 0.4% (1/243), and 0.4% (1/243) were Grade I, II, III, IV, and V complications, respectively. CONCLUSIONS Perioperative complications of HP/HD-PIPAC are comparable with standard pressure/dose PIPAC treatment protocols. Prospective studies are warranted to examine potential improvement in therapy outcomes.
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Affiliation(s)
- Gabriel Ramos Arias
- Department of Surgery, Städtisches Krankenhaus Dortmund, University Hospital of the University Witten/Herdecke, Wuppertal, Germany
| | - Rémy Sindayigaya
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic and Liver Transplant Surgery, Trousseau Hospital, Chambray les Tours, Tours, France
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic and Liver Transplant Surgery, Trousseau Hospital, Chambray les Tours, Tours, France
- University of Münster, Medizinische Fakultät, Münster, Germany
| | | | - Maximilian Schmeding
- Department of Surgery, Städtisches Krankenhaus Dortmund, University Hospital of the University Witten/Herdecke, Wuppertal, Germany
| | - Urs Giger-Pabst
- EA4245 Transplantation, Immunologie, Inflammation, Université de Tours, Tours, France.
- Fliedner Fachhochschule, University of Applied Science Düsseldorf, Düsseldorf, Germany.
| | - Jürgen Zieren
- Department of Surgery, Städtisches Krankenhaus Dortmund, University Hospital of the University Witten/Herdecke, Wuppertal, Germany
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Ramirez MF, Guerra-Londono JJ, Owusu-Agyemang P, Fournier K, Guerra-Londono CE. Temperature management during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Front Oncol 2023; 12:1062158. [PMID: 36741691 PMCID: PMC9894316 DOI: 10.3389/fonc.2022.1062158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/30/2022] [Indexed: 01/20/2023] Open
Abstract
In addition to attaining complete or near complete cytoreduction, the instillation of select heated chemotherapeutic agents into the abdominal cavity has offered a chance for cure or longer survival inpatients with peritoneal surface malignancies. While the heating of chemotherapeutic agents enhances cytotoxicity, the resulting systemic hyperthermia has been associated with an increased risk of severe hyperthermia and its associated complications. Factors that have been associated with an increased risk of severe hyperthermia include intraoperative blood transfusions and longer perfusion duration. However, the development of severe hyperthermia still remains largely unpredictable. Thus, at several institutions, cooling protocols are employed during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Cooling protocols for CRS-HIPEC are not standardized and may be associated with episodes of severe hyperthermia or alternatively hypothermia. In theory, excessive cooling could result in a decreased effectiveness of the intraperitoneal chemotherapeutic agents. This presumption has been supported by a recent study of 214 adults undergoing CRS-HIPEC, where failure to attain a temperature of 38° C at the end of chemo-perfusion was associated with worse survival. Although not statistically significant, failure to maintain a temperature of 38° C for at least 30 minutes was associated with worse survival. Although studies are limited in this regard, the importance of maintaining a steady state of temperature during the hyperthermic phase of intraperitoneal chemotherapy administration cannot be disregarded. The following article describes the processes and physiological mechanisms responsible for hyperthermia during CRS-HIPEC. The challenges associated with temperature management during CRS-HIPEC and methods to avoid severe hypothermia and hyperthermia are also described.
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Affiliation(s)
- Maria F. Ramirez
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States,*Correspondence: Maria F. Ramirez,
| | - Juan Jose Guerra-Londono
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Pascal Owusu-Agyemang
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Keith Fournier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Carlos E. Guerra-Londono
- Department of Anesthesiology, Pain Management, & Perioperative Medicine, Henry Ford Health System, Detroit, MI, United States
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Larsen SG, Graf W, Mariathasan AB, Sørensen O, Spasojevic M, Goscinski MA, Selboe S, Lundstrøm N, Holtermann A, Revheim ME, Bruland ØS. First experience with 224Radium-labeled microparticles (Radspherin®) after CRS-HIPEC for peritoneal metastasis in colorectal cancer (a phase 1 study). Front Med (Lausanne) 2023; 10:1070362. [PMID: 36936230 PMCID: PMC10016379 DOI: 10.3389/fmed.2023.1070362] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/23/2023] [Indexed: 03/05/2023] Open
Abstract
Background Peritoneal metastasis (PM) from colorectal cancer carries a dismal prognosis despite extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). With a median time to recurrence of 11-12 months, there is a need for novel therapies. Radspherin® consists of the α-emitting radionuclide radium-224 (224Ra), which has a half-life of 3.6 days and is adsorbed to a suspension of biodegradable calcium carbonate microparticles that are designed to give short-range radiation to the serosal peritoneal surface linings, killing free-floating and/or tumor cell clusters that remain after CRS-HIPEC. Methods A first-in-human phase 1 study (EudraCT 2018-002803-33) was conducted at two specialized CRS-HIPEC centers. Radspherin® was administered intraperitoneally 2 days after CRS-HIPEC. Dose escalation at increasing activity dose levels of 1-2-4-7-MBq, a split-dose repeated injection, and expansion cohorts were used to evaluate the safety and tolerability of Radspherin®. The aim was to explore the recommended dose and biodistribution using gamma-camera imaging. The results from the planned safety interim analysis after the completion of the dose-limiting toxicity (DLT) period of 30 days are presented. Results Twenty-three patients were enrolled: 14 in the dose escalation cohort, three in the repeated cohort, and six in the expansion cohort. Of the 23 enrolled patients, seven were men and 16 were women with a median age of 64 years (28-78). Twelve patients had synchronous PM stage IV and 11 patients had metachronous PM [primary stage II; (6) and stage III; (5)], with a disease-free interval of 15 months (3-30). The peritoneal cancer index was median 7 (3-19), operation time was 395 min (194-515), and hospital stay was 12 days (7-37). A total of 68 grade 2 adverse events were reported for 17 patients during the first 30 days; most were considered related to CRS and/or HIPEC. Only six of the TEAEs were evaluated as related to Radspherin®. One TEAE, anastomotic leakage, was reported as grade 3. Accordion ≥3 grade events occurred in a total of four of the 23 patients: reoperation due to anastomotic leaks (two) and drained abscesses (two). No DLT was documented at the 7 MBq dose level that was then defined as the recommended dose. The biodistribution of Radspherin® showed a relatively even peritoneal distribution. Conclusion All dose levels of Radspherin® were well tolerated, and DLT was not reached. No deaths occurred, and no serious adverse events were considered related to Radspherin®.Clinical Trial Registration: Clinicaltrials.gov, NCT03732781.
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Affiliation(s)
- Stein Gunnar Larsen
- Department of Gastroenterological Surgery, Section for Surgical Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
- *Correspondence: Stein Gunnar Larsen,
| | - Wilhelm Graf
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Academic Hospital, Uppsala, Sweden
| | - Anthony Burton Mariathasan
- Department of Gastroenterological Surgery, Section for Surgical Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Olaf Sørensen
- Department of Gastroenterological Surgery, Section for Surgical Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Milan Spasojevic
- Department of Gastroenterological Surgery, Section for Surgical Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Mariusz Adam Goscinski
- Department of Gastroenterological Surgery, Section for Surgical Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Silje Selboe
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Nadja Lundstrøm
- Uppsala Academic Hospital, Uppsala, Sweden
- Department of Nuclear Medicine, Uppsala, Sweden
| | - Anne Holtermann
- Department of Gastroenterological Surgery, Section for Surgical Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Mona-Elisabeth Revheim
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind Sverre Bruland
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Oncoinvent AS, Oslo, Norway
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Kang HX, Ma JY, Su YY, Kang S, Feng BJ, Feng XB, Wang XS, Lu YY. Risk factors of temperature increase after cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy. Front Oncol 2023; 13:1120499. [PMID: 37035204 PMCID: PMC10073652 DOI: 10.3389/fonc.2023.1120499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/28/2023] [Indexed: 04/11/2023] Open
Abstract
Background Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the standard treatment for patients with peritoneal cancer (PC). Following CRS-HIPEC, patients may also face risks caused by whole body hyperthermia. This study analyzed the incidence of temperature increases following CRS-HIPEC and identified the attendant risk factors. Methods A retrospective analysis was carried out among 458 patients who received CRS-HIPEC at the Fourth Hospital of Hebei Medical University between August 2018 and January 2021. The patients were divided into two groups according to post-HIPEC axillary temperature (≥38°C), with the demographics and the laboratory test results subsequently analyzed and compared, and the risk factors pertaining to temperature increases analyzed using univariate and multivariate logistic regression. Results During CRS-HIPEC, 32.5% (149/458) of the patients with a temperature increase had an axillary temperature of not lower than 38°C, and 8.5% (39/458) of the patients with hyperpyrexia had an axillary temperature of not lower than 39°C. Female gender, gynecological malignancies, type of chemotherapy drug, increased postoperative neutrophil percentage, and a sharp drop in postoperative prealbumin were associated with the incidence of a temperature increase and axillary temperatures of >38°C. Among these factors, the type of chemotherapy drug was identified as an independent risk factor for a temperature increase during CRS-HIPEC. Conclusion By determining the risk factors pertaining to temperature increases during CRS-HIPEC, medical staff can identify the attendant risks among the patients and thus take preventive measures in a timely manner to maintain the patient's body temperature at a stable level. This suggests that further clinical research should be conducted to build a risk-prediction model for temperature increases following CRS-HIPEC.
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Löke DR, Kok HP, Helderman RFCPA, Bokan B, Franken NAP, Oei AL, Tuynman JB, Tanis PJ, Crezee J. Application of HIPEC simulations for optimizing treatment delivery strategies. Int J Hyperthermia 2023; 40:2218627. [PMID: 37455017 DOI: 10.1080/02656736.2023.2218627] [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: 02/28/2023] [Revised: 05/03/2023] [Accepted: 05/22/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Hyperthermic IntraPEritoneal Chemotherapy (HIPEC) aims to treat microscopic disease left after CytoReductive Surgery (CRS). Thermal enhancement depends on the temperatures achieved. Since the location of microscopic disease is unknown, a homogeneous treatment is required to completely eradicate the disease while limiting side effects. To ensure homogeneous delivery, treatment planning software has been developed. This study compares simulation results with clinical data and evaluates the impact of nine treatment strategies on thermal and drug distributions. METHODS For comparison with clinical data, three treatment strategies were simulated with different flow rates (1600-1800mL/min) and inflow temperatures (41.6-43.6 °C). Six additional treatment strategies were simulated, varying the number of inflow catheters, flow direction, and using step-up and step-down heating strategies. Thermal homogeneity and the risk of thermal injury were evaluated. RESULTS Simulated temperature distributions, core body temperatures, and systemic chemotherapeutic concentrations compared well with literature values. Treatment strategy was found to have a strong influence on the distributions. Additional inflow catheters could improve thermal distributions, provided flow rates are kept sufficiently high (>500 mL/min) for each catheter. High flow rates (1800 mL/min) combined with high inflow temperatures (43.6 °C) could lead to thermal damage, with CEM4310 values of up to 27 min. Step-up and step-down heating strategies allow for high temperatures with reduced risk of thermal damage. CONCLUSION The planning software provides valuable insight into the effects of different treatment strategies on peritoneal distributions. These strategies are designed to provide homogeneous treatment delivery while limiting thermal injury to normal tissue, thereby optimizing the effectiveness of HIPEC.
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Affiliation(s)
- Daan R Löke
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - H Petra Kok
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - Roxan F C P A Helderman
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands
| | - Bella Bokan
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands
| | - Nicolaas A P Franken
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands
| | - Arlene L Oei
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine (CEMM), Laboratory for Experimental Oncology and Radiobiology (LEXOR), Amsterdam, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Johannes Crezee
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
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Thelen S, Mikolajczyk-Martinez A, Diakun A, Khosrawipour T, Zielinski K, Nicpoń J, Kiełbowicz Z, Prządka P, Liszka B, Kuropka P, Li S, Lau H, Kielan W, Khosrawipour V. Evaluating the concept of gas‑based intraperitoneal hyperthermia beyond 43˚C in the treatment of peritoneal metastasis: A pilot study. Exp Ther Med 2022; 24:752. [PMID: 36561969 PMCID: PMC9748640 DOI: 10.3892/etm.2022.11687] [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: 06/06/2022] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
While hyperthermic intraperitoneal applications have demonstrated high efficacy in treating peritoneal metastases (PM), these applications are limited to temperatures of 41-43˚C to prevent a harmful increase in core temperature. However, since gaseous substances display low specific heat capacities, gas-based hyperthermia could potentially increase surface temperatures without affecting the body's core temperature. To the best of our knowledge, the present study is the first to explore the in vivo feasibility of gas-based hyperthermia via spatial and time-based distribution. In the present study, a temperature-isolated, abdominal box model was created with fresh peritoneal tissue exposed to continuous high-volume airflow temperatures ranging between 47 and 69˚C. Heat conduction within the peritoneal tissues was measured using temperature microsensors. Temperature build-up at different time points during the procedure was calculated and the safest option to perform gas-based intraperitoneal hyperthermia beyond 43˚C was identified using an in vivo swine model. In subsequent experiments, viability and cytotoxicity of HT-29 colon cancer cells were measured following short-term hyperthermia. The present study demonstrated that the application of gas-based intraperitoneal hyperthermia with temperatures up to 50˚C is possible without increasing the core temperature to harmful levels. Gas-based intraperitoneal hyperthermia can induce a histological reaction on the peritoneal surface, and it can also result in decreased viability and increased cytotoxicity of HT-29 cells. The concept of extreme hyperthermia may be of great clinical importance as it could significantly increase local cytotoxicity in PM without increasing the body's core temperature. Further studies are required to investigate the benefits, as well as the restrictions, of this novel concept.
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Affiliation(s)
- Simon Thelen
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine University Dusseldorf, D-40225 Duesseldorf, Germany
| | - Agata Mikolajczyk-Martinez
- Department of Biochemistry and Molecular Biology, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, 50-375 Wroclaw, Poland
| | - Agata Diakun
- 2nd Department of General Surgery and Surgical Oncology, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Tanja Khosrawipour
- Department of Surgery (A), University-Hospital Düsseldorf, Medical Faculty, Heinrich-Heine University Dusseldorf, D-40225 Düsseldorf, Germany,Correspondence to: Dr Tanja Khosrawipour, Department of Surgery (A), University-Hospital Düsseldorf, Medical Faculty, Heinrich-Heine University Düsseldorf, 5 Moorenstrasse, D-40225 Düsseldorf, Germany
| | - Kacper Zielinski
- Department of Anesthesiology, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Jakub Nicpoń
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, 50-366 Wroclaw, Poland
| | - Zdzisław Kiełbowicz
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, 50-366 Wroclaw, Poland
| | - Przemysław Prządka
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, 50-366 Wroclaw, Poland
| | - Bartłomiej Liszka
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, 50-366 Wroclaw, Poland
| | - Piotr Kuropka
- Department of Biostructure and Animal Physiology, Wroclaw University of Environmental and Life Sciences, 50-375 Wroclaw, Poland
| | - Shiri Li
- Division of Colon and Rectal Surgery, Department of Surgery, New York Presbyterian Hospital-Weill Cornell College of Medicine, New York, NY 10065, USA
| | - Hien Lau
- Department of Surgery, University of California, Irvine, CA 92868, USA
| | - Wojciech Kielan
- 2nd Department of General Surgery and Surgical Oncology, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Veria Khosrawipour
- 2nd Department of General Surgery and Surgical Oncology, Wroclaw Medical University, 50-367 Wroclaw, Poland,Department of Surgery, Petrus-Hospital Wuppertal, D-42283 Wuppertal, Germany
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7
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Diakun A, Khosrawipour T, Mikolajczyk-Martinez A, Nicpoń J, Thelen S, Kiełbowicz Z, Prządka P, Liszka B, Kulas J, Zielinski K, Li S, Lau H, Kielan W, Khosrawipour V. Safety, feasibility, and application of intraperitoneal gas-based hyperthermia beyond 43°C in the treatment of peritoneal metastasis: An in-vivo pilot study. Front Oncol 2022; 12:953920. [PMID: 36303827 PMCID: PMC9592704 DOI: 10.3389/fonc.2022.953920] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/26/2022] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND 43°Celsius (C) is currently the highest temperature used in the treatment of peritoneal metastasis (PM). Despite sufficient data on water- based hyperthermic solutions in PM treatment, there is currently no information on gas-based hyperthermia extending beyond 43°C. This study is the first to provide in-vivo data on different organ systems during and after intraperitoneal gas-based hyperthermia beyond 43°C. The aim of this study is to explore in-vivo feasibility, safety, and efficacy of this novel concept from a biological perspective. METHODS For this study, three swine were subjected to laparoscopy and subsequent gas-based intraperitoneal hyperthermia at 48°, 49° and 50°C under a high-flow air stream. Intraoperative data from multiple temperature sensors were analysed. Additionally, intraoperative anaesthesiologic and gasometrical data was analysed. Postoperatively, swine were monitored for one week and laboratory work-up was performed on postoperative days 1, 3 and 7. RESULTS During gas-based intraperitoneal hyperthermia, anesthesiologic parameters did not exhibit critical values. No intra- or postoperative complications were observed. Distinct temperature measurements on the skin, cystohepatic triangle and esophagus did not display any temperature increase. Postoperative laboratory workup did not show any changes in hemoglobin, white blood cell count, platelets, or kidney function. DISCUSSION Based on our data, there are no safety concerns for the application of gas-based hyperthermia between 48 - 50°C. In fact, no critical systemic temperature increase was observed. With respect to possible limitations, further in-vivo studies are required to evaluate whether gas-based intraperitoneal hyperthermia may be a therapeutic option for PM patients.
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Affiliation(s)
- Agata Diakun
- 2nd Department of General Surgery and Surgical Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - Tanja Khosrawipour
- Department of Surgery (A), University-Hospital Düsseldorf, Heinrich-Heine University, Düsseldorf, Germany
- Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Agata Mikolajczyk-Martinez
- Department of Biochemistry and Molecular Biology, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Jakub Nicpoń
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Simon Thelen
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine University, Duesseldorf, Germany
| | - Zdzisław Kiełbowicz
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Przemysław Prządka
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Bartłomiej Liszka
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Joanna Kulas
- Department of Biochemistry and Molecular Biology, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Kacper Zielinski
- Department of Anaesthesiology, Wroclaw Medical University, Wroclaw, Poland
| | - Shiri Li
- Division of Colon and Rectal Surgery, Department of Surgery, New York Presbyterian Hospital- Weill Cornell College of Medicine, New York, NY, United States
| | - Hien Lau
- Department of Surgery, University of California, Irvine, Irvine, CA, United States
| | - Wojciech Kielan
- 2nd Department of General Surgery and Surgical Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - Veria Khosrawipour
- 2nd Department of General Surgery and Surgical Oncology, Wroclaw Medical University, Wroclaw, Poland
- Department of Surgery, Petrus-Hospital Wuppertal, Wuppertal, Germany
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8
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Wong LCK, Wong JSM, Seo CJ, Soo KC, Ong CAJ, Chia CS. High intra-abdominal pressure during hyperthermic intraperitoneal chemotherapy (HIPEC) following cytoreductive surgery (CRS) for peritoneal surface malignancies. Int J Hyperthermia 2022; 39:1195-1201. [PMID: 36096487 DOI: 10.1080/02656736.2022.2121861] [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: 10/14/2022] Open
Abstract
OBJECTIVE Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) represent a mainstay of treatment for peritoneal malignancies. There is evidence that HIPEC using high intra-abdominal pressure (IAP) results in increased tissue penetration, although its safety profile remains relatively unknown. We thus aim to evaluate differences in intra- and post-operative outcomes in patients undergoing CRS-HIPEC with different levels of IAP. METHODS This pilot prospective cohort study was conducted from January 2020 to February 2021 with patients undergoing CRS-HIPEC. Low IAP during HIPEC was defined as <18 mmHg and high IAP as ≥18 mmHg. Data was collected on patient and tumor characteristics, intra-operative clinical and biochemical parameters, and immediate post-operative outcomes. RESULTS 40 patients underwent CRS-HIPEC (n low = 20, n high = 20). Median IAP in the low and high IAP groups were 12.0 and 19.0 mmHg respectively. During HIPEC, both groups experienced increase in heart rate, central venous pressure, end tidal CO2, temperature, and serum glucose, with decrease in mean arterial pressure and base excess. There were no significant differences in hemodynamics between the 2 groups. Mild electrolyte derangements and a decrease in hemoglobin were noted in the high IAP group but were of small magnitude. Post-operatively, high IAP did not result in increased rate of complications, time to full feeds, ICU or total hospital stay. CONCLUSIONS High IAP in HIPEC is well tolerated and did not result in additional adverse events.
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Affiliation(s)
- Louis Choon Kit Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Jolene Si Min Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore.,SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore.,SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Chin Jin Seo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
| | - Khee Chee Soo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore.,SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore.,SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Chin-Ann Johnny Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore.,SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore.,SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore.,Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore.,Institute of Molecular and Cell Biology, A*STAR Research Entities, Singapore
| | - Claramae Shulyn Chia
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore.,SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore.,SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore
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9
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Diakun A, Khosrawipour T, Mikolajczyk-Martinez A, Kuropka P, Nicpoń J, Kiełbowicz Z, Prządka P, Liszka B, Li S, Lau H, Kielan W, Khosrawipour V. In-vivo thermodynamic exploration of gas-based intraperitoneal hyperthermia. Front Oncol 2022; 12:925724. [PMID: 36106116 PMCID: PMC9464870 DOI: 10.3389/fonc.2022.925724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/28/2022] [Indexed: 12/14/2022] Open
Abstract
Background While hyperthermic intraperitoneal (i.p) applications are highly efficient in treating peritoneal metastases (PM), they are currently limited to temperatures of 41 – 43° Celsius (C). First data on gas-based i.p. hyperthermia is promising, as this novel method allows a significant temperature rise in superficial peritoneal layers without increasing core temperatures. Until now, key mechanisms of this novel tool, e.g. thermodynamic energy transfer, have not been investigated. This study aims to explore the volume of thermodynamic energy transfer during gas-based i.p. hyperthermia at 48-50°C and its peritoneal effects. Methods For this study, three swine were subjected to gas-based i.p. hyperthermia at varying temperatures (48°, 49° and 50°C) in a diagnostic laparoscopy setting with a high-flow air stream. Temperatures of the i.p. cavity, in- and outflow airstream at the trocar were measured and the thermodynamic energy transfer was calculated. Tissue samples were collected on postoperative day 7 for histopathologic analyses. Results According to our data, temperatures within the intraabdominal cavity and at the outflow site remain relatively stable at < 40°C. An increase in thermodynamic energy transfer is observed with increasing applied temperatures. Gas-based i.p. hyperthermia induced capillary coagulation and white blood cell infiltration within peritoneal layers. Conclusions Gas-based i.p. hyperthermia is an innovative approach which enables the i.p. delivery of specific amounts of thermodynamic energy. Following this procedure, our data indicate remarkable histologic changes on the superficial peritoneal layer most likely attributable to the applied thermodynamic energy. Further studies are required to investigate how these findings can be applied in PM management.
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Affiliation(s)
- Agata Diakun
- 2nd Department of General Surgery and Surgical Oncology, Wroclaw Medical University, Wroclaw, Poland
- *Correspondence: Tanja Khosrawipour, ; Agata Diakun,
| | - Tanja Khosrawipour
- Department of Surgery (A), University-Hospital Düsseldorf, Heinrich-Heine University, Düsseldorf, Germany
- *Correspondence: Tanja Khosrawipour, ; Agata Diakun,
| | - Agata Mikolajczyk-Martinez
- Department of Biochemistry and Molecular Biology, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Piotr Kuropka
- Department of Biostructure and Animal Physiology, Wroclaw University, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Jakub Nicpoń
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Zdzisław Kiełbowicz
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Przemysław Prządka
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Bartłomiej Liszka
- Department of Surgery, Faculty of Veterinary Sciences, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Shiri Li
- Division of Colon and Rectal Surgery, Department of Surgery, New York Presbyterian Hospital- Weill Cornell College of Medicine, New York, NY, United States
| | - Hien Lau
- Department of Surgery, University of California, Irvine, CA, United States
| | - Wojciech Kielan
- 2nd Department of General Surgery and Surgical Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - Veria Khosrawipour
- 2nd Department of General Surgery and Surgical Oncology, Wroclaw Medical University, Wroclaw, Poland
- Department of Surgery, Petrus-Hospital Wuppertal, Wuppertal, Germany
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10
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The Role of Hyperthermia in the Treatment of Peritoneal Surface Malignancies. Curr Oncol Rep 2022; 24:875-887. [PMID: 35325402 DOI: 10.1007/s11912-022-01275-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Hyperthermia is used to treat peritoneal surface malignancies (PSM), particularly during hyperthermic intraperitoneal chemotherapy (HIPEC). This manuscript provides a focused update of hyperthermia in the treatment of PSM. RECENT FINDINGS The heterogeneous response to hyperthermia in PSM can be explained by tumor and treatment conditions. PSM tumors may resist hyperthermia via metabolic and immunologic adaptation. The thermodynamics of HIPEC are complex and require computational fluid dynamics (CFD). The clinical evidence supporting the benefit of hyperthermia is largely observational. Continued research will allow clinicians to characterize and predict the individual response of PSM to hyperthermia. The application of hyperthermia in current HIPEC protocols is mostly empirical. Thus, modeling heat transfer with CFD is a necessary task if we are to achieve consistent and reproducible hyperthermia. Although observational evidence suggests a survival benefit of hyperthermia, no clinical trial has tested the individual role of hyperthermia in PSM.
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11
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Application Effect of Intra-Abdominal Pressure Monitoring System in Early Enteral Nutrition Nursing of ICU Patients. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:3545278. [PMID: 35169392 PMCID: PMC8817885 DOI: 10.1155/2022/3545278] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/13/2021] [Accepted: 01/13/2022] [Indexed: 11/17/2022]
Abstract
In order to study and explore the application effect of intra-abdominal pressure monitoring in guiding ICU patients to implement early enteral nutrition therapy, we selected patients admitted to the emergency department of a hospital and classified them into groups A (n = 105) and B (n = 98). Among them, the A group gave early enteral nutrition treatment by monitoring the residual gastric mass, and the B group gave early enteral nutrition treatment by monitoring the stomach. It has been established that, compared to gastric residue monitoring, intra-abdominal pressure monitoring in ICU patients with early enteral nutrition therapy has an obvious advantage, it helps to improve the prognosis of patients, and intra-abdominal pressure combined with gastric residual monitoring scheme can effectively reduce the early enteral nutrition in the ICU patients, the incidence of abdominal distension, vomiting, and make it reach the goal as soon as possible. Early enteral nutrition in patients with increased tolerance is of great significance.
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12
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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: 6] [Impact Index Per Article: 3.0] [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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13
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Wu MF, Wang LJ, Ye YF, Liu CH, Lu HW, Yao TT, Zhang BZ, Chen Q, Li JB, Peng YP, Zhou H, Lin ZQ, Li J. Efficacy of neoadjuvant hyperthermic intraperitoneal chemotherapy in advanced high-grade serous ovarian cancer (the NHIPEC trial): study protocol for a randomised controlled trial. BMJ Open 2021; 11:e046415. [PMID: 34916306 PMCID: PMC8679100 DOI: 10.1136/bmjopen-2020-046415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy (NACT) is an important treatment option for patients with ovarian cancer. Although intravenous NACT can improve optimal resection rates and decrease surgical morbidity and mortality, these advantages do not translate into a survival benefit. Ovarian carcinoma is mainly confined to the peritoneal cavity, which makes it a potential target for hyperthermic intraperitoneal chemotherapy (HIPEC). Our previous study showed that HIPEC could be used in the neoadjuvant setting, which was named neoadjuvant HIPEC (NHIPEC). Since hyperthermia is an excellent chemosensitiser, we hypothesised that the combination of NHIPEC and intravenous NACT could show superior efficacy to intravenous NACT alone. METHODS This study is a single-centre, open-label, randomised (1:1 allocation ratio) phase 2 trial. A total of 80 patients will be randomly assigned into an experimental group (NHIPEC+intravenous NACT) or a control group (intravenous NACT). Patients in the experimental group will receive NHIPEC following laparoscopic evaluation, and four tubes will be placed via the laparoscopic ports, which will be used to administer NHIPEC. Then, perfusion with docetaxel (60-75 mg/m2) will be performed (43°C for 60 min, Day 0) followed by cisplatin (75 mg/m2, Day 1) infusion (43°C for 60 min) 24 hours later. After NHIPEC, two cycles of intravenous NACT will be given. Patients in the control group will receive three cycles of intravenous NACT. The primary endpoint is the proportion of patients who achieve a Chemotherapy Response Score (CRS) of 3 according to the CRS system. The secondary endpoints include progression-free survival, overall survival and the rates of complete resection and NHIPEC-related adverse events. ETHICS APPROVAL AND DISSEMINATION This study was approved by the Ethics Committee of Sun Yat-sen Memorial Hospital (approval number: 2020-ky-050). Results will be submitted to peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER ChiCTR2000038173.
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Affiliation(s)
- Miao-Fang Wu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Li-Juan Wang
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Yan-Fang Ye
- Clinical Research Design Division, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Chang-Hao Liu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Huai-Wu Lu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Ting-Ting Yao
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Bing-Zhong Zhang
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Qing Chen
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Ji-Bin Li
- Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yong-Pai Peng
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Hui Zhou
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Zhong-Qiu Lin
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Jing Li
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
- Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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14
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Guerra-Londono CE, Owusu-Agyemang P, Corrales G, Rofaeil MM, Feng L, Fournier K, Cata JP. Risk of Intraoperative Hyperthermia and Outcomes in Adults Undergoing Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Ann Surg Oncol 2021; 29:2089-2099. [PMID: 34704181 DOI: 10.1245/s10434-021-10929-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hyperthermic intraperitoneal chemotherapy (HIPEC) is commonly used to treat peritoneal surface malignancies. We aimed to identify risk factors of intraoperative patient hyperthermia and the postoperative outcome of adults undergoing HIPEC PATIENTS AND METHODS: A retrospective, IRB approved, single center cohort study was conducted. Adults treated with cytoreductive surgery and HIPEC between 2006 and 2021 were included. The primary outcome was bladder hyperthermia during perfusion, stratified by severity and duration. Secondary outcomes were postoperative complications and recurrence-free (RFS) and overall (OS) survival. Multivariable logistic regression models were fit to estimate the effects of important covariates. RESULTS Out of 214 patients, 114 had mild hyperthermia (≥ 38 °C) at any time, and in 73 of these it lasted for ≥ 30 min. Independent prognostic factors of mild hyperthermia ≥ 30 min were age (OR = 0.958, 95% CI 0.933-0.984), body mas index (BMI; OR = 0.959 95% CI 0.917-1.002), gender (OR = 0.199, 95% CI 0.092-0.431), and type of chemotherapy [cisplatin versus mitomycin (OR = 0.186, 95% CI 0.070-0.491; oxaliplatin versus mitomycin (OR = 0.430, 95% CI 0.163-1.139)]. Prognostic factors of moderate-to-severe hyperthermia (≥ 39 °C) at any time were perfusion duration (OR = 1.094, 95% CI 1.018-1.177) and blood transfusion (OR = 5.689, 95% CI 1.784-18.137). Intraoperative hyperthermia was not associated with increased postoperative complications but was associated with better RFS and OS. CONCLUSIONS Our study demonstrates age, gender, BMI, and chemotherapy type to be associated with hyperthermia ≥ 38 °C for ≥ 30 min, whereas longer perfusion time and blood transfusion were associated with hyperthermia ≥ 39 °C. Mild hyperthermia at the end of perfusion is associated with better RFS and OS.
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Affiliation(s)
- Carlos E Guerra-Londono
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pascal Owusu-Agyemang
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - German Corrales
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | | | - Lei Feng
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA.
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15
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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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16
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The impact of gastrointestinal anastomotic leaks on survival of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy. Am J Surg 2021; 223:331-338. [PMID: 33832737 DOI: 10.1016/j.amjsurg.2021.03.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/15/2021] [Accepted: 03/28/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Gastrointestinal (GI) leaks after cytoreductive surgery and hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) is a known life-threatening complication that may alter patients' outcomes. Our aim is to investigate risk factors associated with GI leaks and evaluate the impact of GI leaks on patient's oncological outcomes. METHODS A retrospective analysis of perioperative and oncological outcomes of patients with and without GI leaks after CRS/HIPEC. RESULTS Out of 191 patients included in this study, GI leaks were identified in 17.8% (34/191) of patients. Small bowel anastomoses were the most common site (44%). Most of the GI leaks were managed conservatively and re-operation was needed in 44.1% of cases. Univariate analysis identified higher PCI (p = 0.03), higher number of packed cells transfused (p = 0.036), pelvic peritonectomy (p = 0.013), high number of anastomoses (p = 0.003) and colonic resection (p = 0.042) as factors associated with GI leaks. Multivariate analysis identified stapled anastomoses (OR 2.59, p = 0.001) and pelvic peritonectomy (OR 2.33, p = 0.044) as independent factors associated with GI leaks. Disease-free survival tended to be worse in the leak group but did not reach statistical significance (p = 0.235). The 3- and 5-year OS was 73.2% and 52.9% in the leak group compared to 75.8% and 73.2% in the non-leak group (p = 0.236). CONCLUSIONS GI leak showed no impact on overall and disease free survival after CRS/HIPEC.Avoidance of stapled reconstruction in high risk patients with high tumor burden and large number of anastomoses may yield improved outcomes.
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17
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Leiting JL, Cloyd JM, Ahmed A, Fournier K, Lee AJ, Dessureault S, Felder S, Veerapong J, Baumgartner JM, Clarke C, Mogal H, Staley CA, Zaidi MY, Patel SH, Ahmad SA, Hendrix RJ, Lambert L, Abbott DE, Pokrzywa C, Raoof M, LaRocca CJ, Johnston FM, Greer J, Grotz TE. Comparison of open and closed hyperthermic intraperitoneal chemotherapy: Results from the United States hyperthermic intraperitoneal chemotherapy collaborative. World J Gastrointest Oncol 2020; 12:756-767. [PMID: 32864043 PMCID: PMC7428797 DOI: 10.4251/wjgo.v12.i7.756] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/01/2020] [Accepted: 06/02/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis can be performed in two ways: Open or closed abdominal technique.
AIM To evaluate the impact of HIPEC method on post-operative and long-term survival outcomes.
METHODS Patients undergoing CRS with HIPEC from 2000-2017 were identified in the United States HIPEC collaborative database. Post-operative, recurrence, and overall survival outcomes were compared between those who received open vs closed HIPEC.
RESULTS Of the 1812 patients undergoing curative-intent CRS and HIPEC, 372 (21%) patients underwent open HIPEC and 1440 (79%) underwent closed HIPEC. There was no difference in re-operation or severe complications between the two groups. Closed HIPEC had higher rates of 90-d readmission while open HIPEC had a higher rate of 90-d mortalities. On multi-variable analysis, closed HIPEC technique was not a significant predictor for overall survival (hazards ratio: 0.75, 95% confidence interval: 0.51-1.10, P = 0.14) or recurrence-free survival (hazards ratio: 1.39, 95% confidence interval: 1.00-1.93, P = 0.05) in the entire cohort. These findings remained consistent in the appendiceal and the colorectal subgroups.
CONCLUSION In this multi-institutional analysis, the HIPEC method was not independently associated with relevant post-operative or long-term outcomes. HIPEC technique may be left to the discretion of the operating surgeon.
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Affiliation(s)
- Jennifer L Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN 55901, United States
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Ahmed Ahmed
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Andrew J Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Sophie Dessureault
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL 33612, United States
| | - Seth Felder
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL 33612, United States
| | - Jula Veerapong
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA 92093, United States
| | - Joel M Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA 92093, United States
| | - Callisia Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Harveshp Mogal
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Charles A Staley
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States
| | - Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA 01655, United States
| | - Laura Lambert
- Peritoneal Surface Malignancy Program Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, United States
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI 53792, United States
| | - Courtney Pokrzywa
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI 53792, United States
| | - Mustafa Raoof
- Christopher LaRocca, Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010, United States
| | | | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University, Baltimore, MD 21287, United States
| | - Jonathan Greer
- Department of Surgery, Johns Hopkins University, Baltimore, MD 21287, United States
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN 55901, United States
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Reis ACV, Kusamura S, Azmi N, Fumagalli L, Piccioni F, Valenza F, Baratti D, Guaglio M, Cavalleri A, Garrone G, Barretta F, Deraco M. Hemodynamic and respiratory implications of high intra-abdominal pressure during HIPEC. Eur J Surg Oncol 2020; 46:1896-1901. [PMID: 32147425 DOI: 10.1016/j.ejso.2020.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/05/2020] [Accepted: 02/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND cytoreduction surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is currently the standard of care for some peritoneal surface malignancies. There is experimental evidence supporting that high Intra Abdominal Pressure (IAP) during HIPEC could enhance the uptake of drugs by tumor tissues. However, few papers are describing the hemodynamic and respiratory effects of increased IAP during HIPEC. AIMS to evaluate the hemodynamic and respiratory association with different IAPs during HIPEC. METHODS This is part of an IRB board approved prospective randomized controlled trial conducted at The National Tumor Institute of Milan from 2014 to 2017 (NCT0294979). Patients diagnosed with Pseudomyxoma (PMP) or Peritoneal Metastasis of Colorectal Cancer (PM-CRC) were submitted to CRS and then randomized to receive low IAP (8-12 mmHg) or high IAP (18-22 mmHg) HIPEC. Hemodynamic and respiratory data were collected in eight different time-points during the whole procedure. RESULTS 33 patients (n low = 15, n high = 18) with PM-CRC and PMP were analysed. The mean IAP in the low IAP HIPEC group was 11.4 mmHg (SD: 2.5) and 18.1 mmHg (SD: 2.5) in the high IAP HIPEC group (p«0.001). There was no difference in the hemodynamic parameters between both groups, except for the central venous pressure (CVP) that was significantly higher in the high IAP group (p = 0.006). High IAP was well tolerated in the experimental arm with no hemodynamic and ventilation instability observed during the intervention. CONCLUSION We conclude that high IAP at the level of 18-22 mmHg during HIPEC has no significant hemodynamic parameters difference, being feasible and safe in our study.
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Affiliation(s)
- Artur C V Reis
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy; Irmandade Santa Casa de Misericórdia de São José Dos Campos, Department of Gastrointestinal Surgery, São Paulo, Brazil.
| | - Shigeki Kusamura
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Norfarizan Azmi
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Luca Fumagalli
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy
| | - Federico Piccioni
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy
| | - Franco Valenza
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy; University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Dario Baratti
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Marcello Guaglio
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Adalberto Cavalleri
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Laboratory of Department of Preventive and Predictive Medicine, Italy
| | - Giulia Garrone
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Laboratory of Department of Preventive and Predictive Medicine, Italy
| | - Francesco Barretta
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Department of Clinical Epidemiology and Trial Organization, Milan, Italy
| | - Marcello Deraco
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy.
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Abstract
Malignant peritoneal mesothelioma (MPM) is a rare and lethal disease of the peritoneal lining, with high variability in biologic aggressiveness. Morbidity and mortality of the disease are related to progressive locoregional effects within the abdominal cavity, such as distention, pain, early satiety, and decreased oral intake that can ultimately lead to bowel obstruction and cachexia. The standard of care for patients with resectable disease remains cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), with potential survival outcomes greater than 5 years in appropriately selected patients. Patients with inoperable MPM can be offered systemic treatment, although the disease is usually refractory to standard chemotherapic regimens. Patients with MPM should be treated at high volume centers with strong consideration for inclusion in tumor registries and clinical trials. In 2020, research will continue to explore promising genetic and immunologic targets and focus on refinement of surgical methods to optimize CRS-HIPEC approaches.
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Hendrix RJ, Kassira JP, Lambert LA. Elevated Maximum Core Body Temperature During Hyperthermic Intraperitoneal Chemoperfusion (HIPEC) is Associated with Increased Postoperative Complications. Ann Surg Oncol 2019; 27:232-239. [PMID: 31286314 DOI: 10.1245/s10434-019-07495-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Hyperthermia enhances the cytotoxicity of chemotherapeutic agents used during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC). However, this may result in an elevated core body temperature (CBT), with unintended effects on surgical morbidity. This study evaluates the relationship of maximum CBT during CRS/HIPEC on postoperative outcomes. METHODS A retrospective review of patients undergoing CRS/HIPEC from January 2011 to July 2017 was performed. Outcomes were stratified according to maximum CBT reached during HIPEC. Primary study endpoints were 30-day morbidity and 30-day complication severity. RESULTS Overall, 135 consecutive CRS/HIPEC cases were reviewed; 36 (27%) had a maximum CBT ≥ 39.5 °C during the 90-min HIPEC. CBT ≥ 39.5 °C was associated with an increase in 30-day postoperative complications (58% vs. 34%, p = 0.01) and severe Clavien-Dindo grade III or higher complications (22% vs. 11%, p = 0.04). On multivariate analysis, the adjusted odds ratio of having any complication was 3.77 (95% confidence interval [CI] 1.56-9.14) and a Clavien-Dindo grade III or higher complication was 3.46 (95% CI 1.10-10.95) when maximum CBT reached 39.5 °C. Flow rates ≥ 2.35 L/min were associated with lower average CBT (p = 0.05) and improved peritoneal heating (p = 0.02). CONCLUSION Maximum CBT ≥ 39.5 °C is associated with an increased risk of postoperative morbidity. Higher flow rates are associated with improved intraperitoneal heating, lower CBT, and may contribute to optimizing the therapeutic benefit of HIPEC.
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Affiliation(s)
- Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jonathan P Kassira
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Laura A Lambert
- Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
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Turaga KK, Clark Gamblin T, Richard Alexander H, Edwards R, Bartlett DL. Together We Make a Difference. Ann Surg Oncol 2018; 25:1794-1796. [PMID: 29766390 DOI: 10.1245/s10434-018-6338-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Kiran K Turaga
- Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - T Clark Gamblin
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - H Richard Alexander
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, Piscataway Township, NJ, USA
| | - Robert Edwards
- Department of Obstetrics/Gynecology, University of Pittsburgh, Pittsburgh, PA, USA
| | - David L Bartlett
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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