Multimodality treatment strategies have changed prognosis of peritoneal metastases

Evaluating geographical disparities on clinical outcomes following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Rural Australians typically encounter disparities in healthcare access leading to adverse health outcomes, delayed diagnosis and reduced quality of life (QoL) parameters. These disparities may be exacerbated in advanced malignancies, where treatment is only available at highly specialised centres with appropriate multidisciplinary expertise. Thus, this study aims to determine the association between patient residence on oncological, surgical and QoL outcomes following cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC).

METHODS

A retrospective analysis was conducted on consecutive patients undergoing CRS and HIPEC at Royal Prince Alfred Hospital from January 2017 to March 2022. On the basis of their postcode of residence, patients were stratified into metropolitan and regional groups. Data encompassing demographics, oncological, surgical and QoL outcomes were compared. Statistical analysis included chi-square test, t-tests and Kaplan-Meier survival curves.

RESULTS

Among the 317 patients, 228 (72%) were categorised as metropolitan and 89 (28%) as regional. Metropolitan patients presented higher rates of recurrence (61.8% versus 40.0%, p = 0.014) and shorter overall mean survival [3.8 years (95% CI: 3.44-4.09) versus 4.2 years (95% CI: 3.76-4.63), p = 0.019] compared with regional patients. No other statistically significant differences were observed in oncological, surgical and QoL outcomes.

CONCLUSIONS

Most oncological, surgical and QoL parameters did not differ by geographical location of patients undergoing CRS and HIPEC for peritoneal malignancies at a high-volume quaternary referral centre. Observed differences in recurrence and survival may be attributed to the selective nature of surgical referrals and variable follow-up patterns. Future research should focus on characterising referral pathways and its influence on post-operative outcomes.

Effect of tranexamic acid administration on intraoperative blood loss during peritonectomy: a single-center retrospective observational study

BACKGROUND

The efficacy of tranexamic acid in elective major invasive abdominal surgeries has not yet been established. We investigated the effect of tranexamic acid administration on intraoperative blood loss during peritoneal resection of pseudomucinoma and cancerous peritoneal dissemination.

METHODS

Patients aged ≥ 20 years old who underwent peritoneal resection for pseudomucinoma or cancerous peritoneal dissemination at the Kishiwada Tokushukai Hospital were included in this single-center retrospective observational study. The tranexamic acid group received 1000 mg of tranexamic acid at the start of the operation, while the control group received the same intraoperative management as the tranexamic acid group, except for the tranexamic acid administration. The primary endpoint was intraoperative blood loss, and a multivariate analysis of the contributing factors was performed.

RESULTS

The median volume of intraoperative blood loss was 1372 [interquartile range, 842 - 1877] mL and 907 [516 - 1537] mL in the control and tranexamic acid groups, respectively (p < 0.01). The total volume of blood transfusion during the operation was 2040 [1480 - 2380] mL and 1560 [1000 - 2120] mL in the control and tranexamic acid groups, respectively (p = 0.02). Postoperative blood test results revealed D-dimer values of 7.5 [4.1 - 10.7] µg/mL and 1.8 [1.0 - 3.3] µg/mL in the control and tranexamic acid groups, respectively (p < 0.01). Multivariate analysis showed that tranexamic acid administration was significantly associated with decreased intraoperative blood loss (p = 0.02).

CONCLUSION

Tranexamic acid administration may be useful in reducing intraoperative blood loss and blood transfusion volume during highly-invasive surgeries such as peritoneal resection of pseudomucinoma and cancerous peritoneal dissemination.

Cytoreductive surgery and intraperitoneal chemotherapy for peritoneal metastasis of colorectal cancer: long-term follow-up results at a single institution in Korea

PURPOSE

This study aimed to examine the 7-year follow-up results of cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) for peritoneal metastasis (PM) of colorectal cancer.

METHODS

We performed 54 cases of CRS and IPC in 53 patients with PM of colorectal cancer from December 2011 to December 2013. We prospectively collected data and analyzed peritoneal carcinomatosis grade, completeness of cytoreduction, and long-term follow-up (median, 10 [range, 2-92] months) results.

RESULTS

The mean peritoneal cancer index was 15 (1 ~ 35), and complete cytoreduction was possible in 35 (64.8%) patients. Excluding the four patients who died, 11 (22.4%) out of the 49 patients were alive at the time of the last follow-up, and the overall median survival period was 10.3 months. The overall 2- and 5-year survival rates were 31% and 17%, respectively. Patients with complete cytoreduction had a median survival period of 22.6 months, which was significantly longer than that for patients without complete cytoreduction (3.5 months) (P < 0.001). The 5-year survival rate for patients with complete cytoreduction was 24%, and four patients were still alive without disease.

CONCLUSIONS

CRS and IPC show a 5-year survival rate of 17% in patients with PM of colorectal cancer. A possibility of long-term survival is observed in a selected group. Multidisciplinary team evaluation for careful patient selection and CRS training program to achieve complete cytoreduction are significantly important factors in improving survival rate.

Intraperitoneal Glucose Transport to Micrometastasis: A Multimodal In Vivo Imaging Investigation in a Mouse Lymphoma Model

Bc-DLFL.1 is a novel spontaneous, high-grade transplantable mouse B-cell lymphoma model for selective serosal propagation. These cells attach to the omentum and mesentery and show dissemination in mesenteric lymph nodes. We aimed to investigate its early stage spread at one day post-intraperitoneal inoculation of lymphoma cells (n = 18 mice), and its advanced stage at seven days post-inoculation with in vivo [18F]FDG-PET and [18F]PET/MRI, and ex vivo by autoradiography and Cherenkov luminescence imaging (CLI). Of the early stage group, nine animals received intraperitoneal injections, and nine received intravenous [18F]FDG injections. The advanced stage group (n = 3) received intravenous FDG injections. In the early stage, using autoradiography we observed a marked accumulation in the mesentery after intraperitoneal FDG injection. Using other imaging methods and autoradiography, following the intravenous injection of FDG no accumulations were detected. At the advanced stage, tracer accumulation was clearly detected in mesenteric lymph nodes and in the peritoneum after intravenous administration using PET. We confirmed the results with immunohistochemistry. Our results in this model highlight the importance of local FDG administration during diagnostic imaging to precisely assess early peritoneal manifestations of other malignancies (colon, stomach, ovary). These findings also support the importance of applying topical therapies, in addition to systemic treatments in peritoneal cancer spread.

Is there an oncological interest in the combination of CRS/HIPEC for peritoneal carcinomatosis of HCC? Results of a multicenter international study

INTRODUCTION

Peritoneal metastasis (PM) of hepatocellular carcinoma (HCC) without distant spread are rare. The related prognosis is poor without standard treatment available. The role of cytoreduction surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is poorly documented.

METHODS

An international multicentric cohort was constituted by retrospective analysis of 21 patients undergoing CRS/HIPEC for PM of HCC between 1992 and 2016 from 10 reference centers of PSOGI. Data on clinical features, treatment strategies, and survival outcomes were analyzed.

RESULTS

The median time interval from the diagnosis of PM to the procedure was 4.5 months. The median peritoneal cancer index was 14. Sixteen patients had complete cytoreduction (CCR0-1). Ten patients had grades 3 to 4 complications. The median duration of follow-up was 52.2 months. The median OS was 46.7 months. The projected 3y-OS and 5y-OS were 88.9 and 49.4% respectively. The median OS for patients with CCR0-1 resection was not reached whereas it was 5.9 months for those with CCR2-3 resection after CRS (p = 0.0005). The median RFS was 26.3 months and projected RFS at 3 years of 36.5 months Three prognostic factors were associated with improved RFS in the univariate analysis: preoperative chemotherapy (p = 0.0156), PCI >15 (p = 0.009), Number of chemotherapy agents used for HIPEC (p = 0.005).

CONCLUSION

CRS/HIPEC is a safe and effective approach in selected patients with PM of HCC. CRS/HIPEC gives the patient a chance for a good relapse free and overall survival and should be considered as an option.

Physiologic Response to HIPEC: Sifting Through Perturbation to Identify Markers of Complications

Context: The postoperative physiologic response to hyperthermic intraperitoneal chemotherapy (HIPEC) has been poorly studied outside of the immediate perioperative time.

Objective: To characterize the physiologic response during the first 5 days after HIPEC and identify variables associated with major complications.

Methods: Patients undergoing HIPEC and cytoreductive surgery during a 14-month interval were retrospectively identified and their records reviewed for demographics, physiologic response, and major complications. Vital signs and laboratory results were recorded before the operation, immediately after the procedure, and for the first 5 postoperative days.

Results: Thirty-three patients were included. The mean body temperature and heart rate were elevated on postoperative day 1 compared with baseline (preoperative) status (37.1°C vs 36.6°C and 103 vs 78 beats/min, respectively) and remained elevated through postoperative day 5. The mean arterial pressure was lower on postoperative day 1 (73 mm Hg) but returned to baseline on postoperative day 3 (93 mm Hg). Mean creatinine level increased on postoperative day 1 (0.96 mg/dL) but returned to baseline on postoperative day 2 (0.87 mg/dL). Fourteen patients (42%) had major complications. The strongest predictors of major complications were a prolonged operative time (519 vs 403 minutes) and extreme changes in body temperature and renal function.

Conclusions: Hyperthermic intraperitoneal chemotherapy results in a hypermetabolic response that partially returns to baseline around postoperative day 3. Elevated body temperature and impaired renal function are the best predictors of major complications.

Cytoreductive surgery and intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal cancer: 2-year follow-up results at a single institution in Korea

Purpose

The purpose of this study was to examine 2-year follow-up results of cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) for peritoneal carcinomatosis (PC) of colorectal cancer.

Methods

We performed 54 cases of CRS and IPC in 53 patients with PC of colorectal cancer from December 2011 to December 2013. We collected data prospectively and analyzed the grade of PC, morbidity and mortality, and short-term follow-up (median, 10 months; range, 2–47 months) results.

Results

Mean peritoneal cancer index (PCI) was 15 (range, 1–35), and complete cytoreduction was possible in 35 patients (64.8%). Complications occurred in 25 patients (46.3%) and mortality occurred in 4 patients (7.4%). Excluding the 4 mortalities, 17 patients out of 49 patients (31.5%) were alive at the time of the last follow-up and the overall median survival was 10.3 months. Patients with complete cytoreduction had a median survival of 22.6 months, which was significantly longer than the median survival of 3.5 months for patients without complete cytoreduction (P < 0.001). PCI grade, CCR grade, cell type, and postoperative chemotherapy were significant prognostic factors by univariate analysis. Positive independent prognostic factors by multivariate analysis included PCI grade and postoperative chemotherapy.

Conclusion

CRS and IPC increased the survival of patients with low PCI and postoperative systemic chemotherapy was mandatory. However, this combined therapeutic approach showed high rate of complications and mortality. Therefore, this aggressive treatment should be performed in only selected patients by considering the general condition of the patient and the extent of PC.