Multiple ocean parameter-based potential fishing zone (PFZ) location generation and validation in the Western Bay of Bengal

A new conceptual framework based on satellite data, including chlorophyll (CHL), sea surface temperature (SST) fronts, relative winds, current vectors, Ekman transport, and eddies, has been developed to identify potential fishing zones (PFZ) in the Bay of Bengal (BoB). The framework aims to provide persistent forecasts, even under cloudy conditions, based on feature propagation. The validation of the PFZ was carried out using fish catch data collected by the Fishery Survey of India (FSI) between 2016 and 2018. Hooking rates (HR) from longlines and catch per unit effort (CPUE) from trawl nets were used to analyse the data points in hook rate categories (1.0-3.0 and > 3.0) and CPUE categories (50-100 kg and > 100 kg) and interpret them with the PFZ maps. The analysis showed that the high fish catch locations were consistent with persisting features in the BoB, such as high chlorophyll patches, SST fronts, and cyclonic eddies. The high fish catch locations based on hook rate and high CPUE were found to be collocated with the high chlorophyll persisting features and thermal gradients in the BoB. The regression analysis shows that availability of the food (CHL) had the strongest correlation with fish catch, followed by the comfort condition (fronts and eddies).

A new white-spotted moray eel, Gymnothorax aurocephalus sp. nov. (Muraenidae: Muraeninae) from Andaman Sea, India

Gymnothorax aurocephalus sp. nov. is described herein based on 4 specimens. Three were collected from off Swaraj Dweep Island of Andaman and Nicobar Islands (AN Islands) from a depth of 125-130 m and one specimen off Interview Island, AN Islands at a depth of 90 m. This new species is distinguishable from its congeners by the following combination of characters: chocolate brown color overlain with small irregular white spots, golden skin shadings close to rictus; anus slightly before midbody; pointed and serrated jaw teeth; uniserial teeth in jaws and vomer; vertebral formula 7/61/148-149. The species is compared to all its congeners with white spots.

Developmental toxicity in embryo-larval zebrafish (Danio rerio) exposed to strobilurin fungicides (azoxystrobin and pyraclostrobin)

Azoxystrobin and pyraclostrobin are broad spectrum strobilurin fungicides that have been measured in the aquatic environment. Strobilurins inhibit mitochondrial respiration by binding to the mitochondrial respiratory complex III. The goal of this study was to investigate mitochondrial dysfunction and oxidative stress in the developing zebrafish from exposure to azoxystrobin and pyraclostrobin. Exposure studies were performed where zebrafish embryos were exposed to azoxystrobin and pyraclostrobin at 0.1, 10, 100 μg/L from 4 hpf to 48 hpf to measure mitochondrial dysfunction and oxidative stress mRNA transcripts, and 5 dpf to measure movement, growth, oxygen consumption, enzymatic activities, and mRNA transcripts. Results from this study indicated that there was a significant reduction in both basal and maximal respiration at 48 hpf in zebrafish exposed to 100 μg/L of pyraclostrobin. There was no difference in oxidative stress or apoptotic mRNA transcripts at 48 hpf, indicating that the two strobilurins were acting first on mitochondrial function and not directly through oxidative stress. At 5 dpf, standard body length was significantly reduced with exposure to pyraclostrobin and azoxystrobin exposure as compared to the control. These reductions in apical endpoints corresponded with increases in oxidative stress and apoptotic mRNA transcripts in treatment groups at 5 dpf indicating that strobilurins' exposure followed the adverse outcome pathway for mito-toxicants. Our results indicate that strobilurins can decrease mitochondrial function, which in turn lead to diminished growth and movement.

Fitbit step counts during inpatient recovery from cancer surgery as a predictor of readmission

Background

Postoperative ambulation is encouraged to promote timely recovery but is rarely monitored objectively or examined as a predictor of clinical outcomes, despite growing availability of wearable devices that allow passive quantification and remote real-time monitoring of the number of steps taken during recovery.

Purpose

To determine whether the number of steps taken during inpatient recovery predicts 30- and 60-day readmission risk after metastatic cancer surgery.

Methods

Patients diagnosed with metastatic peritoneal cancer and scheduled for surgical resection were enrolled in this observational cohort study at their preoperative clinic visit. Fitbits were placed on patients' wrists upon transfer from the ICU following surgery and worn for the duration of their inpatient stay. Information about hospital readmission was extracted from electronic medical records.

Results

Seventy-one patients participated in the study (mean age = 57.14, range = 31-80 years; 42% female; 51% diagnosed with appendiceal cancer). Mean steps per day were calculated for each participant over the entire inpatient recovery period (mean stay = 12.12 days, 4-37 days). Readmission within 30 and 60 days was medically indicated for 34% and 39% of patients, respectively. After statistically adjusting for age, body mass index, comorbidity, and length of postoperative stay, higher mean steps per day predicted lower 30-day and 60-day readmission risk.

Conclusions

Higher Fitbit step counts during inpatient recovery predicted lower risk of 30- and 60-day readmission after surgery for metastatic peritoneal cancer. Results suggest that passively monitoring perioperative ambulation may identify patients at risk for readmission and highlight opportunities for behavioral intervention.

Comparative Lipid Peroxidation and Apoptosis in Embryo-Larval Zebrafish Exposed to 3 Azole Fungicides, Tebuconazole, Propiconazole, and Myclobutanil, at Environmentally Relevant Concentrations

Azole fungicides have entered the aquatic environment through agricultural and residential runoff. In the present study, we compared the off-target toxicity of tebuconazole, propiconazole, and myclobutanil using embryo-larval zebrafish as a model. The aim of the present study was to investigate the relative toxicity of tebuconazole, propiconazole, and myclobutanil using multiple-level endpoints such as behavioral endpoints and enzymatic and molecular biomarkers associated with their mode of action. Zebrafish embryos were exposed to azoles at environmentally relevant and high concentrations, 0.3, 1.0, and 1000 µg/L, starting at 5 h postfertilization (hpf) up to 48 hpf, as well as 5 d postfertilization (dpf). Relative mRNA expressions of cytochrome P450 family 51 lanosterol-14α-demethylase, glutathione S-transferase, caspase 9, phosphoprotein p53, and BCL2-associated X protein were measured to assess toxicity attributable to fungicides at the mRNA level, whereas caspase 3/7 (apoptosis) and 3,4-methylene​dioxy​amphetamine (lipid peroxidation) levels were measured at the enzymatic level. Furthermore, mitochondrial dysfunction was measure through the Mito Stress test using the Seahorse XFe24 at 48 hpf. In addition, light to dark movement behavior was monitored at 5 dpf using Danio Vision® to understand adverse effects at the organismal level. There was no significant difference in the light to dark behavior with exposure to azoles compared to controls. The molecular biomarkers indicated that propiconazole and myclobutanil induced lipid peroxidation, oxidative stress, and potentially apoptosis at environmentally relevant concentrations (0.3 and 1 µg/L). The results from the mitochondrial respiration assay indicated a slight decrease in spare respiratory capacity with an acute exposure (48 hpf) to all 3 azoles at 1000 µg/L. Based on the present results, propiconazole and myclobutanil are acutely toxic compared to tebuconazole in aquatic organisms at environmentally relevant concentrations. Environ Toxicol Chem 2019;38:1455-1466. © 2019 SETAC.

PCI is Not Predictive of Survival After Complete CRS/HIPEC in Peritoneal Dissemination from High-Grade Appendiceal Primaries

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment option in patients with carcinomatosis from high-grade appendiceal (HGA) primaries. It is unknown if there is a Peritoneal Carcinomatosis Index (PCI) upper limit above which a complete CRS/HIPEC does not assure long-term survival.

METHODS

Retrospective analysis from three centers was performed. The PCI was used to grade volume of of disease. Survival in relation to PCI was studied on patients with complete cytoreduction.

RESULTS

Overall, 521 HGA patients underwent CRS/HIPEC from 1993 to 2015, with complete CRS being achieved in 50% (260/622). Mean PCI was 14.8 (standard deviation 8.7, range 0-36). Median survival for the complete CRS cohort was 6.1 years, while 5- and 10-year survival was 51.7% (standard error [SE] 4.6) and 36.1% (SE 6.3), respectively. Arbitrary cut-off PCI limits with 5-point splits (p = 0.63) were not predictive of a detrimental effect on survival as long as a complete CRS was achieved. A linear effect of the PCI on survival (p = 0.62) was not observed, and single-point PCI cohort splits within a PCI range of < 5 to > 10 were not predictive of survival for complete CRS patients. The PCI correlated with the ability to achieve a complete CRS, with a mean PCI of 14.7 (8.7) for completeness of cytoreduction (CC)0, 22.3 (7.8) for CC1 and 26.1 (9.5) for CC2/3 resections (p = 0.0001, hazard ratio 1.12, 95% confidence interval 1.09), with an HR of 1.15 for each 1-unit increase in the PCI score. Only 21% of the cohort achieved a complete CRS with a PCI ≥ 21.

CONCLUSIONS

The PCI correlates with the ability to achieve a complete CRS in carcinomatosis from HGA. PCI is not associated with survival as long as a complete CRS can be achieved.

Impact of Cellularity on Oncologic Outcomes Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion for Pseudomyxoma Peritonei

BACKGROUND

The Peritoneal Surface Oncology Group International (PSOGI) recommends pathologic reporting of tumor cellularity in patients with pseudomyxoma peritonei (PMP) undergoing cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS-HIPEC). We investigated the prognostic significance of PMP cellularity, or lack thereof (acellular mucin), following CRS-HIPEC.

METHODS

We reviewed clinical data for 310 CRS-HIPEC procedures in low-grade (American Joint Committee on Cancer grade G1) PMP with acellular mucin (n = 19), scant cellularity (n = 30), or moderate cellularity (n = 242). Kaplan-Meier survival curves and multivariate Cox regression models identified prognostic factors affecting oncologic outcomes.

RESULTS

Compared with patients with acellular mucin, those with scant and moderate cellularity had higher PCI and less-frequent complete macroscopic resection. After an estimated median follow-up of 49 months, 4 patients (14%) with scant cellularity and 127 patients (56%) with moderate cellularity progressed, while none of the patients with acellular mucin progressed. While the median progression-free survival (PFS) was not reached for patients with acellular mucin or scant cellularity (estimated 5-year PFS probability of 100 and 83%, respectively), patients with moderate cellularity demonstrated a median PFS of 32 months (estimated 5-year PFS probability of 27%). In a multivariate model, degree of disease cellularity, or lack thereof (acellular mucin), was an independent predictor of PFS but not overall survival.

CONCLUSIONS

Early disease progression is unlikely in patients with acellular mucin undergoing CRS-HIPEC, as opposed to a 14% recurrence rate with scant cellularity. Thorough pathologic assessment for cellularity, or lack thereof (acellular mucin), is vital for accurate prognostication of disease progression for patients with low-grade PMP undergoing CRS-HIPEC.

Institutional Experience with Ostomies Created During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS-HIPEC) is a complex procedure that often requires ostomy creation to protect high-risk anastomoses. This study aimed to evaluate the authors' institutional experience with CRS-HIPEC-associated ostomies, determine predictors of ostomy creation and reversal, and assess their impact on survival.

METHODS

The study analyzed clinicopathologic, perioperative, and oncologic data from a prospective database of 1435 CRS-HIPEC procedures for peritoneal metastases. The Kaplan-Meier method was used to estimate survival. Multivariate analyses identified associations with ostomy creation/reversal and survival.

RESULTS

Ostomies were created in 34% of the patients, most commonly loop ileostomies (82%). Loop ileostomies were reversed in the majority of patients (83%), whereas non-loop ileostomies were infrequently reversed (< 10% reversal rate). In a multivariate logistic regression model, intermediate or high tumor grade, colectomy/proctectomy, longer operative time, and lower Charlson comorbidity index were associated with loop ileostomy creation, whereas incomplete macroscopic resection, colorectal histology, and major postoperative complications were associated with non-reversal of loop ileostomy. In a multivariate Cox proportional hazards model, intermediate or high tumor grade and non-reversal of loop ileostomy were associated with worse overall survival.

CONCLUSIONS

Loop ileostomies were almost always reversed, whereas non-loop ileostomies were almost always permanent. Hospital readmissions for loop ileostomy-related complications were common. Therefore, formal outpatient protocols for prevention and management should be implemented. Non-reversal of loop ileostomy was associated with very poor survival.

Safety and efficacy of combined resection of colorectal peritoneal and liver metastases

BACKGROUND

To determine if a select subgroup of patients with combined liver and peritoneal colorectal metastases would derive oncologic benefit from surgical resection as a component of multimodality treatment.

MATERIALS AND METHODS

We retrospectively compared 32 patients with combined colorectal peritoneal and liver metastases (CRLM) and 173 patients with peritoneal metastases only (CRPM) undergoing cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (CRS-HIPEC). Kaplan-Meier survival curves and multivariate Cox-regression models identified prognostic factors affecting survival.

RESULTS

Major postoperative complications (Clavien-Dindo grades 3-5) occurred in 32% (CRLM) and 17% (CRPM) of patients (P = 0.08). After an estimated median follow-up from surgery of 57 mo, propensity score-adjusted median progression-free survival was 5.1 mo (CRLM) and 7.6 mo (CRPM), whereas median overall survival was 13 mo (CRLM) and 21 mo (CRPM). Multivariate Cox-regression analysis of the CRLM group identified number of liver metastases to be the only independent predictor of poor survival (hazard ratio: 2.3, P = 0.03), with a dramatic decrease in survival in patients with more than three liver metastases.

CONCLUSIONS

Simultaneous resection of colorectal liver metastases at the time of cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion for peritoneal metastases may be associated with worse survival, especially in patients with more than three liver metastases.

Hyperthermic intraperitoneal chemoperfusion as a component of multimodality therapy for ovarian and primary peritoneal cancer

BACKGROUND AND OBJECTIVES

The role of hyperthermic intraperitoneal chemoperfusion (HIPEC) in the multimodality treatment of ovarian peritoneal metastases (OPM) and primary peritoneal cancer (PPC) remains controversial. We hypothesized that cytoreductive surgery (CRS) and HIPEC would provide meaningful survival benefit without excessive morbidity.

METHODS

We reviewed clinicopathologic and perioperative data following 96 CRS-HIPEC procedures for primary or recurrent OPM and PPC. Kaplan-Meier survival curves and multivariate Cox-regression models identified prognostic factors affecting oncologic outcomes.

RESULTS

CRS-HIPEC was mostly performed for recurrent disease (56.3%) and high-grade serous carcinoma (72.9%). Platinum-based systemic chemotherapy was administered to 89.5% of patients, with 75.5% having platinum-sensitive disease at CRS-HIPEC. Complete macroscopic resection was achieved in 70.8% of patients. Clavien-Dindo grade 3/4 morbidity occurred in 23.4% of patients; three patients died within 60-days postoperatively. Median overall survival from diagnosis of peritoneal metastases and CRS-HIPEC was 78 and 38 months, respectively. Completeness of cytoreduction, pathologic subtype, and 30-day morbidity were independent predictors of survival in multiple regression analysis.

CONCLUSIONS

Our study demonstrates promising survival data and supports the role of HIPEC in the multimodality treatment algorithm for primary or recurrent OPM and PPC. However definite indications and timing of HIPEC need to be clarified by prospective studies.

Curative Surgical Resection as a Component of Multimodality Therapy for Peritoneal Metastases from Goblet Cell Carcinoids

BACKGROUND

The impact of histopathologic features on oncologic outcomes for patients with peritoneal metastases from goblet cell carcinoid (GCC) undergoing multimodality therapy, including cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (CRS-HIPEC), is unknown.

METHODS

This study prospectively analyzed 43 patients with GCC undergoing CRS-HIPEC between 2005 and 2013. Pathology slides were re-reviewed to classify GCC into histologic subtypes according to the Tang classification. Kaplan-Meier survival curves and multivariate Cox-regression models identified prognostic factors affecting oncologic outcomes.

RESULTS

The 43 patients in this study underwent 50 CRS-HIPEC procedures for peritoneal metastases from GCC, and the majority received neoadjuvant and/or adjuvant systemic chemotherapy. The GCC demonstrated an aggressive phenotype with frequent lymph node and peritoneal metastases without systemic dissemination. The majority of the patients had Tang B GCC. The estimated median overall survival times after surgery for the patients with Tang A, B, and C GCC were respectively 59, 22, and 13 months. In a multivariate Cox-regression analysis, poor survival was associated with patients who had Tang B or C GCC, those undergoing incomplete macroscopic resection, and those with symptoms at the time of CRS-HIPEC. The patients with Tang A GCC demonstrated oncologic outcomes similar to those with intermediate-grade (American Joint Committee on Cancer [AJCC] grade 2) disseminated mucinous appendiceal neoplasms, whereas the patients with Tang B and C GCC demonstrated survival rates similar to or worse than those with high-grade (AJCC grade 3) disseminated mucinous appendiceal neoplasms.

CONCLUSIONS

Tang classification is an independent prognostic factor for poor survival after multimodality therapy for GCC. Patients with Tang C GCC demonstrate limited survival and are not ideal candidates for a surgical approach.

Depressive Symptoms in Patients Scheduled for Hyperthermic Intraperitoneal Chemotherapy With Cytoreductive Surgery: Prospective Associations With Morbidity and Mortality

PURPOSE

The current study examined prospective relationships between preoperative depressive symptoms and short-term (30-day morbidity and readmission) and long-term (overall survival) outcomes after hyperthermic intraperitoneal chemotherapy with cytoreductive surgery (HIPEC + CS).

METHODS

Ninety-eight patients scheduled for HIPEC + CS completed the Center for Epidemiologic Studies-Depression (CES-D) scale before surgery. Demographic and disease-specific factors and information about morbidity and readmission within 30 days after discharge were gathered from medical records. Survival was measured from date of surgery to death.

RESULTS

Twenty-eight percent of patients had CES-D scores indicative of clinically significant depressive symptoms. Thirty-day morbidity occurred in 31.9% of patients and readmission in 22.2%. At the time of analysis (median follow-up of 49 months), 71.6% of patients were deceased, with median survival time of 11 months for those who died. After adjusting for relevant preoperative demographic and disease-specific factors, depressive symptoms were associated with greater odds of 30-day morbidity (n = 68; odds ratio, 5.50; 95% CI, 1.23 to 24.73; P = .03) and greater likelihood of 30-day readmission (n = 72; odds ratio, 5.92; 95% CI, 1.27 to 27.64; P = .02). Depressive symptoms were associated with shorter survival after adjustment for preoperative demographic and disease-specific factors (n = 87; hazard ratio, 1.88; 95% CI, 1.07 to 3.31; P = .03). This association was no longer significant when intraoperative/postoperative prognostic variables were added to the statistical model (n = 87; hazard ratio, 1.31; 95% CI, 0.72 to 2.37; P = .37).

CONCLUSION

Patients with clinically significant levels of preoperative depressive symptoms are at risk for poor clinical outcomes after HIPEC + CS, including greater risk of 30-day morbidity and readmission. Further research is warranted to determine biobehavioral mechanisms and examine whether effective interventions targeting preoperative depressive symptoms can reduce postoperative risk in this patient population.

Effect of a concomitant urologic procedure on outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

BACKGROUND AND OBJECTIVES

To evaluate whether urologic procedures during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) are associated with adverse postoperative outcomes.

METHODS

We identified patients who underwent CRS-HIPEC at our institution from 2001 to 2012 and compared outcomes between operations that did and did not include a urologic procedure.

RESULTS

A total of 938 CRS-HIPEC procedures were performed, 71 of which included a urologic intervention. Urologic interventions were associated with longer operative times (547 vs. 459 min, P < 0.001) and greater length of stay (15 vs. 12 days, P = 0.003). Major complications (Clavien III and IV) were more common in the urologic group (31% vs. 20%, P = 0.028). On multivariable analysis, urologic procedures were associated with a low anterior resection (OR: 2.25, 95%CI 1.07-4.74, P = 0.033) and a greater number of enteric anastomoses (OR: 1.83, 95%CI 1.31-2.56, P < 0.001). At a median follow up of 17 months (IQR 5.6-35 months), addition of a urologic procedure did not significantly impact overall survival for appendiceal or colorectal cancers.

CONCLUSION

Urologic surgery at the time of CRS-HIPEC is associated with longer operative times, length of stay and increased risk of major complications, but not with decreased overall survival. J. Surg. Oncol. 2016;113:218-222. © 2016 Wiley Periodicals, Inc.

Histologic and Immunohistochemical Alterations Associated with Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) are used to treat peritoneal carcinomatosis from a variety of primary tumor sites. Little is known about the in vivo effects of CRS and HIPEC.

METHODS

We examined tumor and non-neoplastic peritoneal tissue samples from 38 patients undergoing CRS and HIPEC for appendiceal or colorectal carcinomatosis, using conventional histologic analysis and immunohistochemical analysis for markers of early DNA damage (phosphorylated H2AX, γH2AX) and early necrosis (extracellular HMGB1). Findings were correlated with clinicopathologic features and oncologic outcome.

RESULTS

Histologic findings corresponding with CRS and HIPEC included extensive submesothelial inflammatory infiltrate, endothelial activation, mesothelial karyolysis and surface fibrin deposition. Endothelial activation in submesothelial vessels exhibited high specificity for samples obtained following HIPEC relative to samples obtained following CRS but prior to HIPEC. Mesothelial nuclear γH2AX staining and submesothelial extracellular HMGB1 staining increased progressively following CRS and HIPEC, consistent with DNA damage and necrosis. No significant increase in tumor staining for markers was seen with CRS or HIPEC. Submesothelial HMGB1 staining was associated with increased progression-free survival on univariate analysis.

CONCLUSIONS

The immediate histologic effects of CRS and HIPEC are defined and provide evidence that DNA damage and early steps of necrosis are underway in mesothelial tissues at the conclusion of the procedure. Further research will be necessary to investigate the impact of these findings on long-term oncologic outcome, and may provide insight into the downstream effects of CRS and HIPEC that could facilitate refinement of regional therapeutic regimens for carcinomatosis.

Preoperative inflammatory biomarkers and neurovegetative symptoms in peritoneal carcinomatosis patients

BACKGROUND

Inflammation plays a central role in peritoneal carcinomatosis (PC) etiology and progression, and circulating levels of inflammatory biomarkers prior to surgery predict progression-free and overall survival in PC patients. Depression and fatigue are prevalent among PC patients, and experimental research shows that these symptoms may be mediated by proinflammatory cytokines. As yet unstudied is the possibility that the heightened levels of inflammatory markers in PC patients may contribute to their experience of common neurovegetative symptoms.

METHODS

Validated self-report measures of fatigue, depressive symptoms, and quality of life were administered to 64 patients scheduled to undergo aggressive surgical treatment for PC. Serum samples were collected the morning of surgery, and ELISAs were conducted to quantify circulating IL-6, CRP, and TNF-α levels.

RESULTS

Consistent with hypotheses, higher IL-6 levels were associated with more severe fatigue (β=-.39, p<.01) and neurovegetative symptoms of depression (β=.30, p<.05). IL-6 was also related to poorer physical quality of life (β=-.28, p<.05). CRP showed similar significant relationships with fatigue and physical quality of life. Inflammatory biomarkers were not significantly related to emotional symptoms of depression or to emotional or social functioning aspects of quality of life, and TNF-α levels were not related to patient-reported measures.

CONCLUSION

Preoperative inflammatory activity may contribute to patients' experiences of fatigue and neurovegetative depressive symptoms as well as impaired quality of life. These biological mechanisms warrant consideration in the clinical management of neurovegetative symptoms in PC patients.

A comparative analysis of postoperative pancreatic fistulas after surgery with and without hyperthermic intraperitoneal chemoperfusion

BACKGROUND

Postoperative pancreatic fistulas (POPFs) are potentially morbid complications that often require therapeutic interventions. Distal pancreatectomy performed during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) puts patients at risk for POPF. The authors hypothesized that POPFs are more severe after CRS/HIPEC than after pancreatectomy alone.

METHODS

Clinicopathologic and perioperative details, including POPF by International Study Group of Pancreatic Fistula criteria (ISGPF), and oncologic outcomes for patients undergoing distal pancreatectomy during CRS/HIPEC for peritoneal carcinomatosis of appendiceal (n = 31) or colorectal (n = 23) origin (HIPEC group) were compared with those for patients undergoing minimally invasive or open distal pancreatectomy without HIPEC (n = 66) for locally resectable pancreatic adenocarcinoma (non-HIPEC group).

RESULTS

The incidence of POPF was similar between the HIPEC and non-HIPEC groups (26 %). The severity of POPF according to the ISGPF criteria was significantly worse in the HIPEC group. The HIPEC patients had 13 grade B fistulas and 1 grade C fistula compared with 12 grade A fistulas and 4 grade B fistulas in the non-HIPEC group. The HIPEC patients with POPF did not differ in the extent of their CRS, peritoneal cancer index, length of hospital stay, or other postoperative complications from the the HIPEC patients without POPF. The HIPEC patients with colorectal carcinomatosis who experienced POPF had higher disease recurrence in the first year after CRS/HIPEC than those without POPF.

CONCLUSION

The findings showed that POPFs are more severe when distal pancreatectomy is combined with CRS/HIPEC. Moreover, selective use of distal pancreatectomy is important during CRS/HIPEC because POPFs may increase early disease recurrence for patients with colorectal carcinomatosis.

Malignant peritoneal mesothelioma: prognostic factors and oncologic outcome analysis

BACKGROUND

Most patients with malignant peritoneal mesothelioma (MPM) present with late-stage, unresectable disease that responds poorly to systemic chemotherapy while, at the same time, effective targeted therapies are lacking. We assessed the efficacy of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) in MPM.

METHODS

We prospectively analyzed 65 patients with MPM undergoing CRS/HIPEC between 2001 and 2010. Kaplan-Meier survival curves and multivariate Cox-regression models identified prognostic factors affecting oncologic outcomes.

RESULTS

Adequate CRS was achieved in 56 patients (CC-0 = 35; CC-1 = 21), and median simplified peritoneal cancer index (SPCI) was 12. Pathologic assessment revealed predominantly epithelioid histology (81 %) and biphasic histology (8 %), while lymph node involvement was uncommon (8 %). Major postoperative morbidity (grade III/IV) occurred in 23 patients (35 %), and 60-day mortality rate was 6 %. With median follow-up of 37 months, median overall survival was 46.2 months, with 1-, 2-, and 5-year overall survival probability of 77, 57, and 39 %, respectively. Median progression-free survival was 13.9 months, with 1-, 2-, and 5-year disease failure probability of 47, 68, and 83 %, respectively. In a multivariate Cox-regression model, age at surgery, SPCI >15, incomplete cytoreduction (CC-2/3), aggressive histology (epithelioid, biphasic), and postoperative sepsis were joint significant predictors of poor survival (chi square = 42.8; p = 0.00001), while age at surgery, SPCI >15, incomplete cytoreduction (CC-2/3), and aggressive histology (epithelioid, biphasic) were joint significant predictors of disease progression (Chi square = 30.6; p = 0.00001).

CONCLUSIONS

Tumor histology, disease burden, and the ability to achieve adequate surgical cytoreduction are essential prognostic factors in MPM patients undergoing CRS/HIPEC.

Impact of aggressive histology and location of primary tumor on the efficacy of surgical therapy for peritoneal carcinomatosis of colorectal origin

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) for peritoneal carcinomatosis (PC) of colorectal origin increases survival (OS) compared to systemic chemotherapy alone. Signet ring histology demonstrates aggressive behavior with poor survival. We sought to determine whether CRS/HIPEC increases survival in this subset of patients.

METHODS

We reviewed 67 patients with PC of appendiceal (AP, n = 37) or colorectal origin (CRC, n = 30) with signet cell histology from a prospective database between May 2001 and August 2011. Survival analysis and multivariate Cox regression were used to determine prognostic factors for survival.

RESULTS

Complete CRS (CC-0/1) was achieved in 77 % (CRC) and 73 % (AP) of patients. Progression-free survival (PFS) and OS were 9 and 12 months in CRC and 12 and 21 months in AP patients. In the CRC group, univariate predictors of poor survival included female gender, age, American Society of Anesthesiologists score, preoperative albumin, completeness of cytoreduction, and morbidity. In a multivariate Cox regression model, incomplete cytoreduction (CC-2/3) and female gender were joint significant predictors of poor survival. In the AP group, significant univariate predictors of poor survival included higher EBL and PCI score. In a multivariate Cox regression model, blood loss of >500 ml and a body mass index of <25 kg/m(2) were joint significant predictors of poor survival.

CONCLUSIONS

AP signet cell tumors demonstrate a more favorable outcome than CRC signet cell tumors after CRC/HIPEC for carcinomatosis, suggesting an underlying difference in biology. CRS/HIPEC does not confer survival benefit in colorectal signet ring carcinomatosis unless complete cytoreduction can be achieved, whereas appendiceal signet ring carcinomatosis may benefit, regardless of resectability.

Aggressive locoregional surgical therapy for gastric peritoneal carcinomatosis

BACKGROUND

Peritoneal carcinomatosis from gastric cancer (GPC) responds poorly to systemic chemotherapy. Limited published data demonstrate improved outcomes after aggressive locoregional therapies. We assessed the efficacy of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) in GPC.

METHODS

We prospectively analyzed 23 patients with GPC undergoing CRS/HIPEC between 2001 and 2010. Kaplan-Meier survival curves and multivariate Cox regression models identified prognostic factors affecting oncologic outcomes.

RESULTS

CRS/HIPEC was performed for synchronous GPC in 20 patients and metachronous GPC in 3 patients. Adequate CRS was achieved in 22 patients (CC-0 = 17; CC-1 = 5) and median peritoneal cancer index was 10.5. Most patients received preoperative chemotherapy (83 %) and total gastrectomy (78 %). Pathology revealed diffuse histology (65 %), signet cells (65 %) and LN involvement (64 %). Major postoperative morbidity occurred in 12 patients, with 1 in-hospital mortality at postoperative day 66. With median follow-up of 52 months, median overall survival (OS) was 9.5 months (95 % confidence interval 4.7-17.3), with 1- and 3- year OS rates of 50 and 18 %. Median progression-free survival (PFS) was 6.8 months (95 % confidence interval 3.9-14.6). In a multivariate Cox regression model, male gender [hazard ratio (HR) 6.3], LN involvement (HR 1.2), residual tumor nodules (HR 2.4), and >2 anastomoses (HR 2.8) were joint significant predictors of poor OS (χ (2) = 18.2, p = 0.001), while signet cells (HR 8.9), anastomoses >2 (HR 5.5), and male gender (HR 2.4) were joint significant predictors of poor progression (χ (2) = 16.3, p = 0.001).

CONCLUSIONS

Aggressive CRS/HIPEC for GPC may confer a survival benefit in select patients with limited lymph node involvement and completely resectable disease requiring less extensive visceral resections.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Significance of serum tumor marker levels in peritoneal carcinomatosis of appendiceal origin

BACKGROUND

The significance of tumor markers in patients with appendiceal carcinomatosis is poorly defined. We determined preoperative and postoperative tumor marker levels in patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemoperfusion (HIPEC) and examined their association with clinicopathologic features and survival.

METHODS

A total of 176 patients undergoing attempted CRS/HIPEC for appendiceal carcinomatosis had at least 1 tumor marker measured. Marker levels were correlated with tumor characteristics and oncologic outcomes. Kaplan-Meier curves and multivariate Cox regression models were used to identify prognostic factors affecting progression and survival.

RESULTS

At least 1 marker was elevated prior to CRS/HIPEC in 70 % of patients (CEA, 54.1 %; CA19-9, 47.7 %; CA-125, 47.2 %). Among patients with elevated preoperative marker levels, normalization occurred postoperatively in 79.4 % for CEA, 92.3 % for CA19-9, and 60 % for CA-125. Absolute preoperative tumor marker levels correlated with peritoneal carcinomatosis index (PCI) (p < .0002), and the number of elevated markers was associated with PCI and progression-free survival (PFS). Elevated postoperative CEA level was associated with decreased PFS (median, 13 vs 36 months, p = .0008). On multivariate Cox regression analysis, elevated preoperative CA19-9 was associated with shorter PFS (hazard ratio [HR] 2.9, 95 % confidence interval [95 % CI] 1.5-5.3, p = .0008), whereas elevated CA-125 was associated with shorter overall survival (HR 2.6, 95 % CI 1.3-5.4, p = .01).

CONCLUSIONS

Most patients with appendiceal carcinomatosis will have at least 1 elevated tumor marker and will normalize following CRS/HIPEC, allowing for ongoing surveillance. CA19-9 is a promising biomarker for early progression following CRS/HIPEC, whereas CA-125 is associated with shorter survival.

Aggressive management of peritoneal carcinomatosis from mucinous appendiceal neoplasms

BACKGROUND

Peritoneal carcinomatosis (PC) in the setting of mucinous appendiceal neoplasms is characterized by the intraperitoneal accumulation of mucinous ascites and mucin-secreting epithelial cells that leads to progressive compression of intra-abdominal organs, morbidity, and eventual death. We assessed postoperative and oncologic outcomes after aggressive surgical management by experienced surgeons.

METHODS

We analyzed clinicopathologic, perioperative, and oncologic outcome data in 282 patients with PC from appendiceal adenocarcinomas between 2001 and 2010 from a prospective database. Kaplan–Meier survival curves and multivariate Cox-regression models were used to identify prognostic factors affecting oncologic outcomes.

RESULTS

Adequate cytoreduction was achieved in 82% of patients (completeness of cytoreduction score (CC)-0: 49%; CC-1: 33%). Median simplified peritoneal cancer index (SPCI), operative time, and estimated blood loss were 14 (range, 0–21), 483.5 min (range, 46–1,402), and 800 ml (range, 0–14,000), respectively. Pathology assessment demonstrated high-grade tumors in 36% of patients and lymph node involvement in 23% of patients. Major postoperative morbidity occurred in 70 (25%) patients. Median overall survival was 6.72 years (95% confidence interval (CI), 4.17 years not reached), with 5 year overall survival probability of 52.7% (95% CI, 42.4, 62%). In a multivariate Cox-regression model, tumor grade, age, preoperative SPCI and chemo-naïve status at surgery were joint significant predictors of overall survival. Tumor grade, postoperative CC-score, prior chemotherapy, and preoperative SPCI were joint significant predictors of time to progression.

CONCLUSIONS

Aggressive management of PC from mucinous appendiceal neoplasms, by experienced surgeons, to achieve complete cytoreduction provides long-term survival with low major morbidity.

Influence of blood neutrophil to lymphocyte ratio on oncologic outcomes in peritoneal carcinomatosis of appendiceal origin

e14184

Background: The Neutrophil to lymphocyte ratio (NLR), a marker of systemic inflammatory response, is associated with prognosis in various cancers. The aim of this study is to evaluate the association of pre-operative NLR with oncologic outcomes in patients with appendiceal carcinomatosis. Methods: Clinico-pathological data were obtained from a prospectively maintained database of patients with appendiceal carcinomatosis who underwent cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemoperfusion (HIPEC) between 2001 and 2010. Pre-operative absolute neutrophil and lymphocyte counts were used to compute NLR, with elevated NLR defined a priori as >5. Logistic regression modeling and Kaplan-Meier analyses were performed on the available data. Results: 195 patients, with a median age of 54.5 years, underwent CRS and HIPEC. The median follow up time was 1.96 years. There were 41 patients (21%) who had elevated NLR preoperatively. Factors associated with overall survival (OS) were grade (p=0.01), simplified peritoneal cancer index (SPCI) (p=0.013), and age (p=0.02). In patients who did not undergo splenectomy at the time of CRS, elevated NLR, lymph node involvement, SPCI, age and pre-operative albumin were statistically significant predictors of OS on multivariable analysis. None of these factors were significant in patients who underwent splenectomy at the time of CRS. The 5-year overall survival was 57% vs. 31% in patients with NLR<5 compared to NLR>5 respectively (p<0.0001). Time to progression was 30 months compared to 14 months in patients with NLR<5 vs. >5 (p=0.001). Strikingly, the 5-year OS in patients with NLR<5 with or without splenectomy was 63% and 50% compared to patients with NLR>5 with or without splenectomy 37.5% vs. 23%, respectively (p=0.0001). Conclusions: In patients with appendiceal carcinomatosis, pre-operative NLR is a potential systemic inflammatory marker that independently predicts oncologic outcomes. The impact of NLR appears to be influenced by the performance of splenectomy at the time of CRS. Further studies will be required to prospectively validate this systemic inflammatory marker and its interaction with splenectomy.

Bisphosphonate-associated osteonecrosis of the jaw: does it occur in children?

BACKGROUND

Bisphosphonate use in adult patients has been linked to osteonecrosis of the jaw (ONJ). This complication has not been systematically assessed in a paediatric population receiving bisphosphonates.

OBJECTIVE

To assess our cohort of paediatric patients treated with intravenous bisphosphonate for occurrence of ONJ.

DESIGN

Observational study at a tertiary children's hospital.

PATIENTS

A total of 42 paediatric patients with osteoporosis who received bisphosphonate infusions for a mean of 6.5 years (SD 2.7 years) were assessed clinically and radiographically for possible ONJ. Among 42, 37 patients had received disodium pamidronate 1 mg/kg/dose at a mean cumulative dose of 19.8 mg/kg and zoledronic acid (ZA) 0.05 mg/kg/dose at a mean cumulative dose of 0.49 mg/kg; four had received ZA and one received pamidronate alone. Invasive dental treatment during bisphosphonate treatment, a known risk factor for osteonecrosis, was specifically assessed.

RESULTS

In all patients assessed, including 11 who had invasive dental treatment, there were no cases of osteonecrosis.

CONCLUSION

ONJ has so far not been demonstrated in this patient group.

Adding casein phosphopeptide-amorphous calcium phosphate to sports drinks to eliminate in vitro erosion

PURPOSE

Enamel erosion can occur with frequent consumption of sports drinks. The purpose of this study was to determine a minimal concentration of casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP) which when added to a sports drink would eliminate such erosion in vitro.

METHODS

Human enamel specimens were immersed in: (1) the sports drink Powerade; (2) Poweradeplus 4 concentrations of CPP-ACP (0.063%, 0.09%, 0.125%, 0.25%); or (3) double deionized water. Windows of test and control enamel were profiled, and the enamel surface characteristics were examined under scanning electron microscopy (SEM).

RESULTS

The pH of test solutions increased and the titratable acidity decreased with increasing CPP-ACP concentrations. Erosive step lesions occurred in specimens immersed in Powerade (mean depth=38.70kA +/- 5.60), which were eliminated by the addition of CPP-ACP to Powerade at all test concentrations except 0.063% CPP-ACP. Microscopic surface irregularities on test enamel were observed, apparent as adherent granules or globules. These may represent redeposited mineral phases following mobilization of calcium and phosphate from CPP-ACP. Tasters in a taste panel could not distinguish Powerade from Powerade plus 0.125% CPP-ACP.

CONCLUSIONS

Adding casein phosphopeptide-stabilized amorphous calcium phosphate to the sports drink Powerade significantly reduced the beverage's erosivity without affecting the product's taste.

Effect of various infection-control methods for light-cure units on the cure of composite resins

This study (1) compared the curing-light intensity with various barrier infection-control methods used to prevent cross contamination, (2) compared the Knoop hardness value of cured composite resin when various barrier control methods were used, and (3) correlated the hardness of the composite resin with the light-intensity output when different infection-control methods were used. The light-cure unit tips were covered with barriers, such as cellophane wrap, plastic gloves, Steri-shields, and finger cots. The control group had no barrier. Composite resins were then cured for each of the five groups, and their Knoop hardness values recorded. The results showed that there was significant statistical difference in the light-intensity output among the five groups. However, there was no significant statistical difference in the Knoop hardness values among any of the groups. There was also no correlation between the Knoop hardness value of the composite resin with the light-intensity output and the different infection-control methods. Therefore, any of the five infection-control methods could be used as barriers for preventing cross-contamination of the light-cure unit tip, for the light-intensity output for all five groups exceeded the recommended value of 300 W/m2. However, to allow a greater margin of error in clinical situations, the authors recommend that the plastic glove or the cellophane wrap be used to wrap the light-cure tip, since these barriers allowed the highest light-intensity output.