Perioperative outcomes and platinum resistant recurrence in patients undergoing systematic, protocol-based, total parietal peritonectomy during interval cytoreductive surgery for advanced ovarian cancer: results of the TORPEDO study

OBJECTIVE

The TORPEDO (CTRI/2018/12/016789) is the single-arm, prospective, interventional study evaluating the role of a total parietal peritonectomy (TPP) in patients undergoing interval cytoreductive surgery (iCRS). In this manuscript, we report the perioperative outcomes and platinum resistant recurrence (PRR) in 218 patients enrolled in the study.

METHODS

A TPP was performed in all patients undergoing iCRS irrespective of the residual disease extent. hyperthermic intraperitoneal chemotherapy (HIPEC) was performed as per the clinician's discretion with 75 mg/m² of cisplatin. Maintenance therapy was also used at the discretion of the treating clinicians.

RESULTS

From 9th December 2018 to 31st July 2022 (recruitment complete), 218 patients were enrolled at 4 medical centers in India. The median surgical peritoneal cancer index was 14 and a complete gross resection was achieved in 95.8%. HIPEC was performed in 130 (59.6%) patients. The 90-day major morbidity was 17.4% and 2.7% patients died within 90 days of surgery. Adjuvant chemotherapy was delayed beyond 6 weeks in 7.3%. At a median follow-up of 19 months (95% confidence interval [CI]=15.9-35 months), 101 (46.3%) recurrences and 19 (8.7%) deaths had occurred. The median progression-free survival was 22 months (95% CI=17-35 months) and the median overall survival (OS) not reached. Platinum resistant recurrence was observed in 6.4%. The projected 3-year OS was 81.5% and in 80 patients treated before may 2020, it was 77.5%.

CONCLUSION

The morbidity and mortality of TPP with or without HIPEC performed during iCRS is acceptable. The incidence was of PRR is low. Early survival results are encouraging and warrant conduction of a randomized controlled trial comparing TPP with conventional surgery.

A Rare Case of Muco-epidermoid Carcinoma Parotid in a 6-Year-Old Girl and Review of Literature

Mucoepidermoid carcinoma (MEC) is the commonest malignant salivary gland tumor affecting the parotid gland in adults and children. In children and adolescents, there is a peak incidence in the second decade. We came across a 6-year-old girl with intermediate-grade MEC parotid gland, which is very unusual below 10 years of age. A global literature search revealed only 3 other similar cases in children below 10 years of age. She presented with a 2-year history of left parotid gradually increasing hard swelling involving the overlying skin and underlying sternocleidomastoid muscle which was confirmed on a contrast-enhanced computed tomography (CECT) scan of the face and neck as well as a core biopsy to be a MEC left parotid. The patient underwent a left radical parotidectomy sacrificing the main trunk of the facial nerve while carefully preserving its distal branches along with a left selective neck dissection (SND) followed by facial reanimation using primary neurorrhaphy. Histopathology confirmed an intermediate-grade MEC pT4aN2bMx with close deep lobe margin warranting adjuvant radiotherapy. Albeit very rare, salivary gland neoplasms may occur in children in the first decade of life. Appropriate planning regarding oncological resection with/without facial reanimation, appropriate rehabilitation followed by adjuvant treatment based on histopathology ensures a good prognosis.

Cytoreductive Surgery With or Without HIPEC in the Management of Peritoneal Dissemination from Rare Histological Subtypes of Ovarian Cancer - a Retrospective Study by INDEPSO

The aim of this study was to evaluate the potential role of optimal cytoreductive surgery with or without HIPEC in the management of peritoneal dissemination from rare histological subtypes of ovarian cancer and to report the prognostic factors affecting survival. In this retrospective multicentric study, all patients with diagnosis of locally advanced ca ovary with histology other than high-grade serous carcinoma and those having undergone cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy for the same were included. Factors affecting survival were evaluated in addition to studying the clinicopathological features. In the period from January 2013 to December 2021, 101 consecutive patients of ovarian cancer with rare histology underwent cytoreductive surgery with or without HIPEC. The median OS was not reached (NR), and the median PFS was 60 months. On evaluation of factors affecting overall survival (OS) and progression-free survival (PFS), PCI > 15 was associated with not only a decreased PFS (p = 0.019) but also a decreased OS (P = 0.019) on univariate and multivariate analysis. With respect to histology, the best OS and PFS were seen with granulosa cell tumor, mucinous tumors for which median OS and median PFS were NR respectively. Cytoreductive surgery can be performed with an acceptable morbidity in patients with peritoneal dissemination from ovarian tumors of rare histology. The role of HIPEC and impact of other prognostic factors on the treatment and survival outcome need further evaluation in larger series of patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01640-5.

A Descriptive Analysis of Patients Undergoing Cytoreductive Surgery for the First Peritoneal Recurrence from Adult Granulosa Cell Tumours: Focus on Disease Distribution, Morphology of Peritoneal Disease and the Role of HIPEC - a Retrospective Study by INDEPSO

The aim of the present study was to report the clinical outcome and factors affecting survival in patients with first recurrence of AGC treated with cytoreductive surgery with or without HIPEC. The second aim was to study the disease distribution in the peritoneal cavity according to the peritoneal carcinomatosis index (PCI) and the morphology of peritoneal deposits. In this retrospective multicentric study, all patients of adult granulosa cell tumor with peritoneal recurrence were treated with CRS with or without HIPEC. Relevant clinical and demographic data were captured. Multivariable logistic regression was performed to evaluate the factors affecting recurrence after CRS ± HIPEC. Factors affecting survival and second recurrences were evaluated in addition to studying the disease distribution at first recurrence. In the period from January 2013 to December 2021, 30 consecutive patients of recurrent adult type granulosa cell tumor of the ovary undergoing CRS ± HIPEC were included in this study. The median follow-up duration was 55 months [12-96 months]. The median rPFS and rOS were both not reached. HIPEC (p = 0.015) was the only factor independently associated with a longer rPFS. CRS with or without HIPEC can be performed with an acceptable morbidity in patients with the first recurrence from adult granulosa cell tumours. The role of HIPEC, patterns of peritoneal spread and impact of other prognostic factors on the treatment outcome all need further evaluation in larger series of patients.

Long-Term Survival in Patients Treated by Cytoreductive Surgery with or Without HIPEC for Peritoneal Surface Malignancies-A report from the Indian HIPEC Registry

A previous report from the Indian HIPEC registry showed acceptable early survival and morbidity in patients undergoing cytoreductive surgery (CRS) + / - hyperthermic intraperitoneal chemotherapy (HIPEC). The goal of this retrospective study was to evaluate the long-term outcomes in these patients. Three hundred seventy-four patients treated from December 2010 to December 2016 and enrolled in the Indian HIPEC registry were included. All patients had completed 5 years from the date of surgery. The 1-, 3-, 5- and 7-year progression-free (PFS) and overall survival (OS) and factors affecting these were evaluated. The histology was epithelial ovarian cancer in 209 (46.5%), pseudomyxoma peritonei (PMP) in 65 (17.3%) and colorectal cancer in 46 (12.9%) patients. The peritoneal cancer index (PCI) was ≥ 15 in 160 (42.8%). A completeness of cytoreduction (CC) score of 0/1 resection was obtained in 83% (CC-0-65%; CC-1-18%). HIPEC was performed in 59.2%. At a median, follow-up of 77 months (6-120 months), 243 (64.9%) patients developed recurrence, and 236 (63%) died of any cause; 138 (36.9%) were lost to follow-up. The median OS was 56 months (95% CI 53.42-61.07), and the median PFS was 28 months (95% CI 37.5-44.4). The 1-, 3-, 5- and 7-year OS was 97.6%, 63%, 37.7% and 24% respectively. The 1-, 3-, 5- and 7-year PFS was 84.8%, 36.5%, 27.3% and 22% respectively. The use of HIPEC (p = 0.03) and PMP of appendiceal origin (p = 0.01) was independent predictors of a longer OS. CRS + / - /HIPEC may achieve long-term survival in patients with PM from different primary sites in the Indian scenario. More prospective studies are needed to confirm these findings and identify factors influencing long-term survival.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-023-01727-7.

Platinum resistant recurrence and early recurrence in a multi-centre cohort of patients undergoing interval cytoreductive surgery for advanced epithelial ovarian cancer

Background

Aggressive locoregional therapies like hyperthemic intraperitoneal chemotherapy(HIPEC) and total parietal peritonectomy(TPP) have been used to delay recurrence in patients with advanced ovarian cancer undergoing interval cytoreductive surgery(CRS). The aim of this retrospective study was to evaluate the incidence of platinum resistant recurrence (PRR) and early recurrence (ER)(recurrence within 6 months and 1 year of the last dose of platinum based therapy, respectively) in patients undergoing interval CRS. The secondary goal was to study impact of each of these therapies on PRR and ER.

Methods

One-hundred and fifty-three patients undergoing interval CRS from July 2018 to June 2020 were included. The surgical strategy was to perform a TPP in which the entire parietal peritoneum is resected irrespective of the disease extent or a selective parietal peritonectomy (SPP) in which only the peritoneum bearing visible residual disease is resected. The use of HIPEC was at the discretion of the treating oncologists.

Results

The median surgical PCI was 15 [range, 0-37]. A CC-0 resection was obtained in 119 (77.7%) and CC-1 in 29 (18.9%) patients. Eighty-one (53%) patients had a TPP and 72 (47%) had SPP. HIPEC was performed in 98(64%) patients. Bevacizumab maintenance was administered to 31(19.6%) patients. No patients received PARP inhibitors during first-line therapy. PRR was observed in 8(5.2%) patients and ER in 30(19.6%). The respective incidences of PRR and ER were 4.9% and 16% in the TPP group, 4.1% and 23.6% in the SPP group, 9% and 20% in the no-HIPEC group and 3% and 19.3% in the HIPEC groups. On multivariate analysis, CC-0(p=0.014) resection and HIPEC(p=0.030) were independent predictors of a low ER. All patients with PR and 70% with ER had peritoneal recurrence with or without extra-peritoneal sites of recurrence.

Conclusions

The incidence of PRR and ER in this cohort was low as compared to historical data. This low incidence could be attributed to the use of aggressive locoregional therapies like TPP and HIPEC. In future, studies should be conducted to confirm these findings and evaluate the potential additive benefit of TPP and HIPEC coupled together as well as their combination with maintenance therapies.

Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey

OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols have been questioned in patients undergoing cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies. This survey was performed to study clinicians' practice about ERAS in patients undergoing CRS-HIPEC.

METHODS

An online survey, comprising 76 questions on elements of prehabilitation (n=11), preoperative (n=8), intraoperative (n=16) and postoperative (n=32) management, was conducted. The respondents included surgeons, anesthesiologists, and critical care specialists.

RESULTS

The response rate was 66% (136/206 clinicians contacted). Ninety-one percent of respondents reported implementing ERAS practices. There was encouraging adherence to implement the prehabilitation (76-95%), preoperative (50-94%), and intraoperative (55-90%) ERAS practices. Mechanical bowel preparation was being used by 84.5%. Intra-abdominal drains usage was 94.7%, intercostal drains by 77.9% respondents. Nasogastric drainage was used by 84% of practitioners. The average hospital stay was 10 days as reported by 50% of respondents. A working protocol and ERAS checklist have been designed, based on the results of our study, following recent ERAS-CRS-HIPEC guidelines. This protocol will be prospectively validated.

CONCLUSIONS

Most respondents were implementing ERAS practices for patients undergoing CRS-HIPEC, though as an extrapolation of colorectal and gynecological guidelines. The adoption of postoperative practices was relatively low compared to other perioperative practices.

Greater-omentum lesion-score (GOLS) as a predictor of residual disease in different regions of the peritoneal cavity in patients undergoing interval cytoreductive surgery for advanced ovarian cancer and its potential clinical utility

BACKGROUND AND AIM

The greater omentum(GO) is a common site of residual disease in patients receiving neoadjuvant chemotherapy for advanced epithelial ovarian cancer. The presence of tumor in the GO could predict presence of disease in other peritoneal regions. The goal of this study was to perform a correlation between the greater-omentum lesion-score(GOLS) and presence of disease in different peritoneal regions and determine its potential utility in guiding interval cytoreductive surgery(CRS).

METHODS

This prospective study included 134 patients undergoing interval CRS from July 1, 2018 to June 30, 2020. Each region of Sugarbaker's Peritobneal Cancer Index(PCI) was given a lesion score(LS) from 0 to 3 according to the diameter of the largest tumor in the region. The GOLS was recorded separately from other structures in the region. Correlation between the GOLS and surgical and pathological LS in each region was performed.

RESULTS

As the GOLS increased, the incidence of disease(surgical LS) in other regions of the peritoneal cavity increased. Receiver operating characteristic(ROC) curves showed area under curve more than 80% for regions 1-2 and 7-8 indicating a high probability of disease in these regions in patients with GOLS 1-3. The positive predictive value(PPV) of preoperative imaging for GOLS was 95.7%. No cut-off of the GOLS could predict presence of disease on pathology with more than 70% accuracy.

CONCLUSIONS

Presence of disease in the GO warrants performing upper abdominal exploration and/or cytoreduction and interval CRS should be planned accordingly in these patients. Imaging has a high PPV in detecting disease in the GO.

Pattern of recurrence after interval cytoreductive surgery and HIPEC following neoadjuvant chemotherapy in primary advanced stage IIIC/IVA epithelial ovarian cancer

OBJECTIVE

The aim of this study was to evaluate the patterns of recurrence and factors affecting the same after interval cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in primary stage IIIC and IV A epithelial ovarian cancer.

METHODS

In this retrospective multicentric study, all patients with FIGO stages III-C and IV-A epithelial ovarian carcinoma were treated with CRS and HIPEC after receiving neoadjuvant chemotherapy. Relevant clinical and demographic data were captured. Multivariable logistic regression was performed to evaluate the factors affecting recurrence after CRS and HIPEC.

RESULTS

From January 2017 to Jan 2020, 97, consecutive patients of Stage IIIC/IVA epithelial ovarian cancer underwent interval cytoreductive surgery and HIPEC after receiving neoadjuvant chemotherapy. The median duration of follow up duration was 20 months [1-36months]. 21/97 (21.6%) patients presented with disease recurrence. Visceral recurrences involving the lungs, liver and brain were seen in 8/21 (38%) of cases and comprised the commonest sites. On multivariable analysis, nodal involvement (p = 0.05), selective peritonectomy (p = 0.001) and leaving behind residual disease <0.25 mm (CC1) (p = 0.01) was associated with increased risk of disease recurrence. Extent of peritonectomy (OS,p = 0.56, PFS p = 0.047, Log Rank test) and nodal positivity (OS, p = 0.13,PFS,p = 0.057, Log Rank test) were found to impact progression free survival but had no impact on overall survival.

CONCLUSION

There is a higher incidence of systemic recurrences in patients with Stage IIIC/IVA epithelial ovarian carcinoma after CRS and HIPEC. Extent of peritonectomy and nodal clearance impacts patterns of recurrence and progression free survival.

A comparison of outcomes following total and selective peritonectomy performed at the time of interval cytoreductive surgery for advanced serous epithelial ovarian, fallopian tube and primary peritoneal cancer - A study by INDEPSO

OBJECTIVES

To compare clinical outcomes following total and selective peritonectomy performed during interval cytoreductive surgery (CRS) for stage IIIC/IVA serous epithelial ovarian cancer.

METHODS

In this retrospective study, extent of peritonectomy was classified as total parietal peritonectomy (TPP) which comprised of removal of the entire parietal peritoneum and the greater and lesser omenta or selective parietal peritonectomy (SPP) that included 1/>1 of parietal peritonectomies performed to resect sites of residual disease. A comparison of patient and disease characteristics, morbidity, mortality and survival outcomes between the two groups was made.

RESULTS

From January 2013 to December 2017, 79 patients underwent CRS (TPP-30, SPP-49) with or without intraperitoneal chemotherapy (IPC). The median PCI was 14 for TPP and 8 for SPP. The 90-day grade 3-4 morbidity (23.3% for TPP, 14.2% for SPP, p = 0.58) the 90-day mortality was similar (p = 0.58). The median disease free survival (DFS) was 37 months for SPP and 33 months for TPP (p = 0.47) and median overall survival (OS) not reached for both. The 3-year OS was 95% for TPP and 70.8% for SPP (p = 0.06). The only independent predictor of OS was grade 3-4 morbidity (p = 0.01) and not TPP (p = 0.09). Microscopic residual disease was seen in 23.3% with normal looking peritoneum in TPP group.

CONCLUSIONS

TPP was not associated with increased morbidity compared to SPP. There was a trend towards a longer OS in the TPP group and the finding of residual disease in 'normal looking' peritoneum' warrants prospective evaluation of the benefit of TPP in this setting.

Distribution of residual disease in the peritoneum following neoadjuvant chemotherapy in advanced epithelial ovarian cancer and its potential therapeutic implications

INTRODUCTION

Residual disease in 'normal appearing' peritoneum is seen in nearly 30% of the patients following neoadjuvant chemotherapy (NACT) for advanced ovarian cancer. The goal was to study the sequence of response in different regions, the commonest sites of occult residual disease, its incidence in different peritoneal regions and the potential therapeutic implications of these.

METHODS

This was a prospective multi-centre study (July 2018-June 2019). Pathological evaluation of cytoreductive surgery specimens was performed according to a fixed protocol. Prevalence of residual disease in different regions was used to study patterns of response and distribution of residual disease.

RESULT

In 85 patients treated between July 2018 to June 2019, microscopic disease in 'normal appearing' peritoneal regions was seen in 22 (25.2%) and in normal peritoneum around tumor nodules in 30 (35.2%) patients. Regions 4 and 8 of Sugarbaker's PCI had the highest incidence of occult disease and regions 9 and 10 the lowest. The response to chemotherapy occurred in a similar manner in over 95%- the least common site of residual disease was the small bowel mesentery, followed by upper regions (regions 1-3), omentum and middle regions (regions 0, 4, 8), lower regions (regions 5-7) and lastly the ovaries.

CONCLUSIONS

During interval CRS, based on the disease mapping provided in this manuscript, regions that have a high probability of residual disease should be explored and dissected. Complete resection of involved the peritoneal region can completely address the occult disease. The role of resection of the entire region as well as 'normal appearing' parietal peritoneal regions should be prospectively evaluated.

Total Parietal Peritonectomy Can Be Performed with Acceptable Morbidity for Patients with Advanced Ovarian Cancer After Neoadjuvant Chemotherapy: Results From a Prospective Multi-centric Study

BACKGROUND

Total parietal peritonectomy (TPP) removes areas of "normal-appearing" parietal peritoneum bearing microscopic residual disease and has the potential to improve survival of patients undergoing interval cytoreductive surgery (CRS) for advanced serous epithelial ovarian cancer. This report presents the morbidity outcomes for the first 50 patients enrolled in TORPEDO (CTRI/2018/12/016789), a prospective study.

METHODS

All the patients underwent a TPP during interval CRS. A surgical protocol that includes a description of the boundaries for each of the five peritonectomies was followed. The common toxicology criteria for adverse events (CTCAE) classification was used to record 90-day morbidity and mortality.

RESULTS

The median Peritoneal Cancer Index (PCI) for 50 patients was 15 (range, 5-37). A complete cytoreduction (CC-0 resection) was obtained in 80%, a CC-1 resection in 16%. A bowel resection was performed in 70% of the patients. Grade 3 or 4 complications were seen in 11 patients (22%), and one patient died within 90 days after surgery due to intraperitoneal hemorrhage. The most common complications were postoperative fluid collection requiring aspiration (n = 5), intraperitoneal hemorrhage (n = 2), abdominal wound dehiscence (n = 2), pseudo-obstruction (n = 1), urinary sepsis (n = 2), and ileostomy-related complications (n = 2). No bowel fistulas or anastomotic leaks occurred. Microscopic disease in 'normal appearing' peritoneum adjacent to tumor nodules was observed in 46% of the patients, and in regions given a lesion score of 0 in 34%. The parietal peritoneal regions (0-8) had a higher incidence of residual disease (p < 0.001) and occult disease (p < 0.001).

CONCLUSIONS

During interval CRS, TPP can be performed with acceptable morbidity and mortality. The pathologic findings further support this therapeutic rationale. Survival outcomes should determine the future role of such a procedure in routine clinical practice.

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.

Target region resection in patients undergoing cytoreductive surgery for peritoneal metastases-is it necessary in absence of visible disease?

BACKGROUND

The aim was to study the patterns of target region (greater omentum, lesser omentum, falciform and umbilical round ligament) involvement in patients undergoing cytoreductive surgery (CRS) from various primary tumors, factors affecting involvement and implications on surgical practice.

METHODS

All patients undergoing CRS from July 2018 to December 2018 were included in this prospective study. The incidence of target region involvement in presence and absence of visible disease and the impact of primary tumor site, PCI and other variables on target region involvement was evaluated.

RESULTS

In 191 patients, greater omentum was involved in over 15% of patients irrespective of the primary tumor type and in 15.7% in absence of visible disease. 75% of these had PCI <20. The involvement of the other three target regions was higher than 20% in ovarian cancer, appendiceal tumors and peritoneal mesothelioma. Involvement of these 3 regions was associated with a higher PCI (p < 0.001 for all) and omental involvement (p < 0.001for all). 2.1% of colorectal cancer patients had umbilical round ligament involvement, 4.2% had falciform ligament involvement and none had lesser omentum involvement.

CONCLUSIONS

Target region involvement varies according to primary tumour site and disease extent. Resection of the greater omentum should be performed during CRS for PM arising from all primary sites. Resection of other target organs may be performed for selected patients with ovarian cancer, peritoneal mesothelioma and mucinous appendiceal tumors in absence of visible disease. For other patients, it should be done only in presence of visible disease.

Clinico-pathological outcomes after total parietal peritonectomy, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in advanced serous papillary peritoneal carcinoma submitted to neoadjuvant systemic chemotherapy- largest single institute experience

INTRODUCTION

Serous papillary peritoneal carcinoma (SPPC) is a rare clinical entity. Based on the understanding of the pattern of spread, its multifocality, polyclonality and the high frequency of diffuse, widespread peritoneal metastasis, a robust rationale for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for SPPC exists. Herein we report the clinical outcomes of SPPC patients treated with neoadjuvant systemic chemotherapy (NACT) followed by CRS including total parietal peritonectomy and HIPEC.

METHODS

Clinico-pathological data of 22 patients of serous papillary peritoneal carcinoma (SPPC) was retrospectively analyzed from a prospectively maintained database from June 2000 to July 2017. Patients were treated with CRS, total parietal peritonectomy and HIPEC with cisplatin (42 mg/L of perfusate) and doxorubicin (15 mg/L of perfusate) after NACT. Survival curves were calculated from the date of surgery.

RESULTS

22 patients underwent CRS, total parietal peritonectomy and HIPEC. The median age was 62 years (Range 47-72). On histological evaluation, 18/30 (60%) parietal peritonectomy specimens showed microscopic disease, when no disease was evident macroscopically at surgical exploration. Grade III-IV surgical complications were recorded in 4/22 (18%) patients. There was no postoperative mortality. At a median follow up of 12 months, the five-year overall survival (OS) was 64.9%. The median OS was not reached. Median progression-free survival was 32.9 months and progression-free survival at 5 years was 33.2%.

CONCLUSION

CRS with total peritonectomy + HIPEC after NACT, presents as a promising treatment modality for SPPC, and could be associated with good survival results in patients with SPPC.

Chasing Rainbows? the Possibility of "Cure" in Patients with Colorectal Peritoneal Metastases Undergoing Cytoreductive Surgery and HIPEC-a Retrospective Study by INDEPSO

Cytoreductive surgery (CRS) and HIPEC results in a median disease-free survival (DFS) of 12-15 months, overall survival (OS) of 23-63 months, and cure in around 15% of patients with colorectal peritoneal metastases (CPM). The wide variation in OS may largely be attributed to different criteria for patient selection employed by different investigators. To evaluate outcomes of CRS and HIPEC for CPM in patients enrolled in the Indian HIPEC registry. A retrospective analysis of patients enrolled in the registry since its inception in March 2016 was performed. The impact of various prognostic factors on DFS and OS was evaluated. From Jan 2013 to Dec 2017, 68 patients underwent CRS with HIPEC at six Indian centers. The median PCI was nine [range 3-35]. Twenty-two (32.3%) had mucinous tumors. A CC-0 resection was performed in 53 (77.9%) and CC-1 in 14 (20.5%). The median DFS was 12 months [95% CI 11.037-12.963 months] and the median OS 25 months [95% CI 18.718-31.282]. The DFS was inferior in patients with right upper quadrant involvement (p = 0.02) and 90-day major morbidity (p = 0.002) and OS inferior in those with 90-day major morbidity (p < 0.001) and mucinous tumors with a PCI > 20. The DFS compares well with results obtained by pioneering teams but we have no "cured" patients. Better patient selection and utilization of systemic therapies could in the future improve the OS. There is a compelling need to identify subgroups of CPM that benefit from the addition of HIPEC to CRS.

Impact of Radicality Versus Timing of Surgery in Patients with Advanced Ovarian Cancer (Stage III C) Undergoing CRS and HIPEC-a Retrospective Study by INDEPSO

HIPEC in addition to interval CRS has shown a survival benefit of 12 months compared to CRS alone. However, there are many controversial issues pertaining to CRS itself which should be addressed first. To compare NACT and primary CRS approaches when CRS is categorized according to the extent of resection. To evaluate the feasibility of performing HIPEC at these two time points. A retrospective analysis of patients with stage III C ovarian cancer undergoing primary and interval CRS + HIPEC was performed. The surgical approach for interval CRS was classified as (1) resection of sites of residual disease alone or (2) resection of sites involved before NACT. The morphological response was divided into different categories, and surgeons had to state what they consider residual disease and what they do not. From January 2013 to December 2017, 54 patients were included (18-primary; 36-interval). Median PCI 11 vs 6.5 (p = 0.07); CC-0 was obtained in 77.7%. Three surgeons resected previously involved sites; three sites of residual disease only. All surgeons resected areas of scarring. Twenty percent patients had residual disease in "normal-looking" peritoneum. Morbidity (p = 0.09), median OS (p = 0.71), and median DFS (p = 0.54) were similar in the two groups. Early recurrence occurred in 50% with resection of residual disease alone compared to 16.6% when previous disease sites were resected (p = 0.07). Interval CRS should be performed to resect sites involved prior to NACT and not just sites of residual disease. HIPEC can be performed in both primary/interval settings with acceptable morbidity.

Analysis of Clinical Outcomes of Pseudomyxoma Peritonei from Appendicular Origin Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy-A Retrospective Study from INDEPSO

To evaluate the clinical outcomes of patients of pseudomyxoma peritonei of appendiceal origin undergoing cytoreductive surgery and HIPEC. Data collected from members, an independent collaborative group of Indian surgeons specializing in the management of peritoneal surface malignancy (INDEPSO), was analyzed retrospectively. Clinicopathological and perioperative outcomes of patients treated for pseudomyxoma peritonei (PMP) of appendicular origin were evaluated. Ninety-one patients were diagnosed with pseudomyxoma peritonei of appendicular origin between March 2013 and December 2017. The median age was 53 years and 60% were females. The median PCI was 27 [range 3-39] and a CC-0/1 resection was achieved in 83.5% patients. The most common histological grade was low-grade PMP, seen in 71.4% cases. The overall rate of grades 3-4 morbidity was 33% (30/91) and the 90-day mortality rate reported was 6.5%. Pulmonary complications and systemic sepsis emerged as the most significant factors affecting morbidity, mortality, and failure to rescue. At a median follow-up of 24 months, the median OS was not reached and the median PFS was 53 months. On univariate and multivariate analysis, high-grade histology, prior chemotherapy, debulking surgery alone without HIPEC, and high PCI > 10 were predictors of poor progression-free survival. The survival and morbidity results of pseudomyxoma peritonei from appendicular origin following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are encouraging. With further awareness and understanding of the disease, and improvement in surgical expertise and learning curve, there is scope for further reduction in morbidity and better improvement in survival.

Treading the beaten path with old and new obstacles: a report from the Indian HIPEC registry

BACKGROUND

The Indian HIPEC registry is a self-funded registry instituted by a group of Indian surgeons for patients with peritoneal metastases (PM) undergoing surgical treatment. This work was performed to  • Evaluate outcomes of cytoreductive surgery ± HIPEC in patients enrolled in the registry.  • Identify operational problems.

METHODS

A retrospective analysis of patients enrolled in the registry from March 2016 to September 2017 was performed. An online survey was performed to study the surgeons' attitudes and existing practices pertaining to the registry and identify operational problems.

RESULTS

During the study period, 332 patients were enrolled in 8 participating centres. The common indication was ovarian cancer for three centres and pseudomyxoma peritonei for three others. The median PCI ranged from 3 to 23. A CC-0/1 resection was obtained in 94.7%. There was no significant difference in the morbidity (p = .25) and mortality (p = .19) rates between different centres. There was a high rate of failure-to-rescue (19.3%) patients with complications and the survival in patients with colorectal PM was inferior. A lack of dedicated personnel for data collection and entry was the main reason for only 10/43 surgeons contributing data. The other problem was the lack of complete electronic medical record systems at all centres.

CONCLUSIONS

These results validate existing practices and identify country-specific problems that need to be addressed. Despite operational problems, the registry is an invaluable tool for audit and research. It shows the feasibility of fruitful collaboration between surgeons in the absence of any regulatory body or funding for the project.

Multicystic mesothelioma: Operative and long-term outcomes with cytoreductive surgery and hyperthermic intra peritoneal chemotherapy

BACKGROUND

Multicystic peritoneal mesothelioma (MCPM) is an extremely rare disease with 40-50% rate of recurrence after surgical debulking. Due to the recurrent nature of the disease, the option of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) was offered for this condition. In the present study we aimed to describe the outcomes of this strategy in a single center cohort.

METHODS

We retrospectively reviewed a prospectively collected database of all patients with MCPM that underwent the combined procedure in our center. Clinical presentation, operative procedures and outcomes were reviewed.

RESULTS

Between August 1997 and October 2017, 19 patients with MCPM underwent 20 cytoreduction and HIPEC procedures in our center. The majority of the patients were females (n = 17, 89%), and mean age was 42, as reported in other series. Disease extent, as measured by mean peritoneal carcinomatosis index (PCI) was 15.5 ± 9.9 and total number of procedures performed 6.7 ± 2.6. Major complications occurred in 3 (15%) patients, with no perioperative mortality. After a median of follow-up of 69 months (range 4-220) all patients were alive and 4 patients had recurrence (21%). Patients with high PCI (defined by median PCI) had shorter recurrence free survival (RFS) than patient with low PCI (mean RFS = 106.4 ± 6.6 for high PCI vs. 125.6 ± 34.1 for low PCI, p = 0.03).

CONCLUSION

Cytoreduction and HIPEC offer low recurrence rate and prolonged mean RFS for patients with MCPM. The combined procedure can be offered with acceptable morbidity in specialized centers.

Correction to: Clinical Surveillance After Macroscopically Complete Surgery for Low-Grade Appendiceal Mucinous Neoplasms (LAMN) with or Without Limited Peritoneal Spread: Long-Term Results in a Prospective Series

In the original article Massimo Milione's last name was spelled incorrectly. It is correct as reflected here. The original article has also been updated.

Preliminary experience with lateral pelvic lymph node dissection in locally advanced rectal cancer

BACKGROUND

In 15 % to 25 % of patients, the lateral pelvic lymph nodes (LPN) are known to be involved especially with rectal tumors lying below the peritoneal reflection. While total mesorectal excision (TME) ensures removal of locoregional lymph nodes, it does not address the LPN. Lateral pelvic lymph node dissection (LPND) is being performed in selected scenarios for persistent LPN after administration of neoadjuvant chemoradiotherapy (NACTRT). Through our study, we share our initial experience with LPND in patients with persistent pelvic nodes after NACTRT in advanced rectal cancers.

METHODS

From October 2013 to November 2014, eight patients underwent TME with LPND after NACTRT. LPND was performed when pelvic node metastasis was suspected on preoperative magnetic resonance imaging (MRI) and persisted following preoperative NACTRT. Clinicopathological and perioperative details were recorded for these eight patients.

RESULTS

Out of the 144 patients operated with curative intent for rectal LARC, eight (5 %) patients had persistent lateral pelvic nodes following NACTRT. These patients underwent a TME with LPND. The median operative time was 240 min, and the median blood loss was 800 mL. Two out of eight patients showed residual disease in the lateral pelvic nodes (i.e. 25 %). Of these two patients, one also had residual disease in the mesorectal nodes, post NACTRT. The median length of hospital stay was 6 days. No genitourinary complications were reported. The median follow up for these eight patients was 13 months (6-16 months). The 1 year disease free survival was 100 % with all patients surviving till date.

CONCLUSION

LPND can be performed with acceptable perioperative outcomes in carefully selected patients.

Impact of type of surgery (laparoscopic versus open) on the time to initiation of adjuvant chemotherapy in operable rectal cancers

PURPOSE

The COREAN (comparison of open vs. laparoscopic surgery for mid- and low-rectal cancer after neoadjuvant chemoradiotherapy) and the MRC-CLASICC (Medical Research Council-conventional vs. laparoscopic-assisted surgery in colorectal cancer) trials have established the benefits of laparoscopic surgery in rectal cancers regarding shortened hospital stay and speedy recovery. A rapid postoperative recovery is essential for initiation of adjuvant therapy, especially in stage II/III rectal cancers. This study aimed to evaluate whether the type of surgery (laparoscopic or open) had any bearing on the time to initiation of adjuvant chemotherapy (TIAC) after complete radical surgical proctectomy.

METHODS

A subset of 181 consecutive patients of operable rectal cancer, who underwent curative resection of the rectum (laparoscopic or open) and received postoperative adjuvant chemotherapy between July 2013 and December 2014 at a single institution, was studied. The TIAC and the factors determining the same, namely, type of surgery, age, gender, presence of complications, and body mass index, were analyzed.

RESULTS

Of 181 patients, 57 underwent laparoscopic and 124 open resection. Overall complications were seen in 17.6 % (32) patients, 8 in the laparoscopic arm and 24 in the open arm. The median time to start adjuvant chemotherapy after surgery was 21.6 and 23.73 days (p = 0.94) in the laparoscopic and open groups, respectively. On multivariate analysis, the type of surgery (p = 0.398) did not influence the TIAC. The only factor that influenced the TIAC was postoperative complications (p = 0.001).

CONCLUSION

Our study shows that laparoscopic surgery for rectal cancer did not lead to an earlier start of adjuvant chemotherapy.

Harmful effects of nicotine

With the advent of nicotine replacement therapy, the consumption of the nicotine is on the rise. Nicotine is considered to be a safer alternative of tobacco. The IARC monograph has not included nicotine as a carcinogen. However there are various studies which show otherwise. We undertook this review to specifically evaluate the effects of nicotine on the various organ systems. A computer aided search of the Medline and PubMed database was done using a combination of the keywords. All the animal and human studies investigating only the role of nicotine were included. Nicotine poses several health hazards. There is an increased risk of cardiovascular, respiratory, gastrointestinal disorders. There is decreased immune response and it also poses ill impacts on the reproductive health. It affects the cell proliferation, oxidative stress, apoptosis, DNA mutation by various mechanisms which leads to cancer. It also affects the tumor proliferation and metastasis and causes resistance to chemo and radio therapeutic agents. The use of nicotine needs regulation. The sale of nicotine should be under supervision of trained medical personnel.

Clinical outcome of patients with complete pathological response to neoadjuvant chemoradiotherapy for locally advanced rectal cancers: the Indian scenario

Introduction. Neoadjuvant chemoradiotherapy and total mesorectal excision are considered the standard treatment for locally advanced rectal cancer. Various studies have reported pathological downstaging and a complete pathological response rate of 15%-27% following neoadjuvant chemoradiotherapy which has translated into improved survival. We endeavour to determine the clinical outcome of patients attaining a complete pathological tumor response following neoadjuvant chemoradiotherapy in the Indian setting where most of our patient population is younger and presents with aggressive tumor biology. Materials and Methods. Clinicopathological and treatment details were recorded for 64 patients achieving pathological complete response from 2010 to 2013. Disease-free survival (DFS), overall survival (OS), and locoregional and systemic recurrence rates were evaluated for these patients. Results. After a median follow-up of 30.5 months (range 11-59 months), the 3-year overall survival (OS) was 94.6% and the 3-year disease-free survival (DFS) was 88.5%. The locoregional and systemic recurrence rates were 4.7% and 3.1%, respectively. Conclusion. In the Indian subcontinent, despite younger patients with aggressive tumor biology, outcome in complete responders is good.

Sporadic giant mesenteric fibromatosis

Mesenteric fibromatosis is an uncommon tumour which is locally aggressive without any metastatic potential and can occur as a sporadic event or in association with familial adenomatous polyposis syndrome. Giant mesenteric fibromatosis is very rare and is a diagnostic and therapeutic challenge. This is a case report of a rare presentation of deep fibromatosis as a sporadic giant intrabdominal mesenteric tumour in a 29 year old male managed by surgical excision and definitive diagnosis made on the basis of immunohistochemical findings.