Peritoneal metastasis of advanced epithelial ovarian carcinoma treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: A retrospective international multicentric data analysis

INTRODUCTION

The purpose of our study was to evaluate outcome data after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with peritoneal metastasis originating from advanced epithelial ovarian carcinoma (PMOC).

PATIENTS AND METHODS

A retrospective international multi-institutional registry was established through collaborative efforts of participating units affiliated with the Peritoneal Surface Oncology Group.

RESULTS

One thousand four hundred and ninety-one patients from 11 specialized units underwent CRS and HIPEC that of those 326 (21.9%) upfront surgeries, 504 (33.8%) interval surgery, and 661(44.3%) recurrent cases. Complete Cytoreduction(CC0/1) was achieved in 1213 patients (81.3%). Treatment -related mortality was 0.8%, major operative complications (Grades 3-5) was 25.1%. Factors associated with major operative complications include prior surgical score (PSS for recurrent cases; RC) PSS>2,p = 0.000), PCI(≤15, >15 cut-off level; p ≤ 0.000), completeness of cytoreduction (CC, p=0.000), high CA125 levels (>25 mg/dl), presence of ascites, high CRP (>5 mg/dl) levels and low albumin levels (below to 2.5 mg/dl) (p ≤ 0.05). The median survival was 58 months in upfront surgery(UFS), 60 months in interval surgery(IS), and 42 months in RC. The overall survival for five years was 45% for UFS, 37% for IS, 28% for RC cases. CCscore (p = 0.000), CA125, CRP and albumin levels (p ≤ 0.05) were predictors for progression free survival. PCI(p ≤ 0.000), major postoperative complications (p = 0.004), incomplete CRS(CC2/3)(p < 0.001), prior chemotherapy (hazard ratio [HR], 3-8; p < 0.001) and PSS>2 for RC were independent predictors of poor overall survival.

CONCLUSION

The combined treatment strategy for PMOC may be performed safely with acceptable morbidity and mortality in the specialized units.

An International Registry of Peritoneal Carcinomatosis from Appendiceal Goblet Cell Carcinoma Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

PURPOSE

Peritoneal carcinomatosis from appendiceal goblet cell carcinoma (A-GCC) is a rare and aggressive form of appendiceal tumor. Cytoreductive surgery (CRS) and hyperthermic intra peritoneal chemotherapy (HIPEC) was reported as an interesting alternative regarding survival compared to surgery without HIPEC and/or systemic chemotherapy. Our aim was to evaluate the impact of CRS and HIPEC for patients presenting A-GCC through an international registry.

METHODS

A prospective multicenter international database was retrospectively searched to identify all patients with A-GCC tumor and peritoneal metastases who underwent CRS and HIPEC through the Peritoneal Surface Oncology Group International (PSOGI). The post-operative complications, long-term results, and principal prognostic factors were analyzed.

RESULTS

The analysis included 83 patients. After a median follow-up of 47 months, the median overall survival (OS) was 34.6 months. The 3- and 5-year OS was 48.5% and 35.7%, respectively. Patients who underwent complete macroscopic CRS had a significantly better survival than those treated with incomplete CRS. The 5-year OS was 44% and 0% for patients who underwent complete, and incomplete CRS, respectively (HR 9.65, p < 0.001). Lymph node involvement and preoperative chemotherapy were also predictive of a worse prognosis. There were 3 postoperative deaths, and 30% of the patients had major complications.

CONCLUSION

CRS and HIPEC may increase long-term survival in selected patients with peritoneal metastases of A-GCC origin, especially when complete CRS is achieved. Ideally, randomized control trials or more retrospective data are needed to confirm CRS and HIPEC as the gold standard in this pathology.

Mitomycin-C versus oxaliplatin during cytoreductive surgery and HIPEC for peritoneal metastases secondary to colorectal carcinoma: a retrospective analysis

PURPOSE

Combining cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) can benefit patients with peritoneal metastasis from colorectal cancer, however the optimal choice of the HIPEC chemotherapy is still under debate. The present study compares the clinical outcome in patients with peritoneal metastases treated with CRS and HIPEC using Mitomycin - C versus Oxaliplatin.

METHODS

We retrospectively analyzed patients that underwent CRS and HIPEC for recurrent colorectal cancer with peritoneal metastases. Patient characteristics, procedure details, and clinical outcomes were evaluated.

RESULTS

114 consecutive patients were included in the analysis (62 males - 52 females, mean age 58,3 years). The mean intraoperative PCI-score was 15.3 (range: 3 - 36). The mean follow-up period was 28.2 months. Patients receiving MMC - based HIPEC had significantly higher mean overall survival compared to oxaliplatin (54 versus 26 months), translated to a hazard ratio of 0.26 (95% CI 0.128 - 0.529, p<0.01). The HIPEC regimen as well as the completeness of cytoreduction were the only independent prognostic factors of survival in our sample.

CONCLUSIONS

Our results imply that the use of MMC offers a survival advantage over oxaliplatin when used for HIPEC in CRC PC. A randomised trial comparing oxaliplatin and MMC would enhance decision-making in such patients.

Cytoreductive surgery and HIPEC for peritoneal metastasis. Justified hope or desperate illusion? Fifteen years of experience from a Greek Peritoneal Surface Malignancy center

PURPOSE

Peritoneal spread of neoplastic diseases is considered a fatal condition with a dismal prognosis. Few therapeutic options were offered to these patients and surgery had only palliative character. However, advances in surgical techniques and new drugs development, have changed the management of this terminal stage disease. Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC), has been proposed as a promising alternative to palliative surgery and systemic chemotherapy, since 1980s. Many changes through all these years have refined the technique and standardized indications and limits.

METHODS

A retrospective study was performed in our medical records, of all patients treated with CRS and HIPEC since 2006. Survival, complications and prognostic factors were studied in a total of 632 patients.

RESULTS

Female patients were 419 and males were 213. Mean age was 52.6 years. Peritoneal metastases secondary to colorectal cancer were the most frequent treated disease (87 patients), whereas hepatobilliary-pancreatic neoplastic diseases and sarcomas were the less frequent causes of peritoneal carcinomatosis. Patients with peritoneal metastases from ovarian cancer, treated with systemic chemotherapy and then received interval cytoreductive surgery with HIPEC, were the largest group that are still alive (43%), while only 35% of patients with hepatobilliary-pancreatic cancer and peritoneal disease are alive at present. Gender, age, peritoneal cancer index (PCI), completeness of cytoreduction score (CCs), and number of complications were important prognostic factors of overall survival.

CONCLUSIONS

Peritoneal carcinomatosis is still considered a final stage disease with a poor prognosis. The confinement of the neoplastic disease in the peritoneal cavity has led to the development of local therapies with promising results. CRS and HIPEC have evolved significantly over the past several years and are at the present the most valuable treatment in highly selected patients with peritoneal carcinomatosis.

Delayed genital necrosis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with Mitomycin-C

INTRODUCTION

Genital necrosis (GN) is a rare complication of cytoreductive surgery with hyperthermic intraoperative chemotherapy (CRS/HIPEC) which can be confused with necrotizing fasciitis. We present an analysis of GN after CRS/HIPEC to define its natural history.

METHODS

We identified patients with GN after CRS/HIPEC at two peritoneal surface malignancy institutions. Patient demographic, surgical, and postoperative data were extracted from prospective databases.

RESULTS

Of 1597 CRS/HIPECs performed, 13 patients (0.8%) had GN. The median age was 57 years (IQR: 49-64) and 77% (n = 10) were male. Mitomycin-C was the perfusion agent in all cases of GN (100%). The median time to GN onset after CRS/HIPEC was 64 days (IQR: 60-108) and 2 (15%) patients were receiving systemic chemotherapy at the time of GN onset. Symptoms included severe pain (100%), edema (100%), labial or scrotal skin ulceration (92%), signs of infection (39%), and fever (15%). Seven (54%) patients had thrombocytosis >400 ∗10⁹/L, whereas coagulation tests were within normal reference range in 100% cases. All patients initially underwent conservative treatment, with antibiotic therapy administered in 62% (n = 8). Surgical debridement was performed in 9 (70%) cases with median time after GN onset of 57 (IQR: 8-180).

CONCLUSION

GN is a debilitating complication after CRS/HIPEC with delayed onset and a protracted clinical course. Optimal treatment results could be achieved with initial conservative management until complete lesion demarcation followed by surgical debridement. The pathophysiology of GN is unclear, and we call for other researchers attention to better understand the complication and prevention.

Narrative review of hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with advanced ovarian cancer: a critical reappraisal of the current evidence

The implementation of hyperthermic intraperitoneal chemotherapy (HIPEC) in the management of advanced stage epithelial ovarian cancer (EOC) as a standard practice remains debatable despite the emerging data supporting its beneficial effect when used to supplement cytoreductive procedures. The aim of the present review was an attempt to accumulate the currently available evidence on the use of HIPEC for patients with primary and recurrent EOC and to address directives of future research. Based on the currently available literature, the progress in cytoreductive surgical procedures and chemotherapy has brought significant improvement in the management and survival outcomes of selected patients with advanced EOC. The addition of HIPEC seems encouraging based on the outcomes of high-quality clinical trials. There are significant parameters on the use of CRS and HIPEC such as patient selection, the sequencing of procedures, the type of chemotherapy agent and time and the temperature of hyperthermic procedures which require additional investigation. Multidisciplinary team management by surgeons, gynaecologists, oncologists, pathologists and radiologists is of critical importance. Also, additional large prospective well-designed randomised studies are needed in order to update our current knowledge and provide guidelines to improve the management of patients with EOC.

Hyperthermic intraperitoneal chemotherapy in ovarian cancer: Qui Bono?

Ovarian cancer is a major cause of cancer related-death in women around the world. Recent statistics on the worldwide cancer burden by the International Agency for the research on Cancer revealed ovarian cancer being both the eighth most frequent malignancy in the west countries. Peritoneal metastasis from ovarian cancer is a major challenge in the clinical management. Despite the evidence of the benefit of Intraperitoneal Chemotherapy in ovarian cancer with peritoneal deposits it has not been widely adopted, mainly due to logistical difficulties and less to the logoregional morbidity as pain. The role of hyperthermic intraperitoneal chemotherapy (HIPEC) in patients during the end of cytoreductive surgery (CRS) is a more tolerable feasible method with potential advantages as drug distribution, combination with hyperthermia and application before tumor regrowth. The aim of this article is to investigate the potential benefits of HIPEC explains the rationale, data of major clinical trials meta-analyses and recent randomized trial are presented and explains the indications patient selection and the best time to applicate of this aggressive logo regional treatment.

Upfront or intermediate treatment of advanced ovarian cancer patients with cytoreduction plus HIPEC: Results of a retrospective study

BACKGROUND

Newly diagnosed advanced-stage ovarian cancer patients are treated with neoadjuvant chemotherapy, primary or intermediate cytoreductive surgery, and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study is to evaluate the optimal timing of cytoreduction plus HIPEC for advanced ovarian cancer patients.

METHODS

Advanced ovarian cancer patients treated with cytoreductive surgery plus HIPEC at three different hospitals between 2005 and 2019 were subgrouped regarding their time of management with cytoreduction plus HIPEC, upfront or intermediate. We retrospectively assessed the overall survival (OS), the progression-free survival (PFS), and the disease-free survival (DFS) of these groups.

RESULTS

A total of 112 ovarian cancer patients were contained. Of whom, 47 patients were in the upfront group with 24 (51.1%) to be alive, while 65 patients were included in the intermediate group with 34 (52.3%) to be alive. OS (48 vs. 30 months) and DFS (42 vs. 20 months) indicated no significant difference. Although the same median PFS was observed in both groups (10 months), a higher mean PFS was observed in the upfront group (11.9 vs. 9 months, p = 0.023).

CONCLUSION

The treatment of advanced ovarian cancer patients with upfront cytoreductive surgery plus HIPEC is feasible with the same survival results. Further, larger prospective studies need to verify our results.

Is there a role of repeat cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with relapse from peritoneal metastatic disease? A survival analysis

PURPOSE

We aimed to evaluate the role of repeat cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the management of patients with recurrent peritoneal metastatic disease (PM) with special consideration to perioperative outcomes and long-term survival outcomes.

METHODS

Patients with recurrent PM who underwent CRS and HIPEC for the management of the disease for an interval of 15 years were retrospectively analyzed. Primary tumor location, peritoneal cancer index, completeness of cytoreduction (CC), morbidity, mortality, overall survival (OS), and progression-free survival (PFS) after the 1st and 2nd HIPEC were assessed.

RESULTS

A total of 48 patients who underwent repeat CRS and HIPEC for the management of disease relapse were included in this study. The median OS from initial diagnosis was 37 months (range: 12-128) while the PFS after the second CRS and HIPEC was 12 months (range: 0-36). A total of 30 complications were recorded among which 18.8% were classified as major. CC-0 resection was a significant indicator of survival either on univariate or on multivariate analysis.

CONCLUSIONS

The outcomes of the present study indicate the feasibility of repeat CRS and HIPEC procedures in patients with recurrent peritoneal metastasis with significant morbidity, acceptable mortality and long-term survival outcomes which were highly associated with CC status.

Survey on the current gynaecological approach of ovarian cancer patients: The utility of HIPEC

BACKGROUND

The aim of this survey was to acquire an overview of the current management of ovarian cancer with an emphasis on the utility of hyperthermic intraperitoneal chemotherapy (HIPEC).Methods: An email was sent to Oncologists prior to PSOGI International Symposium on Advanced Ovarian Cancer, Athens 11-13 April 2019. Doctors submitted responses on the relevant website. The self-report survey contained 17 questions.

RESULTS

In total, 467 Medical Oncologists, Surgical Oncologists or Gynaecologic Oncologists were participated and answered to this survey. The resectability of disease was evaluated by laparoscopy from 48.5% of the participants, while 51.5% answered that they stage their patients pre-surgically with the use of CT or MRI. The preferred first intervention in advanced ovarian cancer patients is the neoadjuvant chemotherapy followed by interval cytoreductive surgery (72%). Regarding the use of HIPEC, almost half of the participants answered that there is role of HIPEC use in ovarian cancer patients undergoing interval debulking surgery, while almost 70% answered positively about the utility of HIPEC use in ovarian cancer recurrence. As for the role of lymphadenectomy in advanced ovarian cancer patients, half of the responders answered negatively. Finally, only 25% of the participants responded that they always check the BRCA status of their ovarian cancer patients, despite the possible differentiation of treatment based on the molecular profiling (80%).

CONCLUSIONS

The results of this survey indicate the utility of HIPEC in treatment of ovarian cancer patients and the differences in the overall management of ovarian cancer patients in the current clinical practice.

CRS and HIPEC in patients with peritoneal metastasis secondary to colorectal cancer: The small-bowel PCI score as a predictor of survival

Background

Combining cytoreductive surgery (CRS) with Hyperthermic IntraPeritoneal Chemotherapy (HIPEC) can benefit patients with peritoneal metastasis from colorectal cancer. The present study evaluates the small bowel subset of the Peritoneal Cancer Index (Small-Bowel-PCI score (SB-PCI), min-max 0–12) as a prognostic factor in such patients.

Methods

We retrospectively analyzed patients that underwent CRS and HIPEC for recurrent colorectal cancer with peritoneal metastasis. Patient characteristics, procedure details, and clinical outcomes were evaluated.

Results

Eighty patients were included. The mean intraoperative PCI-score was 16.8, with a mean SB-PCI score of 5.9. CC0/1 was achieved in 62/80 patients. The mean follow-up period was 26.3 months. Univariate regression analysis showed that the ECOG status, the presence of severe complications, the HIPEC regimen (oxaliplatin vs. mitomycin-C), the PCI score, the SB-PCI score and the completeness of cytoreduction correlated significantly with overall survival. In multivariate analysis, the SB-PCI and CC score were identified as independent prognostic factors of survival. When the SB-PCI was stratified in three groups (0–4, 5–8 and 9–12), Kaplan–Meier curve analysis showed significant difference in survival (p<0.001).

Conclusions

The SB-PCI correlates with overall survival in patients with peritoneal metastases secondary to colorectal cancer in this retrospective cohort. Its use should be validated in prospective patient series.

Hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer: a "useless intraoperative fever" or the next hot voice in the surgical management of the "silent killer"?

The aim of our opinion letter is to highlight the recent findings in the field of hyperthermic intraperitoneal chemotherapy (HIPEC) use in ovarian cancer management. Two recent studies reveal that ovarian cancer patients treated with HIPEC can extend their survival independently of the timing offered-either at the initial cytoreductive effort or at the time of disease relapse. The research field is flourishing and further data are awaited from randomised control trials. Although, HIPEC is not considered yet as the standard of care in the management of ovarian cancer patients, the initial findings of its use are promising.

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.

Quality of life after cytoreductive surgery and HIPEC: A single centre prospective study

PURPOSE

Cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) has become a crucial method in the management of peritoneal metastasis. This study evaluated the Quality of Life (QoL) post CRS plus HIPEC.

METHODS

80/95 patients underwent CRS plus HIPEC at the Metaxa Cancer Hospital, Piraeus, Greece from 06/2011 to 06/2015 and completed the colorectal version of the Functional Assessment of Cancer Therapy questionnaire (FACTC, version 4) at 1 week pre-operatively and at 1, 3, 6, 12, 18, 24 months post-operatively. The subscales assessed were the physical, social/family, emotional and functional wellbeing.

RESULTS

In all subscales, fluctuations in the scores indicated a worsening of QoL in the first 3 post-operative months, followed by improvement back to pre-operative levels and even better scores later on. Statistical improvement was proven for the physical and emotional well-being subscales.

CONCLUSIONS

The significant improvement in the physical well-being is attributed to the eradication of symptoms, whereas the relevant improvements in the emotional wellbeing subscale are explained both by the pre-operative desperation of the diagnosis or relapse of malignancy, and the post-operative hopefulness after a successful operation.

Survival and nutritional factors on home parenteral nutrition (HPN): Our initial experience

PURPOSE

Home parenteral nutrition (HPN) has been proposed as the treatment of choice in patients suffering from intestinal failure (IF) and has been claimed to improve survival and quality of life either in patients with benign disorders or even in those with malignancies. The purpose of the present analysis was to report characteristics and outcomes of adult patients with IF receiving HPN in Greece.

METHODS

Patients that received HPN between 2011 and 2017 were included in this retrospective analysis. Characteristics of the included patients, cause of HPN, duration of HPN, route of HPN administration, complications as well as survival rates were recorded.

RESULTS

A total of 189 patients were included in the present analysis. Of these, 163 (86.3%) suffered from cancer while 26 (13.7%) received HPN due to non-malignant diseases. The reported mortality was 74.6% while overall severe complications rate was 77%.

CONCLUSIONS

According to the findings of our study, HPN seems to have beneficial effect but it should be considered with caution by the physicians who should take into account the indications of each patient to receive parenteral nutrition, the underlying disease and prognosis and the access of each patient to home care services.

Cytoreductive Surgery Plus Hyperthermic Intraperitoneal Chemotherapy for Patients with Peritoneal Metastases from Endometrial Cancer

Background

More information is needed for selection of patients with peritoneal metastases from endometrial cancer (EC) to undergo cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods

This study analyzed clinical, pathologic, and treatment data for patients with peritoneal metastases from EC who underwent CRS plus HIPEC at two tertiary centers. The outcome measures were morbidity, overall survival (OS), and progression-free survival (PFS) during a median 5 year follow-up period. Uni- and multivariate analyses were performed to identify significant factors related to outcome.

Results

A total of 33 patients met the inclusion criteria and completed the follow-up period. At laparotomy, the median peritoneal cancer index (PCI) was 15 (range 3–35). The CRS procedure required a mean 8.3 surgical procedures per patient, and for 22 patients (66.6%), a complete cytoreduction was achieved. The mean hospital stay was 18 days, and major morbidity developed in 21% of the patients. The operative mortality was 3%. When surgery ended, HIPEC was administered with cisplatin 75 mg/m² for 60 min at 43 °C. During a median follow-up period of 73 months, Kaplan–Meier analysis indicated a 5 year OS of 30% (median 33.1 months) and a PFS of 15.5% (median 18 months). Multivariate analysis identified the completeness of cytoreduction (CC) score as the only significant factor independently influencing OS. Logistic regression for the clinicopathologic variables associated with complete cytoreduction (CC0) for patients with metachronous peritoneal spread from EC who underwent secondary CRS plus HIPEC identified the PCI as the only outcome predictor.

Conclusions

For selected patients with peritoneal metastases from EC, when CRS leaves no residual disease, CRS plus HIPEC achieves outcomes approaching those for other indications such as colon and ovarian carcinoma.

Does upfront therapy with cytoreductive surgery and HIPEC confer a survival benefit in patients with synchronous gastric peritoneal carcinomatosis when compared with patients with metachronous gastric peritoneal carcinomatosis?

Gastric cancer (GC) remains the second leading cause of cancer death worldwide, accounting for 8% of the total cases and 10% of total deaths in 2008. Surgery remains the curative treatment option for GC and the main reason for treatment failure is peritoneal recurrence which, according to the literature, occurs in 40-60% of the cases, despite extensive surgery including D2 lymph node dissection. The hyperthermic intraperitoneal chemotherapy (HIPEC) technique is increasingly used in the treatment of primary and digestive peritoneal carcinomatosis (PC), in association with cytoreductive surgery (CRS). We retrospectively analyzed 14 patients with gastric peritoneal carcinomatosis (GPC) undergoing CRS/HIPEC in the last 10 years. Six patients already had GPC at the time of diagnosis (group A) and 8 developed metachronous GPC (group B). Treatment with CRS and HIPEC didn't seem to confer a survival benefit to patients with synchronous PC from gastric cancer.

Hepatobiliary and pancreatic procedures during cytoreductive surgery and HIPEC

PURPOSE

The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been used as locoregional treatment in selected patients with peritoneal malignancy. The purpose of this study was to report on the outcomes of patients undergoing hepatobiliary and pancreatic procedures during CRS and HIPEC.

METHODS

A prospectively maintained database was used to identify patients that underwent hepatobilliary and/or pancreatic procedures during CRS and HIPEC. Outcome variables included morbidity, 30-day or in-hospital mortality, return to operating theatre, and complications.

RESULTS

Sixty eight patients were included in the study, in whom 67 hepatobiliary and 15 pancreatic procedures were performed. Complete cytoreduction (CC-0/1) was achieved in 64 patients (94.8%). Twelve patients underwent liver resections, 50 underwent resection of Glisson's capsule, 5 underwent procedures of the biliary tree and 15 patients underwent pancreatic procedures. Major complications were encountered in 30/68 patients (44.1%). Pancreatic fistulas (PFs) were observed in 42.8% of the patients that underwent distal pancreatectomy. Reoperation rate was 8.8%, while 2.9% of the patients died during their hospital stay.

CONCLUSION

The need for hepatobiliary procedures bears a significant - but acceptable - rate of morbidity. However, it should not represent a definitive contraindication for CRS and HIPEC.

Perioperative systemic chemotherapy for peritoneal mucinous appendiceal carcinomas treated with cytoreductive surgery & HIPEC

PURPOSE

To identify the role of systemic chemotherapy in the management of appendiceal malignancies.

METHODS

Over a 10-year period (2005 -2014), 52 patients with appendiceal neoplasms were treated at our Peritoneal Surface Malignancy Unit [14 (26.9%) disseminated peritoneal adenomucinosis (DPAM), 30 (57.7%) peritoneal mucinous carcinomatosis of appendiceal origin (PMCA) and 8 (15.4%) PMCA-I]. All patients (100%) underwent cytoreductive surgery (CRS) & hyperthermic intraperitoneal chemotherapy (HIPEC), while 20 (38.5%) of them also received perioperative systemic chemotherapy.

RESULTS

Mean peritoneal cancer index (PCI) was 23.6. Completeness of cytoreduction score (CC-S) was: CC-0 in 26 patients (50%), CC-1 in 20 patients (38.5%) and CC-2 in 6 patients (11.5%). High grade malignancy was reported in 27 patients (51.9%) and low grade malignancy in 25 patients (48.1%). More than half of the patients developed recurrence (n=36, 69.2%), while death was reported in 40.4% (n=21). Median overall survival (OS) in all histologic groups was 24 months for patients who received perioperative systemic chemotherapy and 14 months for patients who did not (p=0.048). Median disease free survival (DFS) in all histologic groups was 19 months for patients who received perioperative systemic chemotherapy and 10 months for patients who did not (p=0.034).

CONCLUSION

We suggest that perioperative systemic chemotherapy serves as a helpful therapeutic tool in the management of peritoneal mucinous appendiceal carcinomas treated with cytoreductive surgery & HIPEC.

Hepatocellular Carcinoma Peritoneal Metastasis: Role of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

INTRODUCTION

Peritoneal dissemination of hepatocellular carcinoma (HCC) is a rare presentation with an incidence of 2-6%. The most common cause of peritoneal deposits is a ruptured HCC that results in tumor spillage into the peritoneal cavity. The overall incidence of spontaneous ruptures of HCC ranges from 5 to 15% and carries a high mortality rate of up to 50%. Other factors influencing peritoneal dissemination are the lymph node metastasis and the direct diaphragmatic invasion and there is no significant association with past history of FNAB, or percutaneous RFA or ethanol injection and lung or adrenal metastasis. Clinical Study: We present our experience with 4 patients with localized peritoneal metastases from HCC controlled and managed with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The mean peritoneal cancer index (PCI) was 10.2. In two cases there is a history of rupture at the onset of diagnosis and in one case dissemination of peritoneal cavity after FNB procedure. All patients after CRS and HIPEC received Sorafenib.

RESULTS

In our study the mean time of onset of peritoneal metastasis was 13.5 months from initial operation and the mean survival was 30 months. Our results are comparable with other studies.

CONCLUSION

Peritoneal metastasis of hepatocellular carcinoma is rare and the benefit of systemic chemotherapy is poor and from Sorafenib is not well described. Surgical resection of extrahepatic HCC metastasis remains challenging. However several case reports and a few case series have provided that surgical resection of HCC peritoneal implants may benefit. We believe from our experience in well-selected patients with peritoneal metastasis from HCC, cytoreductive surgery with HIPEC and Sorafenib may prolong survival compared to systemic chemotherapy alone.

Male breast cancer originating in an ectopic breast tissue in the umbilicus A Case Report

INTRODUCTION

Accessory breast tissue is a rare finding in the general population with an incidence of 1-2%. Carcinomas of accessory breast tissue account for ∼0.3% of breast cancers, 5% of which are arising within a supernumerary breast. They are usually diagnosed at a later stage compared with breast cancer, due to their rarity and low clinical suspicion.

CASE PRESENTATION

We present the case of a 58 years old male who was admitted to our hospital for an umbilical hernia, surgical repair. During surgery a small skin biopsy was excised and sent for pathological examination as routine procedure. The histological report revealed the presence of a poorly differentiated carcinoma. Immunochemical analysis confirmed adenocarcinoma of breast origin.

CONCLUSION

Carcinomas of accessory breast tissue are rare and therefore they are usually of advanced stage in time of diagnosis. Few cases have been reported in literature of accessory breast tissue carcinomas in men. To the best of our knowledge, this is the only case in the literature, of ectopic breast tissue cancer in the umbilicus.

KEY WORDS

Ectopic breast, Male breast cancer, Umbilicus.

Autopsy Findings in Clinically Normal Thyroids

Thyroid glands obtained from 120 consecutive autopsies performed on patients who died from different causes, other than thyroid diseases, were systematically examined by light microscopy. There were 84 males and 36 females; their ages ranged from 1 day to 100 years. Histopathological findings were noted mainly in patients older than 48 years of age. In all cases thyroid lesions were incidental findings and included nodular goiter (26%), thyroiditis (9%), follicular adenomas (7%), papillary microcarci nomas (6%), follicular carcinoma (0.8%), and hemangioma (0.8%). A number of other morphologic changes of importance to surgical pathologists were also evaluated such as the presence of solid cell nests, intrathyroidal ectopic tissues, fibrosis, fat cell infiltration, and vascular changes. Int J Surg Pathol 1 (I): 25-32, 1993

Operating personnel safety during the administration of Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is increasingly used in the treatment of peritoneal malignancies. The administration of HIPEC after complete cytoreduction offers the combination of the pharmacokinetic advantages inherent to the intraperitoneal delivery of cytotoxic chemotherapy, with the direct cytotoxic effects of hyperthermia, and has been reported to offer significantly improved patient outcomes. As a result, this novel method disseminates rapidly, with many surgical teams having developed peritoneal malignancy treatment programs. Protocols are needed for the introduction, handling, and management of chemotherapeutic agents in the operating room to minimize risk to the staff involved in the procedure. The personnel exposure during CRS and HIPEC may arise from different routes, such as air contamination, direct contact, manipulation of perfusates or chemotherapy solutions, and manipulation of objects/tissues exposed to chemotherapeutics. Guidelines for safe administration of HIPEC including environmental contamination risk management, personal protective equipment, and occupational health issues are yet to be established. This review summarizes the existing evidence regarding the safety considerations of HIPEC administration.

Treatment of peritoneal surface malignancies with hyperthermic intraperitoneal chemotherapy-current perspectives

Peritoneal carcinomatosis (ptc) represents advanced malignant disease and has generally been associated with a grim prognosis. Peritoneal surface malignancy is often the major source of morbidity and mortality; it is of major concern in cancer management. Although ptc is categorized as metastatic disease, it represents a special disease pattern considered to be a locoregional disease limited to the abdominal cavity. The combination of cytoreductive surgery (crs) and intraoperative hyperthermic intraperitoneal chemotherapy (hipec) has successfully been used as locoregional treatment for selected patients with ptc from gastric, colorectal, and ovarian cancer; with mesothelioma; and with pseudomyxoma peritonei. In the prophylactic setting, hipec can also be used to prevent ptc in high-risk patients, and the first results of the "second-look" approach are promising. Patient selection-in which the risks of perioperative morbidity and mortality, which are analogous to those for any other major gastrointestinal surgery, are assessed-is of utmost importance. Those risks have to be weighed against the anticipated survival benefit, which depends mainly on tumour biology, extent of disease, and probability of achieving complete crs. The present review discusses the principles of crs and hipec, the most significant recent clinical data, and current perspectives concerning the application of this treatment modality in various malignancies. Ongoing trials and future directions are noted. It appears that the combination of crs and hipec is an indispensable tool in the oncologist's armamentarium.

Intensive care unit hospitalization after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

PURPOSE

Peritoneal metastasis (PM) is nowadays treated with the complex procedure of cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS+HIPEC). Given the fact that the procedure presents high morbidity and mortality rates, admitting patients to the Intensive Care Unit (ICU) seems inevitable. In our study, we have tried to determine the factors that indicate when admission in the ICU is necessary.

METHODS

We retrospectively analyzed 230 patients (140 females, 90 males) with PM, who were operated on from November 2005 until October 2015, and underwent CRS+HIPEC. The patients were divided into two groups, based on whether they were extubated after the operation or not, thus being admitted to the ICU. We also distinguished a group of patients who, after the initial extubation, had to be re-intubated and transferred to the ICU. We assessed morbidity and mortality rates for each of the aforementioned groups, along with the complications developed in each case (thoracic, gastrointestinal, renal).

RESULTS

We found that morbidity and mortality rates in both examined groups were approximately similar; the course changed when a complication occurred, and this increased mortality, especially if the onset of the symptoms was delayed. Also, these rates were much worse for the group that had to be re-intubated and transferred to the ICU.

CONCLUSIONS

On the whole, we conclude that the decision of immediate admission to the ICU post-operatively is hard, as it depends on multiple factors; therefore, the use of an easy predictive method is not realistic and a more individualized and patient-to-patient approach is preferable.

Re-admissions for delayed complications after cytoreductive surgery and HIPEC

BACKGROUND

Peritoneal metastasis (PM) is currently treated with the complex procedure of cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS + HIPEC). This procedure presents high morbidity and mortality rates, but they have only been examined in the immediate post-operative period. The aim of our study is to present, describe and analyze the post-operative events, secondary to a cytoreductive surgery and HIPEC procedure that occurs after the patients' discharge from the hospital.

PATIENTS AND METHODS

We examine retrospectively 219 patients who were discharged from our hospital from the initial 230 patients with PM, who were operated on from August 2005 to August 2015 and underwent CRS and HIPEC. Complications are investigated from the patient's discharge date until the 90th post-operative day, and are categorized with the Clavien-Dindo classification.

RESULTS

We identified 17 patients (7.8%) who developed late complications. No major differences in patient characteristics were identified between this group of 17 patients and the rest, apart from a slightly higher PCI (23.5 vs. 22.3). Mean length of stay at the re-admission was 11.7 days. 5 of the patients (29.4%) had to be re-operated on, whereas we found a mortality of 11.8% (2/17 patients). The most common complications involved abdominal abscesses (17.6%), ureteral strictures (17.6%) and enterocutaneous fistulae (17.6%).

CONCLUSION

Our study highlights the late complications following CRS plus HIPEC procedures, that occur after the patient's discharge from the hospital, an issue that has not been investigated thoroughly yet and may have serious impact on the post-operative quality of life. The role of adjuvant chemotherapy following CRS and HIPEC procedures in the onset of such complications appears to be important and needs further investigation.

Locoregional treatment of peritoneal sarcomatosis A single-centre experience

BACKGROUND

Peritoneal sarcomatosis appears to be responding poorly to systemic chemotherapy. Treatment options traditionally include surgical ressections, chemotherapy and radiation therapy. Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) offers a promising alternative locoregional treatment option.

PATIENTS AND METHODS

We examine retrospectively 8 patients (4 females, 4 males) with peritoneal sarcomatosis. The most common histology type was the liposarcoma (4/8). The chemotherapeutic agents that were administered were mitomycin, cisplatin and doxorubicin. We analyse our cases with regard to the PCI, the CC score, the complications that occurred and the overall survival.

RESULTS

A complete level of cytoreduction (CC0/1) was feasible in 5/8 of patients. We report post-operative complications such as GI leaks and fistulas in 3 cases and infections in 2 cases. Overall survival was proved to depend on the PCI (better overall survival rate when PCI<20) DISCUSSION: We identify acceptable morbidity, comparable to other series of patients undergoing CRS+HIPEC for other histologies. The specific sarcoma type and the previous treatment received prove to be factors that alter significantly the prognosis and the survival rates: therefore, conclusions cannot be safely excluded in such small patient series. On the whole, we conclude that, given the already positive and promising results from CRS+HIPEC in sarcomatosis, more studies need to be performed, in order to determine the role of all the aforementioned factors.

KEY WORDS

Fibrosarcoma, HIPEC, Leiomyosarcoma, Liposarcoma, Rabdomyosarcoma, Sarcomatosis.

Is cholecystectomy and removal of the round ligament of the liver a necessary step in cytoreductive surgery and HIPEC, for peritoneal carcinomatosis?

AIM

To determine if cholecystectomy and liver's round ligament removal is a necessary step during cytoreductive surgery (CRS) and HIPEC METHODS: This was a retrospective observational study based on records from 180 patients treated in our center from 2005 to 2014. All patients have been offered CRS and HIPEC for peritoneal pseudomixoma (20 patients), peritoneal mesothelioma (7 patients), peritoneal carcinomatosis from ovarian cancer (66 patients), colorectal cancer (42 patients), gastric cancer (10 patients), mucinous adenocarcinoma of the appendix (28), and other abdominal malignancies (7 patients). We performed a cholecystectomy and we removed the round ligament of the liver in all patients, even if there wasn't a macroscopic tumor infiltration of the above anatomical structures. We reviewed the histological reports of all 180 patients.

RESULTS

Patients with peritoneal carcinomatosis from mucinous adenocarcinoma of the appendix were treated more aggressively, due to the macroscopic appearance of the disease. Histologic report show no evidence of metastases at the round ligament of the liver in 21, 4% of the patients that were treated with CRS although it was estimated to be involved based on the macroscopic examination at the time of surgery. Tumor involvement of the gallbladder was overestimated, macroscopically, at the same patients in 25% of the cases. In patients with peritoneal carcinomatosis from ovarian cancer, macroscopic appearance of the gallbladder may be delusive. In 25% of the above patients there was a microscopic tumor involvement of the gallbladder, although there was not macroscopic evidence of the disease.

CONCLUSION

More extended cytoreductive surgery is needed in case of peritoneal carcinimatosis from ovarian cancer. In case of PC from mucinous adenocarcinoma of the appendix, it's difficult to calculate the extent of the disease and avoid unnecessary surgical excisions. More data is needed to confirm the above.

KEY WORDS

Cytoreductive surgery, Gallbladder, HIPEC, Peritoneal carcinomatosis, Round ligament of the liver.

Mapping the location of peritoneal metastases using the peritoneal cancer index and the correlation with overall survival: a retrospective study

PURPOSE

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising treatment for patients with peritoneal carcinomatosis (PC). Our objective was to identify new prognostic factors within the Peritoneal Cancer Index (PCI) score in PC patients.

METHODS

140 patients (60 ovarian, 45 colon, 14 gastric, 10 pseudomyxoma peritonei, 5 mesothelioma, 6 sarcoma) with PC treated with CRS+HIPEC from 2007 to December 2013 were retrospectively included. Tumor extent and location were assessed by the PCI and residual disease was recorded using the Completeness of Cytoreduction (CC) score. All clinical data were computed in univariate and multivariate analysis using survival as primary endpoint.

RESULTS

The PCI remains the most important factor concerning the long-term survival. Involved areas 4, 5 and 8 are more favorable in survival vs areas 9, 10 and 11, which predict a significantly worse outcome (p<0.002). Prognosis varies not only depending on how many peritoneal areas are involved but also on the location of the primary tumor.

CONCLUSION

We demonstrated that the involvement of different areas in the PCI system has a significant impact on the final prognosis and survival.

Cytoreductive surgery and HIPEC for peritoneal carcinomatosis. A review on morbidity and mortality

PURPOSE

To review morbidity and mortality of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis.

METHODS

A literature search was conducted to identify studies from centers that perform CRS and HIPEC, and to collect and analyse data about morbidity and mortality.

RESULTS

Twenty-five articles, published from 2006 to 2014 were reviewed. The studies included 24-1069 patients that had been treated with CRS and HIPEC for peritoneal carcinomatosis. The overall rate of severe perioperative morbidity ranged from 0 to 62% and the mortality rate varied from 0 to 10%. Major morbidity was correlated with age, peritoneal carcinomatosis index (PCI), comorbidities, number of digestive anastomoses and institution where the treatment was performed.

CONCLUSION

Although the resultant morbidity is not negligible, with good patient selection this modality appears to be overall safe and effective in experienced hands. The results indicated that this treatment should be practised by institutions with expertise in the management of peritoneal carcinomatosis.

Digestive fistulas after cytoreductive surgery & HIPEC in peritoneal carcinomatosis

PURPOSE

The development of digestice fistulas is a complication of gastrointestinal operations during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). In this article we present the incidence, management and outcome of enterocutaneous digestive fistulas after CRS and HIPEC.

METHODS

Over the past 10 years (2005-2014), 184 patients with peritoneal carcinomatosis underwent CRS and HIPEC. HIPEC was administered in the operating room immediately after CRS, but in 48 (26%) patients this happened before the formation of intestinal anastomosis or repair of seromuscular tears, using the open (coliseum) technique; in the remaining 137 (74%) patients the anastomoses were performed before HIPEC. All patients were operated on by the same surgical team.

RESULTS

Of the 185 patients 16 (8.6%) developed an enterocutaneous digestive fistula. Spontaneous fistula closure was observed in 14 (87.5%) patients. The median duration of spontaneous closure was 18 days (range 9-56). Reoperation was needed in 2 (12.5%) patients. There were 2 (12.5%) deaths.

CONCLUSION

CRS and HIPEC is a well-known treatment modality for peritoneal carcinomatosis. The incidence of digestive fistulas is increased a little compared to that of conventional digestive surgery.

The role of cytoreductive surgery and HIPEC in epithelial ovarian cancer

Epithelial ovarian cancer (EOC) is the most common cause of death from gynecological cancer in the Western world. The current standard treatment of these patients consists of cytoreduction and systemic chemotherapy. One of the most distinct features of EOC is the tendency to disseminate into the peritoneal cavity and remain confined to the peritoneum and intra-abdominal viscera. This makes it an ideal target for loco-regional therapy. Improved long-term results can be achieved in highly selected patients using cytoreductive surgery (CRS), in combination with intra-operative hyperthermic intra-peritoneal chemotherapy (HIPEC). Optimal cytoreduction of advanced ovarian cancer is currently the most relevant prognostic factor. However, even when a complete resection is possible, the appearance of recurrences during follow-up is very common, due to the presence of microscopic residual disease, not visible to the surgeon. HIPEC has become a useful therapeutic strategy to obtain a higher degree of debulking by trying to eliminate the residual microscopic component responsible for recurrences. A summary of the current clinical evidence suggests that the most interesting settings first to explore in randomized trials are secondary CRS after upfront incomplete CRS for stage III ovarian cancer and salvage CRS for recurrent ovarian cancer, two time-points representing failure to initial standard therapy. There is much less indirect evidence for a potential benefit of HIPEC for less advanced stages (I - II) and for earlier time-points in the treatment of ovarian cancer (upfront, interval and consolidation). CRS and HIPEC offer a significant survival benefit in patients with recurrent EOC. This observation applies to both platinum-sensitive and platinum-resistant disease.