Intra- and Interpatient Drug Response Heterogeneity Exist in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Nongynecologic Cancers

BACKGROUND

Select patients with peritoneal metastases are treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). We assayed for intra- and interpatient drug response heterogeneity through testing of patient-derived tumor organoids (PDTOs).

METHODS

PDTOs were generated from CRS/HIPEC patients from December 2021 to September 2022 and subjected to an in vitro HIPEC drug screen. Drug response was assessed with a cell viability assay and cleaved caspase-3 staining.

RESULTS

A total of 31 patients were consented for tissue collection. Viable tissue was harvested from 23, and PDTO generation was successful in 13 (56%). PDTOs were analyzed from six appendiceal, three colorectal, two small bowel, one gastric, and one adrenal tumor. Drug screen results were generated in as few as 7 days (62%), with an average time of 12 days. Most patients received mitomycin-C (MMC) intraoperatively (n = 9); however, in only three cases was this agent considered the optimal choice in vitro. Three sets of PDTOs were resistant (defined as > 50% PDTO viability) to all agents tested and two were pan-sensitive (defined as 3 or more agents with < 50% PDTO viability). In three patients, organoids were generated from multiple metastatic sites and intrapatient drug response heterogeneity was observed.

CONCLUSIONS

Both intra- and interpatient drug response heterogeneity exist in patients undergoing CRS/HIPEC for nongynecologic abdominal cancers. Caution must be used when interpreting patient response to chemotherapeutic agents based on a single site of testing in those with metastatic disease.

Laparoscopic Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Peritoneal Metastasis: Improved Short-term Outcomes Revealed Through Propensity Score Matching Analysis

INTRODUCTION

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the standard of care for selected cases of primary or secondary peritoneal surface malignancies. The study aims to verify the postoperative advantages of laparoscopic CRS-HIPEC.

METHODS

A retrospective analysis of patients who underwent CRS-HIPEC at our institution was performed. Records were extracted from a prospectively maintained database. Patients were divided into two groups, laparoscopic CRS-HIPEC and open CRS-HIPEC, and matched for age, ASA, comorbidities, Prior Surgical Score (PSS), and Peritoneal Cancer Index (PCI) using propensity score analysis. Demographics, clinical, and operative data were compared between the two groups using chi-square or Fisher's exact test and T-test or Mann-Whitney U test.

RESULTS

Between 2016 and 2022, 13 patients underwent laparoscopic CRS-HIPEC. These were matched to 32 open CRS-HIPEC patients (1:2.5), obtaining comparable demographics and clinical and preoperative variables. The two groups had a similar duration and complexity of surgery; however, the mean estimated blood loss was lower during laparoscopic procedures (p = 0.008). Overall morbidity rates were lower after laparoscopic CRS-HIPEC (p = 0.043); however, grade III-IV complications, reintervention, and 90-day readmission rates were comparable between the two groups. A faster postoperative recovery in all aspects of the postoperative course was observed, including hospital length of stay (6 vs. 9.5 days, p = 0.003).

CONCLUSIONS

Laparoscopic CRS-HIPEC is a feasible and safe procedure and shows improved short-term postoperative outcomes in selected patients with limited peritoneal disease compared to the open approach.

2022 Peritoneal Surface Oncology Group International Consensus on HIPEC Regimens for Peritoneal Malignancies: Colorectal Cancer

BACKGROUND

Selected patients with peritoneal metastases of colorectal cancer (PM-CRC) can benefit from potentially curative cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC), with a median overall survival (OS) of more than 40 months.

OBJECTIVE

The aims of this evidence-based consensus were to define the indications for HIPEC, to select the preferred HIPEC regimens, and to define research priorities regarding the use of HIPEC for PM-CRC.

METHODS

The consensus steering committee elaborated and formulated pertinent clinical questions according to the PICO (patient, intervention, comparator, outcome) method and assessed the evidence according to the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework. Standardized evidence tables were presented to an international expert panel to reach a consensus (4-point, weak and strong positive/negative) on HIPEC regimens and research priorities through a two-round Delphi process. The consensus was defined as ≥ 50% agreement for the 4-point consensus grading or ≥ 70% for either of the two combinations.

RESULTS

Evidence was weak or very weak for 9/10 clinical questions. In total, 70/90 eligible panelists replied to both Delphi rounds (78%), with a consensus for 10/10 questions on HIPEC regimens. There was strong negative consensus concerning the short duration, high-dose oxaliplatin (OX) protocol (55.7%), and a weak positive vote (53.8-64.3%) in favor of mitomycin-C (MMC)-based HIPEC (preferred choice: Dutch protocol: 35 mg/m2, 90 min, three fractions), both for primary cytoreduction and recurrence. Determining the role of HIPEC after CRS was considered the most important research question, regarded as essential by 85.7% of the panelists. Furthermore, over 90% of experts suggest performing HIPEC after primary and secondary CRS for recurrence > 1 year after the index surgery.

CONCLUSIONS

Based on the available evidence, despite the negative results of PRODIGE 7, HIPEC could be conditionally recommended to patients with PM-CRC after CRS. While more preclinical and clinical data are eagerly awaited to harmonize the procedure further, the MMC-based Dutch protocol remains the preferred regimen after primary and secondary CRS.

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.

The robotic future of minimally invasive cytoreduction and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been increasingly utilized for peritoneal surface malignancies. This has been commonly utilized for a variety of neoplasms, but, especially mucinous neoplasms of the appendix, ovarian cancer, gastric cancer, colorectal cancer and mesothelioma. Traditionally, CRS/HIPEC has been performed as an open, extensive operation associated with prolonged hospitalization. However, when the peritoneal carcinomatosis index (PCI) is small (<10), minimally invasive approaches can be considered. Such less invasive approaches may be associated with improved postoperative recovery, less complications while preserving oncologic outcomes. The robotic platform offers distinct advantages over laparoscopy with superior visualization and ergonomics which account for its increased utilization in oncologic surgery. Herein, we review available data on minimally invasive approaches to CRS/HIPEC procedures, focusing on patient selection and comparative studies to open CRS/HIPEC. We summarize the existing initial studies on robotically assisted CRS/HIPEC and provide technical insights about our approach to robotically assisted CRS/HIPEC. Current data suggests that treatment of peritoneal surface malignancies with minimally invasive CRS/HIPEC is feasible in selected cases and is associated with improved postoperative recovery. The robotically assisted platform for CRS/ HIPEC deserves further investigation and may improve outcomes after this procedure in the future for carefully selected patients with low PCI.

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.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in the management of peritoneal surface malignancies - An evidence-based review

BACKGROUND

Traditionally, peritoneal surface malignancies (PSM) were considered terminal diseases because of their advanced nature, therefore, systemic chemotherapy was given with palliative intent only. As a result, very poor survival outcomes were observed. But with the introduction of complete Cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC), the scenario has changed dramatically.

METHODOLOGY

An objective electronic database search was performed in Pubmed, NLM Catalog, Google scholar, Bookshelf, and Pubmed Central published in the time period from 2000 till 2020. All the randomized studies were included. In the absence of randomized studies, both prospective and retrospective studies were included. The outcomes of HIPEC were measured in terms of median survival, disease-free survival, overall survival, complications and drug toxicities.

RESULTS

CRS and HIPEC are considered the standard of care for PMP and MPM even in the absence of level 1 evidence due to lack of an effective alternative treatment. In colorectal and gastric cancer, several phase-three trials are showing overall survival benefit in selected cases while there is a prophylactic and palliative role of HIPEC in gastric cancer. Three reported phase 3 trials showed positive results in ovarian cancer. In peritoneal sarcomatosis, the role of HIPEC is yet to be proven.

CONCLUSION

The patient selection is the key to the successful outcomes after HIPEC. HIPEC should be performed by the experienced surgeons in specialized centres with a strong critical care and intensive care support to reduce the morbidity and mortality. Ongoing trials and future directions will prove to be an indispensable arm in the oncological armamentarium.

Establishing of Peritoneal Surface Malignancy Treatment Program: Background in Ukraine, Patient Selection, Staff Schedule, Perioperative Outcomes of First 28 Patients

A combination of cytoreductive intervention with the intrahepatic hyperthermic chemotherapy is a well-established treatment of peritoneal carcinomatosis. There are many challenges in establishing a new peritoneal surface malignancy program in a low-income country regarding perioperative safety and resource allocation. We analyzed the retrospective database to determine the immediate surgical outcomes of the first 28 patients with peritoneal carcinomatosis and the impact of the program on allocation of general hospital and human resources. During the preparatory stage, web conferences with international experts established the goals and general requirements of the program, formalized in a written document; and a peritoneal surface malignancy multidisciplinary team was established. The team created the patient selection criteria, perioperative management checklists, and suggested material and staff requirements for surgical and anesthesia services. Twenty-nine cytoreduction were carried out, of which 18 were followed by HIPEC. The average operative time was 6.2 h. The median blood loss was 350 mL, which did not result in additional blood transfusion requirements for the blood bank. No additional nursing and supportive staff were provided for the ICU and the surgical unit. The average postoperative stay was 8.7 days. One patient died with 30-day mortality rate of 3%. Ten patients (34.5%) developed postoperative complications, of which 6 (20.6%) had grade III and higher Clavien-Dindo complications. Establishing a peritoneal surface malignancy program is possible via staged planning, liberal use of international mentors, and thoughtful resource allocation. This new program did not result in a significant redistribution of resources among other service lines of cancer care within the same institution.

Cytoreductive surgery and HIPEC in a 14 years old patient with peritoneal recurrence of adenocarcinoma of the right colon

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Cytoreduction (CRS) and HIPEC is a feasible and safe treatment of Peritoneal surface malignancies.

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Multidisciplinary evaluation of the patient is mandatory to obtain positive results.

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Cases of CRS and HIPEC in children are few; it’s important to share every cases with the surgical and oncological community.

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In well selected cases, both disease free survival and overall survival are improved.

Introduction

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is nowadays a feasible and effective treatment for peritoneal metastasis. We present a case of a 14 years old child with peritoneal metastasis from recurrent colorectal cancer.

Presentation of case

Colonoscopy and CT-scan were performed leading to the diagnosis of a stenosing adenocarcinoma of the right colon in 2015. Two pelvic lesions were found at the total body PET scan, suspected for peritoneal metastasis. Neoadjuvant chemotherapy was administered, and restaging CT-scan and magnetic resonance (MRI) highlighted a partial response. The patient underwent right laparoscopic hemicolectomy. The postoperative staging was T4 N1 G3. Seven months after the last cycle of adjuvant chemotherapy, CT-scan revealed two huge abdominal masses. The patient underwent explorative laparotomy and bilateral oophorectomy, positive for metastasis from colorectal cancer and peritoneal washing cytology was positive for neoplastic cells. A CT-scan was performed on December 2017 showed a suspect lesion below the anterior abdominal wall. The case was discussed at the tumour board and the indication for CRS and HIPEC was given. In January 2018 the child underwent complete CRS and HIPEC with no complications. No adjuvant chemotherapy was administered. After 11 months the follow up is negative for the recurrent disease.

Discussion and conclusion

Cytoreduction and HIPEC can be performed even in children as a feasible and safe treatment with successful outcomes. As for adults, an appropriate multidisciplinary pre-operative work up and a correct cases selection is needed to have the best results even regarding the quality of life.

Current practices of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal surface malignancies: an international survey of oncologic surgeons

Background

The goal of the study was to investigate the current clinical practices among oncologic surgeons regarding cytoreductive surgery (CRS) with intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods

From September to October 2016, an online questionnaire surveyed the oncologic surgeons by email. The questionnaire included 20 multiple-choice questions of the following: eligibility for the CRS with HIPEC procedure, perioperative staging and surgery skill, assessment of residual tumors, and method used for intraperitoneal HIPEC.

Results

The response rate was 16% (34/217). The majority of respondents (68%) worked at a university hospital. All respondents indicated that mesenteric invasion is the most crucial factor affecting treatment decision. Most surgeons (79%) used the Sugarbaker’s staging system to intraoperatively measure the extent of peritoneal invasion. The methods used to measure the extent of miliary pattern of residual tumor spread, and the amount of residual tumor after electrocauterization varied among the surgeons. Most responders (65%) used the closed system of HIPEC.

Conclusions

Despite the fact that CRS HIPEC is the standard treatment for PSM, the clinical practices are very different according to each clinical situation. Nevertheless, mesenteric invasion was found to be the most important factor impacting the treatment decision-making by the majority of responders.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1377-7) contains supplementary material, which is available to authorized users.

Peritoneal metastases of rare carcinomas treated with cytoreductive surgery and HIPEC - A single center case series

Introduction

In selected cases, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an established treatment for patients suffering from peritoneal metastases from colorectal, ovarian, gastric or appendiceal origin. The effectiveness of this extensive has not been elucidated within other rare diseases by now.

Methods

We conducted a retrospective analysis of patients treated with CRS for peritoneal carcinomatosis during the period between July 2010 and September 2015. Exclusion criteria were adenocarcinomas of the stomach, colon, neoplasms of the appendix, mesothelioma and ovarian cancers. Aim of this study was to examine the feasibility, complication rate and survival of patients with rare diseases.

Results

A total of 14 Patients were included: Four rare gynecological tumors, three adenocarcinomas of the small intestine, three retroperitoneal sarcomas, one cholangiocellular carcinoma, one neuroendocrine gastric tumor, one malignant peripheral nerve sheath tumor and one cancer of unknown primary syndrome. In 12 of 14 patients a macroscopically complete tumorresection could be achieved. No patient died during hospitalization. Seven of 14 patients experienced general complication of grade III according to NCI CTCAE V4.0, while two experienced complications of grade IV. Median follow-up and one year overall survival were 15.5 months and 46.8%, respectively.

Conclusion

For patients with rare tumors, CRS and HIPEC is feasible with an acceptable perioperative morbidity and mortality. To improve knowledge in patient selection and outcome, rare tumors treated with CRS and HIPEC should be documented in central databases (as for example BIG RENAPE, Pierre-Benite, France).

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The difficulties in deciding of whether to perform CRS and HIPEC for PSM arising from unusual malignancies are remaining.

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Perioperative morbidity for extensive surgical treatment and HIPEC is acceptable in specialized PSM centers.

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The prospective registration in tumor registries could help to better define the indications for CRS and HIPEC in rare PSM.

Anaesthetic Considerations in the Perioperative Management of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has emerged as one of the primary modalities of treatment of diffuse peritoneal malignancies. It is a complex surgical procedure with the patients facing major and potentially life threatening alterations of haemodynamic, respiratory, metabolic and thermal balance with significant fluid losses and the perioperative management is challenging for anaesthesiologists and intensive care physicians. Though the alterations are short lived, these patients require advanced organ function monitoring and support perioperatively. The anaesthesiologist is involved in the management of haemodynamics, respiratory function, coagulation, haematologic parameters, fluid balance, thermal variations, and metabolic and nutritional support perioperatively. The chemotherapy instillate used are known to cause nephrotoxicity, cardiotoxicity, dyselectrolytemia and lactic acidosis. The preoperative polypharmacy for pain control, previous surgery and/or chemotherapy, malnourished status secondary to feeding problems and tumour wasting syndrome make the task all the more challenging. The anaesthesiologist also needs to consider the perioperative care from a quality of life perspective and proper preoperative counselling is important. The present overview summarizes the challenges faced by the anaesthesiologist regarding the pathophysiological alterations during the Cytoreductive surgery and Hyperthermic intraperitoneal chemotherapy in the preoperative, intraoperative and postoperative periods.

Complications after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for treatment of peritoneal carcinomatosis: Risk factors for ICU admission and morbidity prognostic score

BACKGROUND AND OBJECTIVES

For patients suffering from peritoneal carcinomatosis, cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is the only curative option. We focused on severe complications in the postoperative course of HIPEC.

METHODS

We studied perioperative data from patients who underwent HIPEC between January 2010 and August 2011. Our primary objective was to identify perioperative risk factors for ICU admission. Our secondary objective was to identify patient that may be re-admitted to the ICU thanks to a prognostic score.

RESULTS

122 patients underwent HIPEC. 32 presented severe adverse events (26.2%) and 7 died (5.7%). Reasons for ICU admission were septic shock in 28.1% of patients, hemorrhagic shock for 21.9%, hemodynamic instability for 15.6%, respiratory causes for 6.2% and post-operative acidosis for 6.2%. Vasopressors were required for 34% and 40.6% were mechanically ventilated.

CONCLUSION

Peritoneal cancer index, diaphragmatic peritonectomy, the need of vasopressive therapy, total volume of fluid leakage collected in drains and total volume of fluid therapy administered at day 1 reported on ideal body weight were the 5 significant variables that we combined to build a morbidity prognostic score. One patient over 4 is likely to present severe complications. A predictive morbidity score provide informative data for clinicians.

Cytoreductive surgery with a hyperthermic intraperitoneal chemotherapy program: Safe after 40 cases, but only controlled after 140 cases

BACKGROUND

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC), used to treat peritoneal surface malignancies (PSM), is a complex procedure with significant major morbidity (MM).

OBJECTIVE

To investigate the learning curve (LC) of CRS with HIPEC in a new specialized surgical unit with a fully trained senior surgeon and individualize the variables associated with morbidity and oncological results.

METHODS

A total of 290 consecutive patients with PSM were included. Complete CRS with HIPEC was performed in 204 patients. A risk-adjusted sequential probability ratio test was used to assess the LC on the basis of rates of incomplete cytoreduction (IC) and MM.

RESULTS

Complete CRS, MM, and mortality rates were 70.4%, 30.4%, and 2.5%, respectively. Tumor histotype, a high peritoneal cancer index (PCI) and the invaded region were the major independent risk factors for IC, whereas previous surgery, high PCI, stomia realization and blood transfusion were predictors of MM. RA-SPRT showed that 140 and 40 cases were needed to achieve the lowest risk of IC and MM, respectively.

CONCLUSION

CRS with HIPEC to treat PSM has a steep LC. Drastic selection has to be made at the beginning, excluding high PCI, rare peritoneal disease and patients previously operated on.

Peritoneal Surface Disease Severity Score as a predictor of resectability in the treatment of peritoneal surface malignancies

BACKGROUND

We evaluated the clinical utility of the Peritoneal Surface Disease Severity Score (PSDSS) as a preoperative predictor of resectability in the treatment of peritoneal surface malignancies.

METHODS

Forty-nine patients were selected for cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) and were stratified according to the PSDSS retrospectively.

RESULTS

Of 52 cytoreductive surgeries performed in 49 patients, HIPEC was performed in 33 cases (63%). We analyzed 31 cases of appendiceal and colorectal cancer patients who underwent CRS and HIPEC and 12 who underwent CRS only. 68% of the patients in whom CRS and HIPEC was performed were classified as PSDSS stage I or II. Contrastingly, all patients in whom CRS and HIPEC was unachievable were scored as PSDSS stage III or IV.

CONCLUSIONS

The outcomes of this study suggest that the PSDSS can be used as a preoperative assessment tool to predict disease resectability in the treatment of peritoneal surface malignancies.

Diffuse malignant peritoneal mesothelioma: long-term survival with complete cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC)

BACKGROUND

Prognosis of diffuse malignant peritoneal mesothelioma (DMPM) has been recently improved by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). As with other peritoneal surface malignancies, the survival benefit is maximal when a complete surgical cytoreduction is achieved, but additional factors predicting long-term outcome are still poorly understood. We sought to investigate outcome and prognostic factors in patients with DMPM treated by complete cytoreduction and HIPEC.

METHODS

From a prospective database, we selected 108 patients with DMPM undergoing complete cytoreduction (residual tumour nodules ≤2.5 mm) and closed-abdomen HIPEC with cisplatin and doxorubicin or mitomycin-C. Twenty-seven patient-, tumour- and treatment-related variables were assessed by multivariate analysis with respect to overall (OS) and progression-free (PFS) survival. A panel of immunohistochemical markers was tested.

RESULTS

Operative mortality was 1.9% and major morbidity 38.9%. Median follow-up was 48.8 months (95% confidence interval (CI) 37.1-60.6). Median OS and PFS were 63.2 months (95%CI 29.6-96.7) and 25.1 months (95%CI 5.1-45.1). The survival curve reached a plateau after 7 years, representing 19 actual survivors of 39 patients (43.6%) with potential follow-up ≥7 years. Cytokeratin 5/6, calretinin, Wilms tumour-1 (WT-1), podoplanin and epithelial growth factor receptor (EGFR) were mostly positive. At multivariate analysis, epithelial histological subtype, negative lymph-nodes, ≤10% Ki67-positive cells correlated with both increased OS and PFS. Positive podoplanin correlated to increased PFS.

CONCLUSIONS

After complete cytoreduction and HIPEC, prognosis of DMPM is primarily dependent on pathologic and biologic features. Patients with DMPM surviving ≥7 years appeared to be cured. Cure rate was 43.6%. Proliferative index and podoplanin may be used for prognostic stratification.

Rationale and techniques of cytoreductive surgery and peritoneal chemohyperthermia

The evolution of loco-regional treatments has occurred in the last two decades and has deeply changed the natural history of primitive and secondary peritoneal surface malignancies. Several phase II-III studies have proved the effectiveness of the combination of cytoreductive surgery with peritoneal chemohyperthermia. Cytoreductive surgery allows the reduction of the neoplastic mass and increases tumoral chemosensitivity. The development of chemohyperthermia finds its origins in the necessity to exceed the limits of intraperitoneal chemotherapy performed in normothermia. It permits a continuous high concentration gradient of chemotherapeutic drugs between the peritoneal cavity and the plasma compartment to and a more uniform distribution throughout the abdominal cavity compared to systemic administration.

Early and long-term postoperative management following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Peritoneal surface malignancies have been traditionally regarded as end-stage conditions amenable to merely palliative options. The combination of aggressive cytoreductive surgery (CRS), involving peritonectomy procedures and multivisceral resections, with intra-operative hyperthermic intra-peritoneal chemotherapy (HIPEC) and/or early postoperative intra-peritoneal chemotherapy (EPIC) to treat the microscopic residual tumor is a new concept. In recent years, promising results have been reported for peritoneal mesothelioma and carcinomatosis of gastrointestinal and gynaecologic origin treated by this combined protocol. However, CRS with HIPEC and/or EPIC is a complex procedure associated with high rates of potentially life-threatening complications. Furthermore, disease progression following comprehensive treatment is not uncommon and represents a relevant cause of treatment failure. The present paper reviews the available information on early postoperative management and long-term follow-up in patients treated with CRS and intraperitoneal chemotherapy. The peculiar clinical and biological alterations that can be expected during an uncomplicated postoperative course, as compared to standard digestive surgery, are discussed. Early recognition and appropriate management of the most common adverse events are addressed, in order to minimize the impact of treatment-related morbidity on survival and quality of life results. Since re-operative surgery with additional HIPEC, has proven to be useful in selected patients with recurrent disease, long-term surveillance aiming at early detection of postoperative disease progression has become a relevant issue. Current results on follow-up investigations are presented.