Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary artery bypass grafting techniques

Impacts of low peritoneal cancer index on the survival outcomes of patient with peritoneal carcinomatosis of colorectal origin

INTRODUCTION

The combination of cytoreductive surgery (CRS) and perioperative chemotherapy (PIC) have been proposed as an innovative technique for peritoneal carcinomatosis and is currently considered as a standard treatment for colorectal peritoneal carcinomatosis (CRPC) in selected patients. Peritoneal cancer index (PCI) has been suggested to be the most important prognostic factors for the outcomes of patients with CRPC. In this paper, we have studied patients with CRPC and a very low PCI of 5 or less and their survival outcomes.

METHODS

This is a retrospective study of prospectively collected data of 60 consecutive patients with CRPC and PCI ≤ 5, who underwent CRS and PIC by the same surgical team at St George hospital in Sydney, Australia between January 1996 and April 2015. Clinical outcomes of these patients were analysed.

RESULTS

Hospital mortality was 0%. 14 patients (23.4%) had grade III/IV morbidity. The median follow-up was 22.2 months (range = 0.1-104.2). The median survival was 80.6 months (95% confidence interval (CI) = 35.1-126.1), with an overall 1-year, 3-year, and 5-year survival rate of 96.1%, 72.6% and 54.7% respectively. Among 60 patients, 31 patients experienced the recurrence of the disease (51.7%). The median disease-free survival was 10.8 months (95% CI = 7.2-14.4).

CONCLUSION

This innovative approach combining CRS and PIC has shown encouraging outcomes and offers hope for patients with CRPC. Our results suggest that CRS and PIC can be performed safely to provide significant survival benefits for patients with low volume of disease. Early referral to specialist centre for evaluation is warranted for better survival outcomes.

Hypoxia Promotes Synergy between Mitomycin C and Bortezomib through a Coordinated Process of Bcl-xL Phosphorylation and Mitochondrial Translocation of p53

Colorectal peritoneal carcinomatosis (CPC) exhibits severe tumor hypoxia, leading to drug resistance and disease aggressiveness. This study demonstrates that the combination of the chemotherapeutic agent mitomycin C with the proteasome inhibitor bortezomib induced synergistic cytotoxicity and apoptosis, which was even more effective under hypoxia in colorectal cancer cells. The combination of mitomycin C and bortezomib at sublethal doses induced activation of c-Jun NH2-terminal kinase and p38 mitogen-activated protein kinase and resulted in Bcl-xL phosphorylation at Serine 62, leading to dissociation of Bcl-xL from proapoptotic Bak. Interestingly, the intracellular level of p53 became elevated and p53 translocated to the mitochondria during the combinatorial treatment, in particular under hypoxia. The coordinated action of Bcl-xL phosphorylation and p53 translocation to the mitochondria resulted in conformational activation of Bak oligomerization, facilitating cytochrome c release and apoptosis induction. In addition, the combinatorial treatment with mitomycin C and bortezomib significantly inhibited intraperitoneal tumor growth in LS174T cells and increased apoptosis, especially under hypoxic conditions in vivo. This study provides a preclinical rationale for the use of combination therapies for CPC patients.

IMPLICATIONS

The combination of a chemotherapy agent and proteasome inhibitor at sublethal doses induced synergistic apoptosis, in particular under hypoxia, in vitro and in vivo through coordinated action of Bcl-xL and p53 on Bak activation.

Cytoreductive surgery (SRC) and hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of peritoneal carcinomatosis: Our initial experience and technical details

OBJECTIVE

The aim of this study is to present our initial experience in peritoneal carcinomatosis treatment and the technical details of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the light of current literature.

MATERIAL AND METHODS

Data of 27 consecutive patients who were treated with CRS and HIPEC for peritoneal carcinomatosis in Medical Park Samsun Hospital, between November 2012 and September 2014 were retrospectively reviewed. Treatment indication and management were evaluated at the multidisciplinary oncology council. All patients underwent CRS and HIPEC with the aim of complete cytoreduction. Patients with unresectable disease and/or palliative surgery were excluded from analysis. Perioperative complications were classified according to Clavien-Dindo classification, and HIPEC-related side effects were identified using National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) criteria. Demographic, clinical and histopathological data of the patients were analyzed.

RESULTS

The mean age was 54 (32-72). Nineteen patients were female. The origin of peritoneal carcinomatosis was colorectal cancer in 12 patients, ovarian cancer in 12 patients, gastric cancer in 2 patients and pseudomyxoma peritonei in 1 patient. The mean Peritoneal Carcinomatosis Index was 12 (3-32), with a mean operative time of 420 (300-660) minutes. Perioperative morbidity, HIPEC-related toxicity and perioperative mortality were observed in eight (30%), one (3.7%) and four patients (14.8%), respectively. During a mean follow up of 13 (1-22) months, overall and disease-free survival rates were 95.8% and 82.6%, respectively. Two patients with colorectal cancer (after 9 and 12 months) and one patient with ovarian cancer (after 11 months) had intra-abdominal recurrence. One patient with ovarian cancer had liver metastases 13 months after surgery, and underwent resection of segments 6-7. The remaining patients are being followed-up without any recurrence.

CONCLUSION

Cytoreductive surgery and HIPEC have favorable results in the treatment of patients with peritoneal carcinomatosis. Compatible with the literature, surgical outcomes of the presented series are encouraging for this treatment modality that have been recently popularized in our country. Careful perioperative evaluation, proper patient selection and multidisciplinary approach are essential for success in curative treatment of peritoneal carcinomatosis.

Evolution of management in peritoneal surface malignancies

Management of peritoneal surface malignancies has gradually evolved by the introduction of cytoreductive surgery in combination with intraperitoneal chemotherapy applications. Recently, peritoneal metastases of intraabdominal solid organ tumors and primary peritoneal malignancies such as peritoneal mesothelioma are being treated with this new approach. Selection criteria are important to reduce morbidity and mortality rates of patients who will experience minimal or no benefit from these combined treatment modalities. Management of peritoneal surface malignancies with this current trend is presented in this review.

Linear Relationship of Peritoneal Cancer Index and Survival in Patients with Peritoneal Metastases from Colorectal Cancer

BACKGROUND

The peritoneal cancer index (PCI) is the main prognostic factor for establishing potentially resectable peritoneal metastases from colorectal cancer. Attempts have been made to set a PCI cutoff on which to base indications of complete cytoreductive surgery (CCRS) with hyperthermic intraperitoneal chemotherapy (HIPEC), but none have reached consensus. The aim of this study was to investigate the relation between the PCI and overall survival (OS).

METHODS

We included all consecutive patients homogeneously treated with CCRS and HIPEC between 2003 and 2012. The PCI was calculated at the end of the surgical procedure. The correlation between the PCI and OS was studied using statistical modeling from the simplest to the most complex methods (including linear, quadratic, cubic, and spline cubic). These models were compared by Akaike's information criteria (AIC).

RESULTS

For the 173 treated patients, 5-year OS reached 41 %. The mean PCI was 10.2 (±6.8). The linear model was the most appropriate to relate the PCI to OS as confirmed with the AIC scoring system. In multivariate analysis, the PCI was confirmed as being the most important prognostic factor (hazard ratio = 1.1 for each supplementary point, p < 0.0001).

CONCLUSIONS

There is a perfect linear correlation between the PCI and OS, which precludes setting a unique PCI cutoff for CCRS + HIPEC. Overall, CCRS + HIPEC is generally indicated for PCI < 12 and contraindicated for PCI > 17. Between 12 and 17, other parameters have to be taken into account, such as the presence of extraperitoneal metastases, general performance status, and chemosensitivity.

Cytoreductive surgery of colorectal peritoneal metastases: outcomes after complete cytoreductive surgery and systemic chemotherapy only

Background

Cytoreductive peritoneal surgery (CRS) associated with hyperthermic peritoneal chemotherapy (HIPEC) has long been considered the standard treatment for colorectal peritoneal metastases (CPM). However, although efficacy of surgery has been demonstrated, evidence supporting HIPEC’s role is less certain.

Method

Overall survival (OS), progression-free survival (PFS) and morbidity were analysed retrospectively for fifty consecutively included patients treated for colorectal CPM with complete CRS and systemic chemotherapy only.

Results

Median peritoneal cancer index (PCI) was 8 (range 1-24). 23 patients had liver or lung metastases (LLM). 22 patients had synchronous CPM. 27 complications occurred (12 Grade 1/2, 14 Grade 3, 1 Grade 4a, 0 Grade 5). Median follow-up was 62.5 months (95 %CI 45.4-81.3), median survival 32.4 months (21.5-41.7). Three- and 5-year OS were 45.5% (0.31-0.59) and 29.64% (0.17-0.44) respectively. Presence of LLMs associated with peritoneal carcinomatosis was significantly associated with poorer prognosis, with survival at 5 years of 13.95% (95 %CI 2.9-33.6) vs. 43.87% (22.2-63.7) when no metastases were present (P= 0.018). Median PFS was 9.5 months (95 %CI 6.2-11.1).

Conclusion

With an equivalent PCI range and despite one of the highest rates of LLM in the literature, our survival data of CRS + systemic chemotherapy only compare well with results reported after additional HIPEC. Tolerance was better with acceptable morbidity without any mortality. Extra-hepatic metastasis (LLM) is a strong factor of poor prognosis. Awaiting the results of the randomized PRODIGE trial, these results indicate that CRS + systemic chemotherapy only is a robust hypothesis to treat colorectal CPM.

Extent of colorectal peritoneal carcinomatosis: attempt to define a threshold above which HIPEC does not offer survival benefit: a comparative study

BACKGROUND

The main prognostic factors after complete cytoreductive surgery (CCRS) of colorectal peritoneal carcinomatosis (PC) followed by intraperitoneal chemotherapy (IPC) are completeness of the resection and extent of the disease. This study aimed to determine a threshold value above which CCRS plus IPC may not offer survival benefit compared with systemic chemotherapy.

METHODS

Between March 2000 and May 2010, 180 patients underwent surgery for PC from colorectal cancer with intended performance of CCRS plus IPC.

RESULTS

Among the 180 patients, CCRS plus IPC could be performed for 139 patients (curative group, 77 %), whereas it could not be performed for 41 patients (palliative group, 23 %). The two groups were comparable in terms of age, gender, primary tumor characteristics, and pre- and postoperative systemic chemotherapy. The mean peritoneal cancer index (PCI) was lower in the curative group (11 ± 7) than in the palliative group (23 ± 7) (p < 0.0001). After a median follow-up period of 60 months (range 47-74 months), the 3-year overall survival (OS) rate was 52 % [95 % confidence interval (CI) 43-61 %] in the curative group compared with 7 % (95 % CI 2-25 %) in the palliative group. Comparison of the survivals for each PCI (ranging from 5 to 36) shows that OS did not differ significantly between the two groups of patients when the PCI was higher than 17 (hazard ratio 0.64; range 0.38-1.09).

CONCLUSION

This study confirmed the major prognostic impact of PC extent. When the PCI exceeds 17 in PC of colorectal origin, CCRS plus IPC does not seem to offer any survival benefit.

Peritoneal metastases of colorectal origin treated by cytoreduction and HIPEC: An overview

Colorectal peritoneal carcinomatosis was considered a terminal condition with a merely palliative treatment that included only supportive care, palliative surgery and the best systemic chemotherapy. Since the birth of a new approach, cytoreductive surgery with peritonectomy procedures together with hyperthermic intraperitoneal chemotherapy and/or early postoperative intraperitoneal chemotherapy to treat peritoneal carcinomatosis, many research groups contributed with promising results using this procedure being up to date this strategy the only one that has shown curative benefits on colorectal peritoneal carcinomatosis achieving reported overall survival rates up to 64 mo and five-year survival rates up to 51%. The aim of this paper is to expose an updated overview of the therapeutic possibilities of these procedures in colorectal peritoneal metastases in the same way that our Unit of Oncologic Surgery has performed since 1997 with more than four hundred procedures.

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy improves survival for patients with peritoneal carcinomatosis from colorectal cancer: a phase II study from a Chinese center

Background

Peritoneal carcinomatosis (PC) is a difficult clinical challenge in colorectal cancer (CRC) because conventional treatment modalities could not produce significant survival benefit, which highlights the acute need for new treatment strategies. Our previous case-control study demonstrated the potential survival advantage of cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) over CRS alone. This phase II study was to further investigate the efficacy and adverse events of CRS+HIPEC for Chinese patients with CRC PC.

Methods

A total of 60 consecutive CRC PC patients underwent 63 procedures consisting of CRS+HIPEC and postoperative chemotherapy, all by a designated team focusing on this combined treatment modality. All the clinico-pathological information was systematically integrated into a prospective database. The primary end point was disease-specific overall survival (OS), and the secondary end points were perioperative safety profiles.

Results

By the most recent database update, the median follow-up was 29.9 (range 3.5–108.9) months. The peritoneal cancer index (PCI) ≤20 was in 47.0% of patients, complete cytoreductive surgery (CC0-1) was performed in 53.0% of patients. The median OS was 16.0 (95% confidence interval [CI] 12.2–19.8) months, and the 1-, 2-, 3-, and 5-year survival rates were 70.5%, 34.2%, 22.0% and 22.0%, respectively. Mortality and grades 3 to 5 morbidity rates in postoperative 30 days were 0.0% and 30.2%, respectively. Univariate analysis identified 3 parameters with significant effects on OS: PCI ≤20, CC0-1 and adjuvant chemotherapy over 6 cycles. On multivariate analysis, however, only CC0-1 and adjuvant chemotherapy ≥6 cycles were found to be independent factors for OS benefit.

Discussion

CRS+HIPEC at a specialized treatment center could improve OS for selected CRC PC patients from China, with acceptable perioperative safety.

Modified selection criteria for complete cytoreductive surgery plus HIPEC based on peritoneal cancer index and small bowel involvement for peritoneal carcinomatosis of colorectal origin

BACKGROUND

Complete cytoreductive surgery (CCRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is on the verge of becoming the gold standard treatment for selected patients presenting peritoneal metastases (PM) of colorectal origin. PM is scored with the peritoneal cancer index (PCI), which is the main prognostic factor. However, small bowel (SB) involvement could exert an independent prognostic impact.

AIM

To define an adequate cut-off for the PCI and to appraise whether SB involvement exerts an impact on this cut-off.

PATIENTS AND METHODS

Patients (n = 139) treated with CCRS plus HIPEC were prospectively verified and retrospectively analyzed. One hundred presented with SB involvement of different extents and at different locations.

RESULTS

All the patients with a PCI ≥ 15 exhibited SB involvement. Five-year overall survival was 48% when the PCI was <15 vs 12% when it was ≥ 15 (p < 0.0001. The multivariate analysis retained two prognostic factors: PCI ≥ 15 (p = 0.02, HR = 1.8), and the involvement of area 12 (lower ileum) (p = 0.001, HR = 3.1). When area 12 was invaded, it significantly worsened the prognosis: 5-year overall survival of patients with a PCI <15 and area 12 involved was 15%, close to that of patients with a PCI ≥ 15 (12%) and far lower than that of patients with a PCI <15 and no area 12 involvement (70%).

CONCLUSION

A PCI greater than 15 appears to be a relative contraindication for treatment of colorectal PM with CCRS + HIPEC. Involvement of the lower ileum is also a negative prognostic factor to be taken into consideration.

Long-term mortality in minimally invasive compared with sternotomy coronary artery bypass surgery in the geriatric population (75 years and older patients)

OBJECTIVES

Ischaemic heart disease is the leading cause of death in the elderly population. Coronary artery bypass graft (CABG) surgery via sternotomy remains the standard of care for patients with multivessel coronary artery disease (CAD). Minimally invasive cardiac surgery (MICS)-CABG via left thoracotomy has been used as an alternative to sternotomy. The aim of our study was to assess the overall survival after MICS-CABG and sternotomy-CABG in elderly patients with CAD.

METHODS

This observational study included patients who underwent coronary bypass from 2005 to 2008. Patients 75 years and older (n = 159) were included in the final analysis. Each arm was further divided into the MICS-CABG group or sternotomy-CABG group. Primary outcome and overall survival were obtained from our records and the social security death index.

RESULTS

Among patients 75 years and older (159 patients), MICS-CABG had a significantly lower 5-year all-cause mortality than sternotomy-CABG (19.7 vs 47.7%, P < 0.001). Similarly, Kaplan-Meier curves showed significantly higher overall survival in the MICS-CABG group compared with sternotomy-CABG (log-rank P = 0.014). After adjusting for confounders, MICS-CABG demonstrated a lower mortality than sternotomy-CABG (HR 0.51, 95% confidence interval 0.26-0.97, P = 0.04). For patients less than 75 years old, MICS and sternotomy groups had similar survival according to both uni- and multivariate analyses.

CONCLUSIONS

The adjusted models demonstrated that MICS-CABG has a significantly better long-term survival than sternotomy-CABG despite slightly differing baseline characteristics. Further studies are needed to compare the short- and long-term outcomes of the two approaches among the elderly population.

Clinical benefit of surgery for stage IV colorectal cancer with synchronous peritoneal metastasis

BACKGROUND

Peritoneal metastasis is well-known as a poor prognostic factor in patients with colorectal cancer. It is important to improve the prognosis of patients with colorectal cancer and synchronous peritoneal metastasis. This study aimed to clarify the factors affecting R0 resection and the prognosis of colorectal cancer patients with synchronous peritoneal metastasis.

METHODS

We investigated the data of patients with stage IV colorectal cancer between 1991 and 2007 in 16 hospitals that were members of the Japanese Society for Cancer of the Colon and Rectum.

RESULTS

Of the 564 colorectal cancer patients with synchronous peritoneal metastases, 341 also had hematogenous metastases. The 5-year overall survival rates in patients with and without R0 resection were 32.4 and 4.7 %, respectively. A Cox proportional hazards model showed that histologic type of poorly differentiated adenocarcinoma, regional lymph node metastasis, liver metastasis, chemotherapy after surgery, R0 resection, the Japanese classification of peritoneal metastasis, and the size of peritoneal metastases were independent prognostic factors. Of the 564 patients, 28.4 % had R0 resection. The Japanese classification of peritoneal metastasis (P1-P2, p = 0.0024) and absence of hematogenous metastases (p < 0.0001) were associated with R0 resection.

CONCLUSIONS

P1-P2 peritoneal metastasis and the absence of hematogenous metastasis were the most favorable factors benefiting from synchronous resection of peritoneal metastasis. In addition, chemotherapy after surgery was essential.

Metastatic colorectal cancer: survival comparison of hepatic resection versus cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Liver resection has long been considered the standard of care for resectable colorectal hepatic metastases (HM). Patients with colorectal peritoneal surface disease (PSD) are now also being treated with aggressive therapy in the form of cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A retrospective comparison of optimally-treated colorectal cancer patients with HM or PSD obtained from prospectively maintained databases (1991-2010).

RESULTS

Liver resection was performed on 179 patients with HM, while 93 PSD patients received a complete cytoreduction followed by HIPEC. Patients differed in terms of age, performance status, site of primary cancer, T stage, and the use of perioperative chemotherapy. Five-year overall survival for HM patients was 36 %, with a median survival of 46 months, compared with 26 % and 34 months in patients with PSD (p = 0.024). When stratified by resection status, R0 HM (n = 170) and R0 PSD (n = 48) patients had similar median survival (49 vs. 41 months; p = 0.39). Median survival following R1 resection was also similar among HM (n = 9) and PSD (n = 45) patients (28 vs. 23 months; p = 0.68). Multivariate analysis identified distinctly different independent prognostic factors between HM and PSD patients. Major morbidity was 21 and 23 % (p = 0.88), while mortality was 3.9 versus 5.4 % (p = 0.55) in the HM and PSD patients, respectively.

CONCLUSION

Colorectal HM and PSD are distinct biologic diseases with different presentations and unique prognostic factors. However, long-term survival following CS/HIPEC is comparable to liver resection when stratified by completeness of resection. Furthermore, perioperative morbidity and mortality are similar.

Early and mid-term results of minimally invasive coronary artery bypass grafting

INTRODUCTION

Minimally invasive coronary artery bypass grafting (MICABG) is a less invasive method of performing surgical revascularization. This technique coupled with use of off pump technique of surgical revascularization makes it truly less invasive. This method is highly effective even in high-risk patients. Results of this procedure are comparable to standard off pump technique and are better than percutaneous coronary intervention utilizing drug-eluting stent. We present an early and mid-term result of the use of this technique.

METHOD

We enrolled 33 patients for analysis operated between 2008 and 2012. Operation was performed utilizing off-pump technique of coronary artery bypass grafting through a minimal invasive incision. Left internal mammary artery graft was done for single vessel disease and radial artery was utilized for other grafts if required. Median follow up of 2.5 years (6 months-4 years) is available.

RESULTS

Median age was 58.5 years (41-77) and all were male. Single vessel disease was present in 7, double vessel in 14 and triple vessel disease in 12 patients. All the patients had normal left ventricular size and function. There was no operative and 30-day mortality. Conversion to median sternotomy to complete the operation was done in 6.6% (2 out of 33 patients). One patient had acute myocardial infarction and there were no deaths during follow up.

CONCLUSION

MICABG is a safe and effective method of revascularization in low risk candidates for coronary artery bypass grafting.

Prognostic factors of peritoneal metastases from colorectal cancer following cytoreductive surgery and perioperative chemotherapy

BACKGROUND

Prolonged survival of patients affected by peritoneal metastasis (PM) of colorectal origin treated with complete cytoreduction followed by intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) has been reported. However, two-thirds of the patients after complete cytoreduction and perioperative chemotherapy (POC) develop recurrence. This study is to analyze the prognostic factors of PM from colorectal cancer following the treatment with cytoreductive surgery (CRS) + POC.

PATIENTS AND METHODS

During the last 8 years, 142 patients with PM of colorectal origin have been treated with CRS and perioperative chemotherapy. The surgical resections consisted of a combination of peritonectomy procedures.

RESULTS

Complete cytoreduction (CCR-0) was achieved at a higher rate in patients with peritoneal cancer index (PCI) score less than 10 (94.7%, 71/75) than those of PCI score above 11 (40.2%, 37/67). Regarding the PCI of small bowel (SB-PCI), 89 of 94 (91.5%) patients with ≤2 and 22 of 48 (45.8%) patients with SB-PCI ≥ 3 received CCR-0 resection (P < 0.001). Postoperative Grade 3 and Grade 4 complications occurred in 11 (7.7%) and 14 (9.9%). The overall operative mortality rate was 0.7% (1/142). Cox hazard model showed that CCR-0, SB-PCI ≤ 2, differentiated carcinoma, and PCI ≤ 10 were the independent favorite prognostic factors.

CONCLUSIONS

Complete cytoreduction, PCI, SB-PCI threshold, and histologic type were the independent prognostic factors.

Primary peritoneal serous carcinoma treated by cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy. A multi-institutional study of 36 patients

AIM

Primary peritoneal serous carcinoma (PPSC) is a rare condition, histologically identical to ovarian serous carcinoma and often diagnosed at late stage. There is not any standardized treatment for PPSC. A retrospective multicentric study was performed in French speaking centers to evaluate cytoreduction surgery and Hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal carcinomatosis from different origins. The manuscript's aim was to study the particular population with PPSC.

METHODS

Between September 1997 and July 2007, 36 patients with PPSC from 9 institutions underwent 39 procedures.

RESULTS

Mortality and morbidity rates were 5.6% and 20.6% respectively. The overall survival at 1, 3 and 5 years are respectively 93.6, 71.5 and 57.4%. The median overall survival was not reached. By univariate analysis, the only factor that had prognostic value was PCI (p = 0.03).

CONCLUSIONS

The therapeutic approach combining cytoreductive surgery with HIPEC may achieve long-term survival in patients with PPSC.

Randomized clinical trials for colorectal cancer peritoneal surface malignancy

Upwards of 40% of patient with colorectal cancer develop peritoneal carcinomatosis (CRCPC). Of the 2500 patients reported in the literature, 1000 underwent cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC), resulting in median survival of 22 to 63 months. However, level I data from prospective randomized trials are limited. Further trials are indicated to identify peritoneal carcinomatosis in at-risk patients early in the natural history of the disease and confirm the efficacy of multimodality therapy (CRS/HIPEC/systemic therapy) in those with CRCPC amenable to CRS in the modern era of novel targeted and cytotoxic systemic therapy.

Complications and toxicities after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

INTRODUCTION

The purpose of our study was to evaluate the perioperative complications, toxicity, mortality rates after cytoreductive surgery (CRS), and effects of hyperthermic intraperitoneal chemotherapy (HIPEC) used in the treatment of peritoneal surface malignancies.

METHODS

Between September 2007 and March 2012, we performed 118 CRS and HIPEC with the closed abdominal technique on 115 patients with peritoneal carcinomatosis (PC). Systemic toxicities were graded according to the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 3.0 criteria and were analyzed from a prospectively collected database.

RESULTS

The mean age of patients was 53.4 (range, 20-82) years; 76.3 % were female. PC was synchronous to primary cancer in 53.4 % of patients, metachronous in 41.5 %, and recurrent in 5.1 % of the patients. PCI was ≥15 in 53.4 % of the patients, and CC-0 cytoreduction was achieved in 68.5 % of the patients. Perioperative mortality was observed in 9 (7.6 %) patients. A total of 98 complications were observed in 46 (39.0 %) patients, and 4 patients underwent 6 reoperations for perioperative surgical complications. We observed toxicity in 25.4 % of the patients, nephrotoxicity in 18.6 %, and hematological toxicity in 13.6 % of patients. No significant difference was observed among age, gender, PCI and CC scores, origin of the primary tumor, and occurrence of toxicity and surgical complications. Prolonged operation times resulted in higher complication and/or toxicity rates (P < 0.01).

CONCLUSIONS

Cytoreductive surgery and HIPEC is a combined treatment strategy for peritoneal surface malignancies with acceptable complication and toxicity rates.

Risk factors for recurrence following complete cytoreductive surgery and HIPEC in colorectal cancer-derived peritoneal surface malignancies

PURPOSE

Recurrent disease following complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a relevant clinical scenario. We aimed to determine risk factors for recurrence.

METHODS

Prospectively collected data of patients enrolled in the Peritoneal Surface Malignancy Program at the University of Tübingen between 2005 and 2011 were retrospectively analyzed. All patients were treated by standardized CRS and HIPEC. Recurrence was defined either radiographically by CT, PET-CT scan, or reoperation.

RESULTS

Fifty-two patients received complete CRS (CC-0/CC-1) and HIPEC. Median time to recurrence was 229 days (103-1,028). Overall recurrence rate within follow-up was 48 %. Of patients with recurrent disease, 44 % experienced extraperitoneal systemic tumor spread. In multivariate analysis, grading of ≥ 3 was shown as an independent risk factor for recurrent disease, while a trend was observed for maximal tumor load in the upper abdominal region. Clinical parameters did not show an impact on recurrence.

CONCLUSIONS

Primary tumor grading seems to be an independent risk factor for recurrence following complete CRS and HIPEC in colorectal cancer-derived peritoneal surface malignancies.

Risk of renal dysfunction after less invasive multivessel coronary artery bypass grafting

OBJECTIVE

Several centers have established that off-pump, multivessel coronary artery bypass grafting performed via a small thoracotomy (MVST) is feasible. However, this procedure can be challenging when posterolateral coronary targets need to be grafted. We hypothesized that use of cardiopulmonary bypass via peripheral access (MVST-PA) would improve outcomes compared with a completely off-pump approach (OP-MVST).

METHODS

This was a prospective observational study of patients undergoing OP-MVST (n = 46) versus MVST-PA (n = 45) using bilateral internal mammary artery grafts onto the left anterior descending coronary artery and circumflex/right coronary artery distribution. Hemostasis was quantified by measuring platelet function (aggregometry), chest tube output, thrombolysis in myocardial infarction bleeding score (%hematocrit change at 24 hours), and transfusion requirements. The rate of mortality and major morbidity at 30 days was defined according to The Society of Thoracic Surgeons criteria. Estimated glomerular filtration rate (normalized to baseline levels) was determined daily until discharge.

RESULTS

The OP-MVST versus MVST-PA groups had similar risk factors at baseline and risks of composite morbidity/mortality at 30 days. However, renal failure was significantly increased after OP-MVST (10.87 vs 0%, P = 0.05), and MVST-PA affected hemostasis as evidenced by inhibition of platelet function (latency to response on aggregometry, 29.9 vs 17.9 seconds; P = 0.04) and higher transfusion requirement (2.31 vs 0.85 units of red blood cells/patient, P = 0.04; 55.6% vs 34.8% transfused; P = 0.059). However, 24-hour chest tube output was similar (645 vs 750 mL; P = 0.53).

CONCLUSIONS

In comparison with a completely off-pump strategy, use of cardiopulmonary bypass to assist MVST reduced the risk of renal dysfunction with only modest tradeoffs in other morbidities, for example, altered coagulation and higher transfusion requirements. These data justify further study of the effect of MVST-PA on renal complications.

[Peritoneal carcinomatosis of colorectal origin: results of cytoreductive surgery with peritonectomy and hyperthermic intraoperative chemotherapy]

Until recently peritoneal carcinomatosis (PC) arising from colorectal cancer (CRC) was considered to be a terminal disease manifestation. Despite palliative systemic chemotherapy (CHT) the majority of patients died within a few months. Nowadays cytoreductive surgery (CRS) of the peritoneal cavity in combination with hyperthermic intraperitoneal CHT and perioperative systemic CHT may offer a chance for long-term survival in selected groups of patients. In this study we report the results obtained with this treatment strategy in 30 consecutive patients. Data were assessed prospectively. After a median follow-up of 16.9 months the median survival time in all 30 patients reached 24.3 months. Favorable prognostic factors are a low extent of intraperitoneal metastases as characterized by a low peritoneal cancer index (median survival PCI ≤ 10: 33.2 months vs. PCI 11-19: 12.1 months) and a complete or nearly complete CRS (median survival CCR 0/1: 33.1 months vs. CCR2/3: 12.1 months). The 2-year overall survival was 89% for patients with a PCI ≤ 10 and 65% for those with surgical CCR 0/1 cytoreduction. As not every patient with CRC and PC may profit from this relatively aggressive therapy an interdisciplinary patient selection (tumor board) and treatment in experienced surgical oncology centers is recommended.

Mortality and Morbidity after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis

<b><i>Background:</i></b> Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with improved survival in selected patients with peritoneal carcinomatosis. This treatment, however, has been associated with a relatively high rate of perioperative mortality and morbidity. <b><i>Method:</i></b> A review of clinical studies before March 2013 was performed to examine the impact of CRS-HIPEC on early mortality and morbidity. Factors associated with a poor perioperative outcome were identified. The importance of the learning curve was examined. Clinical outcomes were synthesized through a narrative review. <b><i>Results:</i></b> In-hospital mortality in high-level centres (>100 patients) ranged from 0.9 to 5.8%. The morbidity rate ranged from 36 to 84%; the overall rate of major or grade III/IV morbidity ranged from 0 to 52%. Factors that were consistently associated with a poor perioperative outcome included extensive peritoneal disease and markers of increased operative effort such as operation length, blood loss, and number of peritonectomy procedures performed. Several studies showed that morbidity decreases as operating volume increases. Moving forward, there is a need to evaluate strategies to reduce perioperative mortality whilst not compromising oncological outcomes. <b><i>Conclusion:</i></b> CRS-HIPEC is associated with an acceptable rate of perioperative mortality and morbidity. Morbidity decreases with increased experience and is strongly associated with the extent of disease.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Where are we?

Peritoneal surface malignancies are generally associated with poor prognosis. In daily clinical routine, systemic chemotherapy is still considered the only reasonable therapy despite of encouraging results of cytoreductive surgery (CRS) along with intraperitoneal hyperthermic chemotherapy (HIPEC). The Achilles heel of CRS and HIPEC is appropriate patient selection and precise surgical technique preventing patients from excessive morbidity and mortality. Given these findings, new concepts of second look surgery for high risk patients allow detection of peritoneal spread ahead of clinical symptoms or presence of peritoneal masses reducing perioperative morbidity. In addition, personalized intraperitoneal chemotherapy might further improve outcome by appreciating individual tumor biology. These days, every physician should be aware of CRS and HIPEC for treatment of peritoneal surface malignancies. Since there is now sufficient data for the superiority of CRS and HIPEC to systemic chemotherapy in selected patients, our next goal should be providing this strategy with minimal morbidity and mortality even in the presence of higher tumor load.

Surgical results of patients with peritoneal carcinomatosis treated with cytoreductive surgery using a new technique named aqua dissection

During 2004 to 2011, 81, 420, and 166 patients with colorectal cancer (CRC), epithelial appendiceal neoplasm (APN), and gastric cancer (GC) with PC were treated with cytoreductive surgery (CRS) plus perioperative chemotherapy. CRS was performed by peritonectomy techniques using an aqua dissection. Results. Complete cytoreduction was done in 62/81 (76.5%), 228/420 (54.3%), and 101/166 (60.8%) of patients with CRC, APN, and GC. The main reasons of incomplete resections were involvement of all peritoneal regions and diffuse involvement of small bowel. The incidence (64%, 302/470) of CC-0 resection after introduction of an aqua dissection was significantly higher than before (42%, 82/197). A total of 41 (6.1%) patients died postoperatively. Major complication (grade 3-4 complications) occurred in 126 patients (18.9%). A reoperation was necessary in 36 patients (5.4%). By the multivariate analysis, PCI scores capable of serving as thresholds for favorable versus poor prognosis in each group and CC scores demonstrated as the independent prognostic factors. Conclusions. Peritonectomy using an aqua dissection improves the incidence of complete cytoreduction, and improves the survival of patients with PC. Patients with PCI larger than the threshold values should be treated with chemotherapy to improve the incidences of complete cytoreduction.

Experience after 100 patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

AIM: To investigate perioperative patient morbidity/mortality and outcome after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS: Of 150 patients 100 were treated with cytoreductive surgery and HIPEC and retrospectively analyzed. Clinical and postoperative follow-up data were evaluated. Body mass index (BMI), age and peritoneal carcinomatosis index (PCI) were chosen as selection criteria with regard to tumor-free survival and perioperative morbidity for this multimodal therapy.

RESULTS: CRS with HIPEC was successfully performed in 100 out of 150 patients. Fifty patients were excluded because of intraoperative contraindication. Median PCI was 17 (1-39). In 89% a radical resection (CC0/CC1) was achieved. One patient died postoperatively due to multiorgan failure. Neither PCI, age nor BMI was a risk factor for postoperative complications/outcome according to the DINDO classification. In 9% Re-CRS with HIPEC was performed during the follow-up period.

CONCLUSION: Patient selection remains the most important issue. Neither PCI, age nor BMI alone should be an exclusion criterion for this multimodal therapy.

Small bowel involvement is a prognostic factor in colorectal carcinomatosis treated with complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy

Background

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising treatment for patients with peritoneal carcinomatosis (PC). Our objective was to identify new prognostic factors in patients with PC from colorectal cancer treated with this procedure.

Methods

All patients with PC from colorectal cancer treated by HIPEC from January 2000 to December 2007 were prospectively included. The tumor extension was assessed by the Peritoneal Cancer Index (PCI) and the residual disease was recorded using the completeness cytoreductive score (CCs). All clinical and treatment data were computed in univariate and multivariable analyses using survival as primary end point.

Results

We carried out 51 complete procedures in 49 consecutive patients. The mean PCI was 10. The allocation of CCs was: CC-0 = 37, CC-1 = 14. The five-year overall and progression-free survival rate were 40% and 20%, respectively. Several prognostic factors for survival were identified by univariate analysis: PCI < 9 (P < 0.001), CC-0 vs. CC-1 (P < 0.01) and involvement of area 4 (P = 0.06), area 5 (P = 0.031), area 7 (P = 0.014), area 8 (P = 0.022), area 10 (P < 0.0001), and area 11 (P = 0.02). Only the involvement of the distal jejunum (area 10) was significant in the multivariable analysis (P = 0.027).

Conclusions

We demonstrated that the involvement of area 10 (distal jejunum of the PCI score) was an independent factor associated with poor prognosis.

Cytoreduction and hyperthermic intraperitoneal chemotherapy for patients with peritoneal carcinomatosis dissemination from colorectal cancer

SUMMARY Peritoneal carcinomatosis is an insidious condition that afflicts up to 20% of patients with colorectal cancer annually. Symptoms are related to disease progression in the peritoneal cavity such as bloating and intermittent abdominal pain; diagnostic imaging studies will frequently underestimate the extent of disease. The strategy of operative cytoreduction and hyperthermic intraperitoneal chemotherapy has become increasingly utilized as a therapeutic approach, however, most of the data regarding its efficacy come from single-institution studies. With increased understanding of optimal patient selection and treatment parameters, cytoreduction with hyperthermic intraperitoneal chemotherapy will likely become increasingly accepted as part of an integrated multimodal strategy to treat patients with peritoneal carcinomatosis from colorectal cancer in the future.

Intraoperative hyperthermic versus postoperative normothermic intraperitoneal chemotherapy for colonic peritoneal carcinomatosis: a case-control study

BACKGROUND

Cytoreductive surgery and intraperitoneal chemotherapy has improved prognosis in patients with peritoneal carcinomatosis. The main modes of intraperitoneal chemotherapy treatment are peroperative hyperthermic intraperitoneal chemotherapy (HIPEC) and normothermic sequential postoperative intraperitoneal chemotherapy (SPIC). The aim of this study was to compare HIPEC and SPIC with respect to overall survival, disease-free survival, morbidity, and mortality in patients with peritoneal carcinomatosis from colon cancer.

PATIENTS AND METHODS

A matched case-control study was conducted in patients with surgical macroscopic complete removal of carcinomatosis; matching was according to the peritoneal cancer index score. Thirty-two patients were included, 16 in each group (HIPEC and SPIC). Overall survival, disease-free survival, morbidity, mortality, and clinicopathological parameters were compared.

RESULTS

Median overall survival was 36.5 months in the HIPEC group and 23.9 months in the SPIC group (P = 0.01). Median disease-free survival for these groups was 22.8 (HIPEC) and 13.0 months (SPIC; P = 0.02). Morbidity was not statistically different, 19% in SPIC and 37% in HIPEC. Postoperative mortality was observed in one patient in each group.

CONCLUSION

HIPEC was associated with improved overall survival and disease-free survival compared with SPIC at similar morbidity and mortality, suggesting that HIPEC is the treatment of choice in colonic peritoneal carcinomatosis.

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Outcomes following surgery for colorectal cancer with synchronous peritoneal metastases

BACKGROUND

The optimal treatment of peritoneal carcinomatosis of colorectal origin appears to be a combination of systemic chemotherapy and complete surgical cytoreduction with synchronous intraperitoneal chemotherapy. The aim of this study was to assess the feasibility of, and outcomes following, surgical treatment and systemic chemotherapy alone.

METHODS

Prospectively collated data from the Erlangen Registry for Colorectal Cancer were analysed for patients presenting with peritoneal carcinomatosis of colorectal origin between 1990 and 2006. Operative and adjuvant treatment, along with details of postoperative morbidity, were evaluated and correlated with survival outcomes after 5 years.

RESULTS

Some 125 patients underwent surgical resection for colorectal cancer and synchronous peritoneal carcinomatosis. Two-thirds also had non-peritoneal distant metastases. R0/R1 resection was possible in 24 (59 per cent) of 41 patients with peritoneal metastases alone, and in a further seven patients with both peritoneal and distant metastases (overall R0/R1 resection rate 24·8 per cent). In-hospital morbidity and mortality rates were 32·0 and 12·0 per cent respectively. Twenty-three of the 31 patients who underwent R0/R1 resection developed recurrent disease. Median survival for the entire group was 12 months. Following R0/R1 resection median survival was 25 months and the 5-year survival rate 22 per cent. Six (4·8 per cent) of the 125 patients survived for more than 5 years.

CONCLUSION

Complete resection of all metastatic disease was associated with improved survival and was possible in almost 60 per cent of patients with peritoneal metastases alone.

Cyto-reductive Surgery combined with Hyperthermic Intra-peritoneal Chemotherapy for Peritoneal Surface Malignancies: current treatment and results

Cyto-reductive Surgery (CS) combined with Hyperthermic Intra-peritoneal Chemotherapy (HIPEC) as loco-regional treatment of Peritoneal Surface Malignancies (PSM) has increasingly gained acceptance in clinical practice. This review summarizes the more relevant studies on this topic. Indications, pre-operative work-up, technical aspects, outcome and future directions of this combined approach in the treatment of Peritoneal Surface Malignancies are discussed here and proposed in an informative and didactic manner.

Selection Criteria for Complete Cytoreduction after Cytoreductive Surgery for Peritoneal Surface Malignancy: Lessons Learned from Our First Series of Patients

The appropriate selection criteria for complete cytoreduction in patients with peritoneal surface malignancies have not been determined. We performed a retrospective analysis of all patients receiving cytoreductive surgery (CRS) during the study period of 2004 to 2008 to determine appropriate selection criteria for successful complete cytoreduction. During the study period, 38 patients underwent attempted CRS. Cytoreduction was scored complete, incomplete, or not reported in 53 per cent (n = 20), 37 per cent (n = 14), and 11 per cent (n = 4), respectively. Median overall survival for compete and incomplete cytoreduction was 56 months versus 5 months ( P = 0.011), respectively. Compared with incomplete cytoreduction, patients receiving complete cytoreduction were more likely to have a lower Peritoneal Cancer Index (PCI) and not have received preoperative systemic chemotherapy (CT). Univariate analysis verified PCI greater than 20 (hazard ratio [HR], 0.048; CI, 0.004 to 0.515; P = 0.01) and CT (HR, 0.17; 0.004 to 0.77; P = 0.021) as predictors of incomplete cytoreduction. Small bowel (100%), periportal region (33%), and mesentery (27%) were the most common sites of residual disease. In conclusion, PCI less than 20 and the need for preoperative chemotherapy should be strongly considered when selecting patients with peritoneal surface malignancy for attempted cytoreduction. Early evaluation of the small bowel, mesentery, and periportal region for resectability prevents unnecessary surgery.

Evolution of locoregional treatment for peritoneal carcinomatosis: single-center experience of 308 procedures of cytoreductive surgery and perioperative intraperitoneal chemotherapy

BACKGROUND

Peritoneal carcinomatosis imposes an enormous clinical burden to the oncologic community. This study reports the patterns of care of the locoregional approach of cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy as a curative procedure for peritoneal carcinomatosis from the experience of a single tertiary center in Australia.

METHODS

We performed a review of clinical records from a prospective database of patients who were treated at the St George Hospital Peritoneal Surface Malignancy Program according to a standard protocol.

RESULTS

A total of 308 CRS were performed in 249 patients with peritoneal surface malignancy; the mean age was 53 years and 55% were women. Over the years, we expanded the age limit for treatment (P = .03), reduced intensive care unit stays (P = .04), reduced amount of blood transfusion (P = .03), treated patients with a higher peritoneal cancer index (P < .001), achieved higher rates of complete cytoreduction (P = .003), increased use of PIC (P < .001), and improved complication rate (P = .02) and mortality rate (P = .01). The median survival of patients treated over the years also improved (P = .001).

CONCLUSIONS

We show the maturity of the treatment of peritoneal carcinomatosis with CRS and perioperative intraperitoneal chemotherapy in our institution after an initial learning curve with expansion of the selection criteria, improved perioperative outcomes, improved surgical results, and long-term survival outcomes.

Effects of intraperitoneal chemotherapy with mitomycin C on the prevention of peritoneal recurrence in colorectal cancer patients with positive peritoneal lavage cytology findings

BACKGROUND

The detection of intraperitoneal free cancer cells in colorectal cancer (CRC) patients is associated with a poorer prognosis. The aim of this study was to investigate the effects of intraperitoneal chemotherapy (IPC) with mitomycin C (MMC) on preventing peritoneal recurrence in CRC patients with positive peritoneal lavage cytology findings.

METHODS

A total of 52 CRC patients who had no clinically confirmed peritoneal dissemination and whose status of peritoneal lavage cytology was positive were investigated. Conventional peritoneal lavage cytology was performed. Overall, 31 of the 52 patients (59.6%) were administered IPC with MMC. Before closure of the abdomen, 4 silicon catheters were inserted into peritoneal cavity. After closure, the perfusate (diluting 20 mg MMC with 500 ml saline) was instilled from the catheter, and all catheters were clumped. All catheters were opened 1 h later.

RESULTS

The mean follow-up period was 83.1 months. According to univariate analyses of all 52 patients and the subgroup of 36 patients with stage II or III tumors, patients with IPC had a significantly better peritoneal recurrence-free survival and cancer-specific survival than patients who did not receive IPC (P < 0.005). In multivariate analysis, IPC remained an independent prognostic factor for peritoneal recurrence-free survival in all patients.

CONCLUSIONS

It appears that IPC with MMC is an effective treatment to prevent peritoneal recurrence and prolong the cancer-specific survival in CRC patients without peritoneal dissemination, but who have positive peritoneal lavage cytology. It is necessary to verify the effectiveness of IPC with MMC in a prospective trial.

Toward curative treatment of peritoneal carcinomatosis from nonovarian origin by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy: a multi-institutional study of 1,290 patients

BACKGROUND

Peritoneal carcinomatosis (PC) from nonovarian malignancies long has been regarded as a terminal disease. Over the past decade, new locoregional therapeutic approaches combining cytoreductive surgery with perioperative intraperitoneal chemotherapy (PIC) have evolved that have demonstrated improved survival.

METHODS

A retrospective, multicenter cohort study was performed in French-speaking institutions to evaluate toxicity and principal prognostic factors after cytoreductive surgery and PIC (hyperthermic intraperitoneal chemotherapy [HIPEC] and/or early postoperative intraperitoneal chemotherapy [EPIC]) for PC from nongynecologic malignancies.

RESULTS

The study included 1290 patients from 25 institutions who underwent 1344 procedures between February 1989 and December 2007. HIPEC was performed in 1154 procedures. The principal origins of PC were colorectal adenocarcinoma (N = 523), pseudomyxoma peritonei (N = 301), gastric adenocarcinoma (N = 159), peritoneal mesothelioma (N = 88), and appendiceal adenocarcinoma (N = 50). The overall morbidity and mortality rates were 33.6% and 4.1%, respectively. In multivariate analysis, patient age, the extent of PC, and institutional experience had a significant influence on toxicity. The overall median survival was 34 months; and the median survival was 30 months for patients with colorectal PC, not reached for patients with pseudomyxoma peritonei, 9 months for patients with gastric PC, 41 months for patients with peritoneal mesothelioma, and 77 months for patients with PC from appendiceal adenocarcinoma. Independent prognostic indicators in multivariate analysis were institution, origin of PC, completeness of cytoreductive surgery, extent of carcinomatosis, and lymph node involvement.

CONCLUSIONS

A therapeutic approach that combined cytoreductive surgery with PIC was able to achieve long-term survival in a selected group of patients who had PC of nonovarian origin and had acceptable morbidity and mortality. The current results indicated that this treatment should be centralized to institutions with expertise in the management of PC.

Cytoreductive surgery associated to hyperthermic intraperitoneal chemoperfusion for desmoplastic round small cell tumor with peritoneal carcinomatosis in young patients

PURPOSE

Desmoplastic round small cell tumor (DRSCT) is a rare intraabdominal mesenchymal tissue neoplasm in young patients and spreads through the abdominal cavity. Its prognosis is poor despite a multimodal therapy including chemotherapy, radiotherapy, and surgical cytoreduction (CS). hyperthermic intraperitoneal chemotherapy (HIPEC) is considered as an additional strategy in the treatment of peritoneal carcinomatosis; for this reason, we planned to treat selected cases of children with DRSCT using CS and HIPEC.

METHODS

Peritoneal disease extension was evaluated according to Gilly classification. Surgical cytoreduction was considered as completeness of cytoreduction-0 when no macroscopic nodule was residual; HIPEC was performed according to the open technique.

RESULTS

We described 3 cases: the 2 first cases were realized for palliative conditions and the last one was operated on with curative intent. There was no postoperative mortality. One patient was reoperated for a gallbladder perforation. There was no other complication related to HIPEC procedure.

CONCLUSIONS

Surgical cytoreduction and HIPEC provide a local alternative approach to systemic chemotherapy in the control of microscopic peritoneal disease in DRSCT, with an acceptable morbidity, and may be considered as a potential beneficial adjuvant waiting for a more specific targeted therapy against the fusion protein.

Mucinous adenocarcinomas with intra-abdominal dissemination: a review of current therapy

Peritoneal carcinomatosis has been considered a terminal disease with a median survival time of 5.2-12.6 months. Systemic chemotherapy and cytoreductive surgery (CRS) have long been used to treat macroscopic disease, with limited success. However, a comprehensive treatment approach involving cytroreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) has evolved into a novel approach for peritoneal carcinomatosis. Surgery removes the primary cancer and any dissemination within the peritoneal cavity and adjuvant HIPEC eradicates macroscopic or microscopic tumor residue, thus reducing the risk for recurrence. This approach offers a new potential treatment option for patients with metastatic disease confined to the peritoneum. The present review provides an update of the most recent data on the current therapy for pseudomyxoma peritonei (PMP) and mucinous colorectal adenocarcinoma (MCA) with metastatic disease confined to the peritoneum.

A critical evaluation of risk factors for complications after cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis

BACKGROUND

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with colorectal peritoneal carcinomatosis (CRPC). This treatment modality is associated with relatively high rates of perioperative morbidity and mortality. This study evaluated the clinical and treatment-related risk factors for perioperative morbidity and mortality in patients with CRPC who underwent CRS and PIC.

METHODS

Sixty-three consecutive patients who underwent CRS and PIC for CRPC were evaluated. Adverse events were rated from grades I to V with increasing severity. Clinical and treatment-related risk factors for grades III and IV/V morbidity were determined.

RESULTS

There were no perioperative deaths (0%). The grades III and IV morbidity rates were 14 and 17%, respectively. A peritoneal cancer index >12 (p = 0.019), transfusion >4 units (p = 0.028), number of peritonectomy procedures >3 (p = 0.013), left upper quadrant peritonectomy procedure (p < 0.001), and number of primary colonic anastomosis >1 (p = 0.004) were associated with grade IV morbidity on univariate analysis. Only left upper quadrant procedure was associated with grade IV morbidity on multivariate analysis (p = 0.002). Only number of primary colonic anastomosis >1 (p = 0.037) was associated with grade III morbidity on univariate analysis. This also was associated with grade III morbidity on multivariate analysis (p = 0.028).

CONCLUSIONS

CRS and PIC has an acceptable risk of perioperative morbidity in carefully selected patients with CRPC. Patients who require extensive surgery have the highest risk for a severe adverse event. Preoperative evaluation of patients is essential to improve perioperative outcome.

Peritoneal carcinomatosis from gastric cancer: a multi-institutional study of 159 patients treated by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy

BACKGROUND

Peritoneal carcinomatosis (PC) from gastric cancer has long been regarded a terminal disease with a short median survival. New locoregional therapeutic approaches combining cytoreductive surgery with perioperative intraperitoneal chemotherapy (PIC) have evolved and suggest improved survival.

MATERIALS AND METHODS

A retrospective multicentric study was performed in French-speaking centers to evaluate the toxicity and the principal prognostic factors in order to identify the best indications. All patients had cytoreductive surgery and PIC: hyperthermic intraperitoneal chemotherapy (HIPEC) and/or early postoperative intraperitoneal chemotherapy (EPIC).

RESULTS

The study included 159 patients from 15 institutions between February 1989 and August 2007. The median follow-up was 20.4 months. HIPEC was the PIC used for 150 procedures. Postoperative mortality and grade 3-4 morbidity rates were 6.5 and 27.8%, respectively. By multivariate analysis, the institution had a significant influence on toxicity. The overall median survival was 9.2 months and 1-, 3-, and 5-year survival rates were 43, 18, and 13%, respectively. The only independent prognostic indicator by multivariate analysis was the completeness of cytoreductive surgery. For patients treated by complete cytoreductive surgery, the median survival was 15 months with a 1-, 3-, and 5-year survival rate of 61, 30, and 23%, respectively.

CONCLUSIONS

The therapeutic approach combining cytoreductive surgery with PIC for patients with gastric carcinomatosis may achieve long-term survival in a selected group of patients (limited and resectable PC). The high mortality rate underlines this necessarily strict selection that should be reserved to experienced institutions involved in the management of PC and gastric surgery.

Multidisciplinary therapy for treatment of patients with peritoneal carcinomatosis from gastric cancer

There is no standard treatment for peritoneal carcinomatosis (PC) from gastric cancer. A novel multidisciplinary treatment combining bidirectional chemotherapy [neoadjuvant intraperitoneal-systemic chemotherapy protocol (NIPS)], peritonectomy, hyperthermic intraperitoneal chemoperfusion (HIPEC) and early postoperative intraperitoneal chemotherapy has been developed. In this article, we assess the indications, safety and efficacy of this treatment, review the relevant studies and introduce our experiences. The aims of NIPS are stage reduction, the eradication of peritoneal free cancer cells, and an increased incidence of complete cytoreduction (CC-0) for PC. A complete response after NIPS was obtained in 15 (50%) out of 30 patients with PC. Thus, a significantly high incidence of CC-0 can be obtained in patients with a peritoneal cancer index (PCI) ≤ 6. Using a multivariate analysis to examine the survival benefit, CC-0 and NIPS are identified as significant indicators of a good outcome. However, the high morbidity and mortality rates associated with peritonectomy and perioperative chemotherapy make stringent patient selection important. The best indications for multidisciplinary therapy are localized PC (PCI ≤ 6) from resectable gastric cancer that can be completely removed during a peritonectomy. NIPS and complete cytoreduction are essential treatment modalities for improving the survival of patients with PC from gastric cancer.

Multidisciplinary therapy for treatment of patients with peritoneal carcinomatosis from gastric cancer

There is no standard treatment for peritoneal carcinomatosis (PC) from gastric cancer. A novel multidisciplinary treatment combining bidirectional chemotherapy [neoadjuvant intraperitoneal-systemic chemotherapy protocol (NIPS)], peritonectomy, hyperthermic intraperitoneal chemoperfusion (HIPEC) and early postoperative intraperitoneal chemotherapy has been developed. In this article, we assess the indications, safety and efficacy of this treatment, review the relevant studies and introduce our experiences. The aims of NIPS are stage reduction, the eradication of peritoneal free cancer cells, and an increased incidence of complete cytoreduction (CC-0) for PC. A complete response after NIPS was obtained in 15 (50%) out of 30 patients with PC. Thus, a significantly high incidence of CC-0 can be obtained in patients with a peritoneal cancer index (PCI) ≤ 6. Using a multivariate analysis to examine the survival benefit, CC-0 and NIPS are identified as significant indicators of a good outcome. However, the high morbidity and mortality rates associated with peritonectomy and perioperative chemotherapy make stringent patient selection important. The best indications for multidisciplinary therapy are localized PC (PCI ≤ 6) from resectable gastric cancer that can be completely removed during a peritonectomy. NIPS and complete cytoreduction are essential treatment modalities for improving the survival of patients with PC from gastric cancer.

Extensive lymphadenectomy in colorectal cancer with isolated para-aortic lymph node metastasis below the level of renal vessels

BACKGROUND AND OBJECTIVES

The effects of isolated metastatic node dissection in the para-aortic region have not been established in colorectal cancer (CRC). The authors undertook to evaluate the role of para-aortic lymph node (PALN) dissection in CRC with isolated PALN metastasis.

METHODS

Between January 1993 and March 2006, 24 patients underwent PALN dissection for isolated PALN metastasis from CRC. Patients with distant metastases other than to PALNs, or with nodal metastasis above the celiac axis were excluded. The control group was composed of 53 patients with isolated PALN metastasis below the level of the renal hilum that was not surgically removed.

RESULTS

Median disease-free interval after PALN dissection was 14 months. The postoperative complication rate was 27.8%, which was not significantly different from that of the control group. Median survivals in the PALN dissection and control groups were 64 (range, 17-111) and 33 (range, 24-42) months, respectively. The overall 5-year survival rate was 53.4% in the PALN dissection group, versus 12.0% in the control group (P = 0.045).

CONCLUSIONS

The findings of this study suggest that PALN dissection increases the survival of patients with isolated PALN metastasis from CRC, and that it has a tolerable morbidity rate.

Cytoreductive procedures-strategies to reduce postoperative morbidity and management of surgical complications with special emphasis on anastomotic leaks

Cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) for the therapy of peritoneal carcinomatosis are associated with substantial morbidity and acceptable mortality. Patient selection, learning curve, patient warming, and reduced blood loss are the main factors to decrease morbidity. Morbidity is mostly associated with bowl fistulas and anastomotic leakages. Depending on the site of leaks they may be managed conservatively or by reoperation. For standardization of study reports on morbidity and mortality the CTCAE classification is recommended.