1
|
Reis ACV, Kusamura S, Azmi N, Fumagalli L, Piccioni F, Valenza F, Baratti D, Guaglio M, Cavalleri A, Garrone G, Barretta F, Deraco M. Hemodynamic and respiratory implications of high intra-abdominal pressure during HIPEC. Eur J Surg Oncol 2020; 46:1896-1901. [PMID: 32147425 DOI: 10.1016/j.ejso.2020.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/05/2020] [Accepted: 02/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND cytoreduction surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is currently the standard of care for some peritoneal surface malignancies. There is experimental evidence supporting that high Intra Abdominal Pressure (IAP) during HIPEC could enhance the uptake of drugs by tumor tissues. However, few papers are describing the hemodynamic and respiratory effects of increased IAP during HIPEC. AIMS to evaluate the hemodynamic and respiratory association with different IAPs during HIPEC. METHODS This is part of an IRB board approved prospective randomized controlled trial conducted at The National Tumor Institute of Milan from 2014 to 2017 (NCT0294979). Patients diagnosed with Pseudomyxoma (PMP) or Peritoneal Metastasis of Colorectal Cancer (PM-CRC) were submitted to CRS and then randomized to receive low IAP (8-12 mmHg) or high IAP (18-22 mmHg) HIPEC. Hemodynamic and respiratory data were collected in eight different time-points during the whole procedure. RESULTS 33 patients (n low = 15, n high = 18) with PM-CRC and PMP were analysed. The mean IAP in the low IAP HIPEC group was 11.4 mmHg (SD: 2.5) and 18.1 mmHg (SD: 2.5) in the high IAP HIPEC group (p«0.001). There was no difference in the hemodynamic parameters between both groups, except for the central venous pressure (CVP) that was significantly higher in the high IAP group (p = 0.006). High IAP was well tolerated in the experimental arm with no hemodynamic and ventilation instability observed during the intervention. CONCLUSION We conclude that high IAP at the level of 18-22 mmHg during HIPEC has no significant hemodynamic parameters difference, being feasible and safe in our study.
Collapse
Affiliation(s)
- Artur C V Reis
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy; Irmandade Santa Casa de Misericórdia de São José Dos Campos, Department of Gastrointestinal Surgery, São Paulo, Brazil.
| | - Shigeki Kusamura
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Norfarizan Azmi
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Luca Fumagalli
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy
| | - Federico Piccioni
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy
| | - Franco Valenza
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy; University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Dario Baratti
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Marcello Guaglio
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Adalberto Cavalleri
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Laboratory of Department of Preventive and Predictive Medicine, Italy
| | - Giulia Garrone
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Laboratory of Department of Preventive and Predictive Medicine, Italy
| | - Francesco Barretta
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Department of Clinical Epidemiology and Trial Organization, Milan, Italy
| | - Marcello Deraco
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy.
| |
Collapse
|
2
|
Carlier C, Mathys A, De Jaeghere E, Steuperaert M, De Wever O, Ceelen W. Tumour tissue transport after intraperitoneal anticancer drug delivery. Int J Hyperthermia 2018; 33:534-542. [PMID: 28540828 DOI: 10.1080/02656736.2017.1312563] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Intraperitoneal (IP) drug delivery, either as an intraoperative chemoperfusion or as an adjuvant, repeated instillation, is an established treatment modality in patients with peritoneal carcinomatosis. The efficacy of IP drugs depends on its ability to penetrate the tumour stroma in order to reach their (sub)cellular target. It is known, that drug penetration after IP delivery is limited to a few millimetres. Here, we review the basic tissue transport mechanisms after IP delivery and discuss the biophysical barriers and obstacles that limit penetration distance. In addition, we review the physical and pharmaceutical interventions that have been studied in order to improve delivery of small molecular and macromolecular drugs after IP instillation. These interventions could inform the design of future clinical trials aiming at an improved efficacy of IP-based drug delivery in carcinomatosis patients.
Collapse
Affiliation(s)
- Charlotte Carlier
- a Laboratory for Experimental Surgery, Department of Surgery , Ghent University , Ghent , Belgium
| | - Ada Mathys
- a Laboratory for Experimental Surgery, Department of Surgery , Ghent University , Ghent , Belgium
| | - Emiel De Jaeghere
- b Department of Radiation Oncology and Experimental Cancer Research , Ghent University , Ghent , Belgium
| | - Margo Steuperaert
- c Biofluid, Tissue and Solid Mechanics for Medical Applications (bioMMeda), Department of Electronics and Information Systems, iMinds Medical IT Department , Ghent University , Ghent , Belgium
| | - Olivier De Wever
- b Department of Radiation Oncology and Experimental Cancer Research , Ghent University , Ghent , Belgium.,d Cancer Research Institute Ghent (CRIG), Ghent University , Ghent , Belgium
| | - Wim Ceelen
- a Laboratory for Experimental Surgery, Department of Surgery , Ghent University , Ghent , Belgium.,d Cancer Research Institute Ghent (CRIG), Ghent University , Ghent , Belgium
| |
Collapse
|
3
|
de Bree E, Michelakis D, Stamatiou D, Romanos J, Zoras O. Pharmacological principles of intraperitoneal and bidirectional chemotherapy. Pleura Peritoneum 2017; 2:47-62. [PMID: 30911633 PMCID: PMC6405033 DOI: 10.1515/pp-2017-0010] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 04/05/2017] [Indexed: 12/19/2022] Open
Abstract
Intraperitoneal chemotherapy is associated with a significant pharmacokinetic and pharmacodynamic benefit and can, alone or in combination with systemic chemotherapy (bidirectional chemotherapy), be used for treating primary and secondary peritoneal surface malignancies. Due to the peritoneal-plasma barrier, high intraperitoneal drug concentration can be achieved by intraperitoneal chemotherapy, whereas systemic concentration remains low. Bidirectional chemotherapy may provide in addition adequate drug concentrations from the side of the subperitoneal space to the peritoneal tumour nodules. Major pharmacological problems of intraperitoneal chemotherapy are limited tissue penetration and poor homogeneity of drug distribution to the entire seroperitoneal surface. Significant pharmacological determinants of intraperitoneal chemotherapy are choice of drug, drug dosage, solution volume, carrier solution, intra-abdominal pressure, temperature, duration, mode of administration, extent of peritonectomy and interindividual variability. Drugs most commonly applied for intraperitoneal chemotherapy include mitomycin C, cisplatin, carboplatin, oxaliplatin, irinotecan, 5-fluoruracil, gemcitabine, paclitaxel, docetaxel, doxorubicin, premetrexed and melphalan. The drugs and their doses that are used vary widely among centres. While the adequate drug choice for intraperitoneal and bidirectional chemotherapy is essential, randomized clinical trials to determine the most optimal drug or drug combination are lacking, and only eight retrospective comparative clinical studies are available. Further clinical pharmacological studies are required to determine the most effective drug regimen for intraperitoneal and bidirectional chemotherapy in various indications. In the future, reliable drug sensitivity testing and genetic profiling of peritoneal metastases will be needed for enabling patient-specific therapy.
Collapse
Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, Heraklion, Greece
| | - Dimosthenis Michelakis
- Department of Surgical Oncology, Medical School of Crete University Hospital, Heraklion, Greece
| | - Dimitris Stamatiou
- Department of Surgical Oncology, Medical School of Crete University Hospital, Heraklion, Greece
| | - John Romanos
- Department of Surgical Oncology, Medical School of Crete University Hospital, Heraklion, Greece
| | - Odysseas Zoras
- Department of Surgical Oncology, Medical School of Crete University Hospital, Heraklion, Greece
| |
Collapse
|
4
|
Raspé C, Flöther L, Schneider R, Bucher M, Piso P. Best practice for perioperative management of patients with cytoreductive surgery and HIPEC. Eur J Surg Oncol 2016; 43:1013-1027. [PMID: 27727026 DOI: 10.1016/j.ejso.2016.09.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/01/2016] [Accepted: 09/13/2016] [Indexed: 12/17/2022] Open
Abstract
Due to the significantly improved outcome and quality of life of patients with different tumor entities after cytoreductive surgery (CRS) and HIPEC, there is an increasing number of centers performing CRS and HIPEC procedures. As this procedure is technically challenging with potential high morbidity and mortality, respectively, institutional experience also in the anesthetic and intensive care departments is essential for optimal treatment and prevention of adverse events. Clinical pathways have to be developed to achieve also good results in more comorbid patients with border line indications and extensive surgical procedures. The anesthesiologist has deal with relevant fluid, blood and protein losses, increased intraabdominal pressure, systemic hypo-/hyperthermia, and increased metabolic rate in patients undergoing cytoreductive surgery with HIPEC. It is of utmost importance to maintain or restore an adequate volume by aggressive substitution of intravenous fluids, which counteracts the increased fluid loss and venous capacitance during this procedure. Supplementary thoracic epidural analgesia, non-invasive ventilation, and physiotherapy are recommended to guarantee adequate pain therapy and postoperative extubation as well as fast-track concepts. Advanced hemodynamic monitoring is essential to help the anesthesiologist picking up information about the real-time fluid status of the patient. Preoperative preconditioning is mandatory in patients scheduled for HIPEC surgery and will result in improved outcome. Postoperatively, volume status optimization, early nutritional support, sufficient anticoagulation, and point of care coagulation management are essential. This is an extensive update on all relevant topics for anesthetists and intensivists dealing with CRS and HIPEC.
Collapse
Affiliation(s)
- C Raspé
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Germany.
| | - L Flöther
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Germany
| | - R Schneider
- Department of General- and Visceral Surgery, Halle-Wittenberg University, Germany
| | - M Bucher
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Germany
| | - P Piso
- Department for General- and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| |
Collapse
|
5
|
Intensive Care Management of Patient After Cytoreductive Surgery and HIPEC - A Concise Review. Indian J Surg Oncol 2016. [PMID: 27065716 DOI: 10.1007/s13193- 016-0511-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hyperthermic intraperitoneal chemotherapy (HIPEC) in combination with cytoreductive surgery is a targeted treatment approach in which tumors that have spread through the lining of the abdomen are removed and then heated chemotherapy is perfused throughout the abdomen, with the intent of killing any remaining cancer cells that may be present after all the visible disease has been removed surgically. The chemotherapy is administered in high dosages to the targeted area and washed out, thereby limiting the systemic toxicity. The procedure usually takes 8 to 18 h and is most commonly used to treat appendiceal, colorectal or mesothelioma tumors including those that have failed standard chemotherapy and/or prior surgeries. Patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Intensive monitoring and timely detection of possible complications and appropriate remedial action is crucial for better surgical results.
Collapse
|
6
|
Intensive Care Management of Patient After Cytoreductive Surgery and HIPEC - A Concise Review. Indian J Surg Oncol 2016; 7:244-8. [PMID: 27065716 DOI: 10.1007/s13193-016-0511-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 02/12/2016] [Indexed: 12/21/2022] Open
Abstract
Hyperthermic intraperitoneal chemotherapy (HIPEC) in combination with cytoreductive surgery is a targeted treatment approach in which tumors that have spread through the lining of the abdomen are removed and then heated chemotherapy is perfused throughout the abdomen, with the intent of killing any remaining cancer cells that may be present after all the visible disease has been removed surgically. The chemotherapy is administered in high dosages to the targeted area and washed out, thereby limiting the systemic toxicity. The procedure usually takes 8 to 18 h and is most commonly used to treat appendiceal, colorectal or mesothelioma tumors including those that have failed standard chemotherapy and/or prior surgeries. Patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Intensive monitoring and timely detection of possible complications and appropriate remedial action is crucial for better surgical results.
Collapse
|
7
|
Security and efficiency of a closed-system, turbulent-flow circuit for hyperthermic intraperitoneal chemotherapy after cytoreductive ovarian surgery: perioperative outputs. Arch Gynecol Obstet 2014; 290:121-9. [PMID: 24488579 DOI: 10.1007/s00404-014-3153-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 01/09/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To present physiologic intraoperative data and immediate postoperative outcomes of patients diagnosed with epithelial ovarian cancer submitted to cytoreductive surgery and hyperthermic peritoneal intraoperative chemotherapy (HIPEC) with a closed-circuit, turbulent-flow system. MATERIALS AND METHODS A closed-circuit system with CO2 turbulent flow was used for paclitaxel HIPEC during 60 min for patients diagnosed with stage II or higher and recurrent epithelial ovarian cancer. Perioperative hemodynamic and metabolic statuses were followed, as well as physiologic recovery during the first 12 postoperative hours. A non-parametric statistical analysis was performed. RESULTS At the end of the hyperthermia phase, temperature was 37.7 ± 0.6 °C, heart rate 88 ± 19 bpm, cardiac index 2.8 ± 0.5 L min(-1) m(-2), stroke volume variation 14.6 ± 3.6 % and extravascular lung water 8.7 ± 1.9 mL kg(-1). No hyperdynamic status was recorded. The length of stay in the ICU was 2½ days, and 12.7 ± 7 days in hospital. Average postoperative intubation time was 11.7 ± 17.4 h. At the ICU admission time, glucose, lactic acid and hemoglobin were the only values out of range, but close to normal. SOFA median was 3 at admission and 0 the following day. CONCLUSION A turbulent-flow, closed-circuit use for hyperthermic peritoneal intraoperative chemotherapy resulted in no hyperdynamic response or coagulopathy, had good tolerance and promoted early physiologic recovery.
Collapse
|
8
|
Li N, Bo CW, Zou CP, Ma WH, Zheng Z, An YH. Efficacy of continuous hyperthermic peritoneal perfusion chemotherapy for malignant seroperitoneum. Shijie Huaren Xiaohua Zazhi 2013; 21:3757-3761. [DOI: 10.11569/wcjd.v21.i33.3757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the curative effect and adverse effects of continuous hyperthermic peritoneal perfusion chemotherapy versus simple intraperitoneal chemotherapy in the management of malignant seroperitoneum secondary to gastrointestinal tumors.
METHODS: Eighty-four inpatients with malignant seroperitoneum secondary to gastrointestinal tumors treated at our hospital between October 2010 and February 2013 were enrolled in the study. They were randomly and equally divided into either a study group to undergo continuous hyperthermic peritoneal perfusion chemotherapy or a control group to receive intraperitoneal chemotherapy. The differences in curative effect, quality of life and adverse effects were compared between the two groups.
RESULTS: The rate of ascites control was significantly higher in the study group than in the control group (88.33% vs 59.52%, P < 0.05). The rate of improvement of quality of life was also higher in the study group (88.1% vs 53.76%, P < 0.05). Adverse effects included mild nausea and vomiting, temporary abdominal pain, CTCAE grade Ⅰ-Ⅱ bone marrow depression (BMD), and no grade Ⅲ-Ⅳ BMD was identified. No significant differences in adverse effect were observed between the two groups.
CONCLUSION: Continuous hyperthermic peritoneal perfusion chemotherapy is superior to simple intraperitoneal chemotherapy in the management of malignant seroperitoneum in terms of ascite control, improvement of quality of life, and adverse effects.
Collapse
|
9
|
An overview of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for the anesthesiologist. Anesth Analg 2013; 116:924-31. [PMID: 23460568 DOI: 10.1213/ane.0b013e3182860fff] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Anesthesiologists face several perioperative challenges when patients need cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion. To adequately care for these patients, anesthesiologists must understand the goals and objectives of the operation in addition to having a basic knowledge of the chemotherapeutic drugs that are frequently used. Optimal anesthetic management of patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion requires control of a complex interplay of physiologic mechanisms, including hyperthermia, abdominal hypertension, electrolyte abnormalities, coagulopathies, increased cardiac index, oxygen consumption, and decreased systemic vascular resistance. As this surgery continues to gain popularity among oncologic surgeons, further studies that clearly define the chemistry, pharmacokinetics, pharmacodynamics, and end points of efficacy need to be performed to elucidate optimal perioperative management.
Collapse
|
10
|
Desgranges FP, Steghens A, Rosay H, Méeus P, Stoian A, Daunizeau AL, Pouderoux-Martin S, Piriou V. [Epidural analgesia for surgical treatment of peritoneal carcinomatosis: a risky technique?]. ACTA ACUST UNITED AC 2011; 31:53-9. [PMID: 22154448 DOI: 10.1016/j.annfar.2011.08.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 08/25/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND To study the risks of haemodynamic instability, and the possible occurrence of spinal haematoma, meningitis and epidural abscess when epidural analgesia is performed for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS We retrospectively analyzed the data of 35 patients treated by HIPEC with oxaliplatin or cisplatin. An epidural catheter was inserted before induction of general anaesthesia. Postoperatively, a continuous epidural infusion of ropivacain, then a patient-controlled epidural analgesia were started. RESULTS The epidural catheter was used peroperatively before HIPEC in 12 subjects (34%), and after HIPEC in 23 subjects (66%). The median dose of ropivacain given peroperatively in the epidural catheter was 40 mg (30-75). Norepinephrin was used in two subjects (6%) peroperatively (median infusion rate 0.325 μg/kg per minute [0.32-0.33]), and in four subjects (11%) in the postoperative 24 hours. No spinal haematoma, meningitis or epidural abscess were noted. Five subjects (14%) had a thrombopenia or a prothrombin time less than 60% before catheter removal. Two subjects (6%) had a leukopenia before catheter removal. No thrombopenia or blood coagulation disorders were recorded the day of catheter removal. CONCLUSION In this series of 35 patients, the use of epidural analgesia for HIPEC does not seem to be associated with a worse risk of haemodynamic instability, spinal haematoma, meningitis or epidural abscess. HIPEC with platinum salt is not incompatible with the safety of epidural analgesia, with an optimized fluid management peroperatively and the following of perimedullary anesthesia practice guidelines.
Collapse
Affiliation(s)
- F-P Desgranges
- Département d'anesthésie-réanimation, centre régional de lutte contre le cancer Léon-Bérard, Lyon, France.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Schmidt C, Moritz S, Rath S, Grossmann E, Wiesenack C, Piso P, Graf BM, Bucher M. Perioperative management of patients with cytoreductive surgery for peritoneal carcinomatosis. J Surg Oncol 2009; 100:297-301. [PMID: 19697426 DOI: 10.1002/jso.21322] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important tool in the management of patients with peritoneal malignancies. It is a complex surgical procedure with significant fluid loss during debulking leading to relevant pathophysiological alterations and therefore a challenge for anesthesiologists and critical care physicians. This review summarizes perioperative changes in hemodynamics, oxygen supply, coagulation, hematopoetic parameters and fluid status during cytoreductive surgery and HIPEC and how to deal with these pathophysiological alterations.
Collapse
Affiliation(s)
- C Schmidt
- Department of Anesthesiology, University of Regensburg, Regensburg, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Schmidt C, Creutzenberg M, Piso P, Hobbhahn J, Bucher M. Peri-operative anaesthetic management of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Anaesthesia 2008; 63:389-95. [PMID: 18336490 DOI: 10.1111/j.1365-2044.2007.05380.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) is a long and complex procedure with significant blood and fluid loss during debulking and important pathophysiological alterations during the HIPEC phase. We performed a retrospective analysis of 78 consecutive patients undergoing cytoreductive surgery with HIPEC at a university hospital. Our data demonstrate large intra-operative fluid turnover, with 51% of patients requiring a blood transfusion. During HIPEC, airway pressure and central venous pressure increased with a lower oxygenation ratio as a result of increased intra-abdominal pressure with the closed abdomen technique. As a consequence of the raised body temperature, heart rate, end tidal carbon dioxide and arterial lactate levels increased with a slight metabolic acidosis. Peri-operative analysis of routine clotting parameters revealed disturbances of the coagulation status. For pain management, 72% of patients received supplementary thoracic epidural analgesia with consequential peri-operative opioid sparing and a reduced duration of postoperative ventilation.
Collapse
Affiliation(s)
- C Schmidt
- Department of Anaesthesiology, University of Regensburg, Franz-Josef-Strauss-Allee 11, 93042 Regensburg, Germany.
| | | | | | | | | |
Collapse
|
13
|
de Bree E, Rosing H, Filis D, Romanos J, Melisssourgaki M, Daskalakis M, Pilatou M, Sanidas E, Taflampas P, Kalbakis K, Beijnen JH, Tsiftsis DD. Cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy with paclitaxel: a clinical and pharmacokinetic study. Ann Surg Oncol 2008; 15:1183-92. [PMID: 18239973 DOI: 10.1245/s10434-007-9792-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Revised: 12/07/2007] [Accepted: 12/08/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intraperitoneal chemotherapy has been recommended as a treatment option for ovarian cancer with peritoneal dissemination. Although its treatment duration is significantly shorter, intraoperative hyperthermic intraperitoneal perfusion chemotherapy (HIPEC) has several advantages over simple intraperitoneal instillation chemotherapy. While platinum compounds have usually been used, only a few have administered paclitaxel during HIPEC. Its large molecular weight suggests a much more favorable pharmacokinetic profile than that of platinum compounds. The pharmacokinetics of paclitaxel during and after HIPEC have not been studied before. METHODS Thirteen women, mainly with ovarian cancer, underwent cytoreductive surgery and HIPEC with 175 mg/m(2) paclitaxel for 2 h. Morbidity was noted. Peritoneal fluid samples and blood samples were harvested during and until 5 days after HIPEC for pharmacokinetic study in ten patients. RESULTS No treatment-related mortality was noted. Overall morbidity was 38% (two wound infections, one deep venous thrombosis, two grade 1 thrombopenia, one grade 2 neutropenia, and one grade 3 pancytopenia). Mean maximal intraperitoneal paclitaxel concentration was 101 mg/L, which was an average of 1178 times higher than the peak plasma levels. The peritoneal fluid versus plasma AUC ratio was 1462 for the 2-h HIPEC duration and 366 for the total 5-day study period. Cytotoxic drug concentrations were detected in peritoneal fluid for a mean period of 2.7 days, despite drainage of the drug solution after 2 h of treatment. CONCLUSIONS HIPEC with paclitaxel following cytoreductive surgery is feasible, relatively safe, and associated with a highly favorable pharmacokinetic profile, despite its short treatment duration. Larger studies with a more homogenous patient cohort and adequate follow-up should be performed to demonstrate its efficacy.
Collapse
Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, University Hospital, Crete University Medical School, P.O. Box 1352, 71 110, Herakleion, Greece.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Sarnaik AA, Sussman JJ, Ahmad SA, McIntyre BC, Lowy AM. Technology for the delivery of hyperthermic intraoperative intraperitoneal chemotherapy: a survey of techniques. RECENT RESULTS IN CANCER RESEARCH. FORTSCHRITTE DER KREBSFORSCHUNG. PROGRES DANS LES RECHERCHES SUR LE CANCER 2007; 169:75-82. [PMID: 17506250 DOI: 10.1007/978-3-540-30760-0_6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Peritoneal metastases are common sequelae of gastrointestinal malignancy. The treatment of peritoneal metastases through use of aggressive surgical cytoreduction including peritonectomy coupled with HIPEC has now been reported in several large single-institution series. The available literature suggests that in experienced hands and with appropriate patient selection cytoreduction and HIPEC can be an effective therapy, particularly when all macroscopic tumor deposits are removed. Different techniques involving the administration of intraperitoneal chemotherapy have been reported, including the closed intraoperative technique, the open or coliseum technique, and the open technique using a PCE device. All techniques have been associated with mortality and morbidity that is significant, but generally consistent with other major surgical procedures. In theory, the coliseum and PCE techniques may have less associated morbidity because of improved heat distribution; however, this remains to be definitively proven in a controlled clinical trial. Such controlled studies are critical to defining the best techniques for HIPEC administration and the appropriate role for this treatment regimen in patients with peritoneal metastases. The development of a program in cytoreductive surgery and HIPEC requires a comprehensive patient care team led by appropriately trained surgeons. Such teams are best suited to provide the highest-quality care to patients with peritoneal surface malignancy.
Collapse
Affiliation(s)
- Amod A Sarnaik
- Department of Surgery, University of Cincinnati College of Medicine, Barrett Cancer Center, OH 45219-0772, USA
| | | | | | | | | |
Collapse
|
15
|
de Bree E, Tsiftsis DD. Principles of perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis. Recent Results Cancer Res 2007; 169:39-51. [PMID: 17506248 DOI: 10.1007/978-3-540-30760-0_4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, Herakleion, Greece
| | | |
Collapse
|
16
|
de Bree E, Theodoropoulos PA, Rosing H, Michalakis J, Romanos J, Beijnen JH, Tsiftsis DD. Treatment of ovarian cancer using intraperitoneal chemotherapy with taxanes: from laboratory bench to bedside. Cancer Treat Rev 2006; 32:471-82. [PMID: 16942841 DOI: 10.1016/j.ctrv.2006.07.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2006] [Revised: 07/02/2006] [Accepted: 07/04/2006] [Indexed: 01/20/2023]
Abstract
The combination of a taxane, paclitaxel or docetaxel, and a platinum compound has become the systemic chemotherapy of choice for primary ovarian cancer and has demonstrated high efficacy. However, ultimately most patients will die from this disease. Hence, there is a need for even more effective systemic chemotherapy or different treatment strategies. Intraperitoneal chemotherapy with taxanes is such an alternative treatment option. Ovarian cancer is theoretically an attractive malignancy for this regional treatment, because the disease remains largely confined to the peritoneal cavity. The choice of taxanes for this kind of chemotherapy is rational, because of its high activity against ovarian cancer cells and expected favourable pharmacokinetics because of limited absorption from the peritoneal cavity due to their large molecular weight and first-pass effect in the liver. In animal model and human pharmacokinetic studies, very high intraperitoneal drug concentrations and exposure and high peritoneal tumour concentrations were achieved, while systemic drug levels were low. The combination of intraperitoneal chemotherapy with hyperthermia enhances the penetration and cytotoxic activity of many drugs. Although data concerning thermal enhancement of taxane cytotoxicity are inconsistent, experimental studies show that at high locoregional concentrations there seems to be such an effect. Recently, feasibility and efficacy of this treatment have evidently been demonstrated in various clinical studies. A large randomized trial revealed improvement of outcome by intraperitoneal instillation chemotherapy with paclitaxel and cisplatin as first-line treatment. Moreover, promising results have been observed after intraoperative hyperthermic intraperitoneal chemotherapy with docetaxel for recurrent disease.
Collapse
Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, P.O. Box 1352, 71110 Herakleion, Greece.
| | | | | | | | | | | | | |
Collapse
|
17
|
de Bree E, Rosing H, Beijnen JH, Romanos J, Michalakis J, Georgoulias V, Tsiftsis DD. Pharmacokinetic study of docetaxel in intraoperative hyperthermic i.p. chemotherapy for ovarian cancer. Anticancer Drugs 2003; 14:103-10. [PMID: 12569296 DOI: 10.1097/00001813-200302000-00003] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to evaluate the pharmacokinetics and toxicity of docetaxel in continuous hyperthermic perfusion peritoneal chemotherapy (CHPPC) after cytoreductive surgery for peritoneal involvement of gynecological malignancies, mainly ovarian cancer. Eighteen patients, with a mean age of 64 years (range 51-80), underwent cytoreductive surgery and subsequent CHPPC with 75 mg/m2 docetaxel at 41-43 degrees C. One patient was treated twice. In eight cases, peritoneal fluid and blood samples were obtained for pharmacokinetic analysis. Death occurred in two heavily pretreated elderly patients with a high volume i.p. tumor recurrence, probably reflecting poor patient selection (mortality rate 10.5%). Other complications, mainly minor, were recorded after 63% of the procedures. Hematological docetaxel-induced toxicity was limited, while the incidence of wound complications was relatively high and probably caused by the direct exposure of the wound to docetaxel during CHPPC. The maximal i.p. versus plasma concentration ratio ranged from 17 to 95 (average 45), while the i.p. versus systemic exposure ratio varied between 105 and 555 (average 207). We conclude that the use of docetaxel in CHPPC following cytoreductive surgery seems feasible and results in a high i.p. versus systemic exposure ratio. The AUC for the peritoneal cavity is on average 13-27 times higher after i.p. administration of 75 mg/m2 during CHPPC than the AUC achieved in the systemic compartment after i.v. administration of the recommended dose of 100 mg/m2, while docetaxel-induced systemic toxicity is highly limited.
Collapse
Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, University Hospital, Herakleion, Greece.
| | | | | | | | | | | | | |
Collapse
|
18
|
de Bree E, Romanos J, Tsiftsis DD. Hyperthermia in anticancer treatment. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2002; 28:95. [PMID: 11869025 DOI: 10.1053/ejso.2001.1220] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
19
|
Abstract
The peritoneal surface remains an important failure site for patients with colorectal cancer. Peritoneal metastases of colorectal cancer are at present considered equal to distant metastatic disease. Consequently, peritoneal carcinomatosis is treated with systemic chemotherapy and surgery only to palliate complications such as obstruction. Despite the development of new chemotherapeutic agents and combinations, the results remain disappointing with a limited impact on survival. Colorectal carcinoma cells are relatively resistant to chemotherapy. Intraperitoneal chemotherapy seems to be an attractive approach in the treatment of high-risk colorectal cancer and peritoneal carcinomatosis from colorectal origin providing high local drug concentration with limited systemic side effects. Adjuvant early postoperative intraperitoneal chemotherapy is worthwhile for consideration as treatment option after resection of high-risk colorectal cancer. In the treatment of peritoneal carcinomatosis postoperative intraperitoneal chemotherapy leads to inadequate exposure of the peritoneal surface. Only an intraoperative intraperitoneal chemotherapy performed with direct cytotoxic drugs such as MMC and cisplatin overcome this problem. The limited drug penetration in tissue implies the need for extensive cytoreductive surgery. The results of phase II studies suggest that an increased median survival can be achieved with this approach. The natural history of this disease and the heterogeneity of the patients are such that only a randomized trial design will adequately answer the question whether regional treatment of patients with peritoneal dissemination of colorectal cancer actually prolongs survival. The results of such a study are to be expected in approximately 2 years time.
Collapse
Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, The Netherlands Cancer Institute (Antoni van Leeuwenhoek Hospital), Amsterdam, The Netherlands
| | | | | |
Collapse
|
20
|
Witkamp AJ, de Bree E, Van Goethem R, Zoetmulder FA. Rationale and techniques of intra-operative hyperthermic intraperitoneal chemotherapy. Cancer Treat Rev 2001; 27:365-74. [PMID: 11908929 DOI: 10.1053/ctrv.2001.0232] [Citation(s) in RCA: 182] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In recent years surgical cytoreduction followed by intra-operative hyperthermic intraperitoneal chemotherapy (HIPEC) was introduced as treatment modality in patients with peritoneal surface malignancy. In the current review the rational for this approach, the prerequisites and the different techniques used are discussed. METHODS A literature search through PubMed was performed. RESULTS Pharmacokinetic studies have shown an important dose advantage for intraperitoneal versus intravenous application. Hyperthermia enhances the penetration of cytostatic drugs into tumour tissue and also shows synergism with various cytostatic drugs. The penetration depth of drugs into tissue is limited, therefore HIPEC can only be effective in patients with minimal residual disease after (aggressive) surgery. HIPEC can be conducted in various ways, without clear proven advantage of one method over the others. Local complications after this combined treatment approach are mainly surgery related. Intraperitoneal chemotherapy may cause systemic toxicity, dependent on the drug used. In randomised studies cytoreductive surgery followed by HIPEC has proven its value in the prevention of peritoneal dissemination in gastric cancer. Phase II data on HIPEC in peritoneal carcinomatosis of colorectal origin and pseudomyxoma peritonei are promising, but randomised studies are still not available. CONCLUSION Aggressive surgical cytoreduction and HIPEC in patients with peritoneal surface malignancy has a clear rational and seems to have clinical value.
Collapse
Affiliation(s)
- A J Witkamp
- Department of Surgical Oncology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, CX 1066 Amsterdam, the Netherlands
| | | | | | | |
Collapse
|
21
|
Witkamp AJ, de Bree E, Kaag MM, Boot H, Beijnen JH, van Slooten GW, van Coevorden F, Zoetmulder FA. Extensive cytoreductive surgery followed by intra-operative hyperthermic intraperitoneal chemotherapy with mitomycin-C in patients with peritoneal carcinomatosis of colorectal origin. Eur J Cancer 2001; 37:979-84. [PMID: 11334722 DOI: 10.1016/s0959-8049(01)00058-2] [Citation(s) in RCA: 166] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Peritoneal seeding from colorectal cancer has a very poor prognosis and is relatively resistant to systemic chemotherapy. We performed a phase I/II trial to investigate the feasibility and effectiveness of extensive cytoreductive surgery in combination with intra-operative hyperthermic intraperitoneal chemotherapy (HIPEC) in these patients. 29 patients with peritoneal carcinomatosis of colorectal origin without evidence of distant metastases underwent cytoreductive surgery and intra-operative HIPEC with mitomycin-C (MMC), followed by systemic chemotherapy with 5-fluorouracil (5-FU)/leucovorin. Surgical complications occurred in 11 patients (38%). One patient died directly related to the treatment, resulting in a mortality rate of 3%. MMC toxicity existed mainly of leucocytopenia (in 15 patients; 52%). After a median follow-up of 38 months (range 26-52 months) we found a 2- and 3-year survival rate (Kaplan-Meier) of 45 and 23%, respectively. Extensive cytoreductive surgery and HIPEC is feasible in patients with peritoneal seeding of colorectal cancer. First results suggest that a higher median survival could be achieved compared with conventional palliative surgery and systemic chemotherapy, therefore a randomised phase III study is now being conducted.
Collapse
Affiliation(s)
- A J Witkamp
- Department of Surgical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Huis, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Witkamp AJ, de Bree E, Kaag MM, van Slooten GW, van Coevorden F, Zoetmulder FA. Extensive surgical cytoreduction and intraoperative hyperthermic intraperitoneal chemotherapy in patients with pseudomyxoma peritonei. Br J Surg 2001; 88:458-63. [PMID: 11260116 DOI: 10.1046/j.1365-2168.2001.01701.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pseudomyxoma peritonei remains a fatal disease. However, extensive surgical cytoreduction combined with intraoperative heated intraperitoneal chemotherapy (HIPEC) has recently emerged as a new treatment modality, which might improve survival. METHODS Patients underwent treatment if the tumour appeared to be technically resectable on preoperative abdominal computed tomography and there were no distant metastases. After aggressive surgical cytoreduction, HIPEC with the administration of mitomycin C was performed for 90 min. Depending on histological grading, patients received adjuvant 5-fluorouracil and leucovorin therapy. RESULTS Forty-six patients were treated. Optimal surgical cytoreduction was obtained in 40 patients. Postoperative surgical complications occurred in 18 patients. Four patients died as a direct result of the treatment. Bone marrow suppression due to mitomycin C toxicity occurred in 22 patients. There was no other major toxicity related to the HIPEC procedure. After a median follow-up of 12 months, 40 patients are alive, eight of whom have proven recurrence. The actuarial survival rate (Kaplan-Meier) at 3 years was 81 per cent. CONCLUSION These results confirm that extensive surgery combined with HIPEC is feasible in patients with pseudomyxoma peritonei and that improved long-term survival might be achieved.
Collapse
Affiliation(s)
- A J Witkamp
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
23
|
de Bree E, Christodoulakis M, Tsiftsis D. Malignant peritoneal mesothelioma treated by continuous hyperthermic peritoneal perfusion chemotherapy. Ann Oncol 2000; 11:753-6. [PMID: 10942067 DOI: 10.1023/a:1008328120555] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Malignant mesothelioma of the peritoneum is a rare tumour for which the therapeutic approach has not yet been standardized. The efficacy of the current regimes is limited. Effective locoregional therapy is crucial, since this tumour is most often confined to the peritoneal cavity at the time of the initial diagnosis and remains there for much of its clinical course. If and when haematogenous metastases occur, they rarely contribute to the death of the patient, which is often caused by the overgrowth of the primary tumour and its local complications. A case of diffuse malignant peritoneal mesothelioma treated by cytoreductive surgery and continuous hyperthermic peritoneal perfusion with cisplatin is reported. The patient received systemic combination chemotherapy postoperatively. She is in good condition and free of disease 28 months after her treatment. Continuous hyperthermic peritoneal perfusion chemotherapy has recently been used in patients with secondary peritoneal carcinomatosis from digestive and gynecological malignancies with promising results. It is also possible that the same treatment alone or in combination with systemic chemotherapy may be effective in the treatment of primary peritoneal malignancies, as in the case of diffuse peritoneal mesothelioma.
Collapse
Affiliation(s)
- E de Bree
- Department of Surgical Oncology, Medical School, University of Crete, Herakleion, Greece.
| | | | | |
Collapse
|