High mortality after abdominal operation in patients with large-volume malignant ascites

Natural History and Management of Small-Bowel Obstruction in Patients After Cytoreductive Surgery and Intraperitoneal Chemotherapy

BACKGROUND

Small-bowel obstruction (SBO) after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a common complication associated with re-admission that may alter patients' outcomes. Our aim was to characterize and investigate the impact of bowel obstruction on patients' prognosis.

METHODS

This was a retrospective analysis of patients with SBO after CRS/HIPEC (n = 392). We analyzed patients' demographics, operative and perioperative details, SBO re-admission data, and long-term oncological outcomes.

RESULTS

Out of 366 patients, 73 (19.9%) were re-admitted with SBO. The cause was adhesive in 42 (57.5%) and malignant (MBO) in 31 (42.5%). The median time to obstruction was 7.7 months (range, 0.5-60.9). Surgical intervention was required in 21/73 (28.7%) patients. Obstruction eventually resolved (spontaneous or by surgical intervention) in 56/73 (76.7%) patients. Univariant analysis identified intraperitoneal chemotherapy agents: mitomycin C (MMC) (HR 3.2, p = 0.003), cisplatin (HR 0.3, p = 0.03), and doxorubicin (HR 0.25, p = 0.018) to be associated with obstruction-free survival (OFS). Postoperative complications such as surgical site infection (SSI), (HR 2.2, p = 0.001) and collection (HR 2.07, p = 0.015) were associated with worse OFS. Multivariate analysis maintained MMC (HR 2.9, p = 0.006), SSI (HR 1.19, p = 0.001), and intra-abdominal collection (HR 2.19, p = 0.009) as independently associated with OFS. While disease-free survival was similar between the groups, overall survival (OS) was better in the non-obstruction group compared with the obstruction group (p = 0.03).

CONCLUSIONS

SBO after CRS/HIPEC is common and complex in management. Although conservative management was successful in most patients, surgery was required more frequently in patients with MBO. Patients with SBO demonstrate decreased survival.

Impact of hospital surgical volume on complete gross resection (CGR) rates following primary debulking surgery for advanced stage epithelial ovarian carcinoma

BACKGROUND

To investigate the impact of hospital surgical volume on the rate of complete gross resection for patients with advanced stage epithelial ovarian carcinoma undergoing primary debulking surgery.

METHODS

The National Cancer Data Base was used to identify patients undergoing between 2010 and 2014 for an advanced stage (III-IV) epithelial ovarian cancer. For analyses purposes facility surgical volume was divided into tertiles (high, intermediate and low). Patients with bulky stage III disease who underwent primary debulking surgery with known residual disease status were selected for further analysis.

RESULTS

A total of 8894 patients with macroscopic peritoneal disease were included. Rates of complete gross resection for patients managed in low, intermediate and high-volume centers were 41.0%, 41.6% and 43.3% respectively (p = 0.20). After controlling for year of diagnosis, age, insurance status, presence of co-morbidities, histology, size of peritoneal implants, stage, and complexity of surgery, patients undergoing primary debulking surgery at low (OR: 0.85, 95% CI: 0.74, 0.97, p = 0.013) and intermediate (OR: 0.90, 95% CI: 0.82, 0.99, p = 0.043) volume centers had a lower likelihood of achieving complete gross resection compared to those managed in high volume centers.

CONCLUSIONS

After controlling for multiple potential confounders, patients receiving surgery in high volume centers had a higher likelihood of complete gross resection following primary debulking surgery for advanced-stage epithelial ovarian cancer.

"The impact of debulking surgery in patients with node-positive epithelial ovarian cancer: Analysis of prognostic factors related to overall survival and progression-free survival after an extended long-term follow-up period"

OBJECTIVE

to estimate the prognostic factors associated with survival and progression free survival (PFS) in patients with node-positive epithelial ovarian cancer (EOC) after an extended long-term follow-up period.

METHODS

Data was provided by the Tumor Registry of the Mayo Clinic, Scottsdale, Arizona on 116 node-positive EOC patients who underwent primary cytoreductive surgery observed over the period 1996-2014.

RESULTS

At censoring date, 21 patients were alive (18%), 95 dead (82%), 18 without evidence of disease (NED) (15 alive, 3 dead) and 76 with evidence of disease (ED) (2 alive, 74 dead). Twenty-nine ED patients (38.2%) experienced a recurrence within 2 years, 53 patients (69.7%) before 5 years. No recurrences were recorded after 10 years. The median follow-up in alive patients was 169.8 months (1.20-207.9 months), 34.9 months (0.30-196.2 months) in dead patients, 128.4 months for NED patients (72.8-202.5 months) and 34.6 months (0.1-106.9 months) in ED patients. Multivariate analysis showed an increased risk of dead in patients with age ≥ 60 years (HR: 3.20; p < 0.002), stage IVA/B (compared with stage IIIA1/2, HR: 4.31; p < 0.001 and stage IIIB/C, HR: 5.31; p < 0.010) and incomplete surgery (compared with complete surgery, HR: 3.10; 95% CI, 1.41-6.77; p < 0.003) and a decreased PFS in stage IVA/B (compared with stages IIIB/C; p = 0.003 and stage IIIA; p = 0.000) and residual volume after surgery >0.6 cm (compared with residual disease <0.5 cm; p < 0.023).

CONCLUSIONS

prognostic factors for an extended long-term PFS are similar as those for survival, because after 17-year follow-up period, the majority of alive patients are NED patients.

Outcome measures other than morbidity and mortality for patients with incurable cancer and gastrointestinal obstruction

OBJECTIVE

To prospectively evaluate outcome measures of patients undergoing palliative surgical evaluation for gastrointestinal obstruction.

METHODS

Patients with an incurable malignancy undergoing consultation for gastrointestinal obstruction were prospectively enrolled from November 2009 to July 2012. We evaluated two patient-reported outcome measures of quality of life (Functional Assessment of Cancer Therapy-General [FACT-G]) and treatment satisfaction (Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction-General Version 1 [FACIT-TS-G]) and five observational outcome measures (symptom improvement, 30 "good days," ability to tolerate diet at discharge, discharge home, and death within 90 days).

RESULTS

Of 53 patients enrolled, 13 had gastric outlet obstruction, 22 had small bowel obstruction, and 18 had large bowel obstruction. Patient-reported measures could not be analyzed because only 19 patients (36%) completed the FACT-G and FACIT-TS-G survey at 1-month follow-up. However, we were able to obtain results for the 5 clinical observational outcomes in all patients. Symptom improvement was obtained in 41 (77%) patients, 30 "good days" in 40 (75%), ability to tolerate diet at discharge in 45 (85%), discharge to home in 46 (87%), and 18 (34%) of patients died within 90 days of evaluation. Large bowel obstruction was associated with symptom improvement, and noncolorectal cancer histology and carcinomatosis were negatively associated with having 30 "good days." The ability to tolerate oral intake at discharge was associated with Eastern Cooperative Oncology Group performance status and no recent chemotherapy administration. Death within 90 days was independently associated with noncolorectal cancer histology, ascites, and nonsurgical treatment.

CONCLUSIONS

Observational outcome measures can provide follow-up data and the identification of variables associated with outcome for patients who are unable to respond to outpatient surveys.

Pilot study of CD147 protein expression in epithelial ovarian cancer using monoclonal antibody 12C3

AIM

CD147 is a membrane glycoprotein that is expressed in various cancer cells and is involved in tumor invasion and metastasis by inducing stromal fibroblastic cells to produce matrix metalloproteinases. This study was carried out to evaluate the correlation between CD147 expression and various clinicopathologic parameters, including histological grade and prognosis in a small sample set of human ovarian cancer patients.

MATERIAL AND METHODS

Paraffin-embedded surgical tissue samples from 25 patients with ovarian serous and endometrioid adenocarcinoma were stained with anti-CD147 antibody (monoclonal antibody 12C3: MoAb 12C3) for immunohistochemical analysis.

RESULTS

CD147 protein was expressed in 84.0% (21 of 25 cases) of cancerous lesions, but not in normal lesions. CD147 expression by ovarian cancer cells was inversely correlated with overall survival. There was no correlation between CD147 expression and histological grade.

CONCLUSIONS

These results suggest that measurement of CD147 expression may enhance the understanding of the pathophysiology of epithelial ovarian cancer.

Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors influencing spontaneous resolution

Malignant bowel obstruction (MBO) is a frequent complication in advanced cancer patients, especially in those with abdominal tumors. Clinical management of MBO requires a specific and individualized approach that is based on disease prognosis and the objectives of care. The global prevalence of MBO is estimated to be 3% to 15% of cancer patients. Surgery should always be considered for patients in the initial stages of the disease with a preserved general status and a single level of occlusion. Less invasive approaches such as duodenal or colonic stenting should be considered when surgery is contraindicated in obstructions at the single level. The priority of care for inoperable and consolidated MBO is to control symptoms and promote the maximum level of comfort possible. The spontaneous resolution of an inoperable obstructive process is observed in more than one third of patients. The mean survival is of no longer than 4-5 weeks in patients with consolidated MBO. Polymodal medical treatment based on a combination of glucocorticoids, strong opioids, antiemetics, and antisecretory drugs achieves very high symptomatic control. This review focuses on the epidemiological aspects, diagnosis, surgical criteria, medical management, and factors influencing the spontaneous resolution of MBO in advanced cancer patients.

Diverse mechanisms for activation of Wnt signalling in the ovarian tumour microenvironment

Wnt signalling pathways have been shown to play key roles in both normal development and tumorigenesis. Progression of many human cancers is associated with defined mutations in Wnt pathway components that result in dysregulated β-catenin-mediated gene transcription. Although Wnt pathway mutations are rare in epithelial ovarian cancer (with the exception of the endometrioid histotype), accumulating evidence supports a role for Wnt signalling in ovarian tumorigenesis in the absence of genetic mutations. The present review summarizes evidence in support of activated Wnt signalling in ovarian tumours and discusses alternative mechanisms for Wnt pathway activation in the ovarian tumour microenvironment.

Current management of small bowel obstruction

SBO is a common disease with multiple causes. The most significant advances over the past several years have involved, first, decision-making techniques to promptly and accurately identify patients who will require exploration, and, second, the increasing use of laparoscopic techniques. "Complete" bowel obstruction is becoming an outdated term, as treatment algorithms use predictive models and oral contrast challenges to select patients for operation without recourse to the notion of "complete obstruction." Laparoscopic techniques are gaining acceptance as a primary modality in the treatment of SBO. Appropriate patient selection is necessary for success, but successful laparoscopic SBO management can reduce postoperative pain, minimize hospital stay, and may lead to fewer adhesions, possibly preventing further adhesive SBO. Strangulation obstruction is the major cause of morbidity and mortality in SBO. Although unrecognized strangulation obstructions remain, their incidence is decreasing with the new protocols in development. Future efforts should focus on incorporating predictive models into management with the goal of eliminating unrecognized strangulation obstructions. Further refinement of the predictive models incorporating outcomes of oral contrast challenges and molecular biomarker data may allow surgeons to reach this goal. In addition, the benefit of the elimination of interpractitioner variability conferred by standardized protocols will in itself improve patient outcomes.

Predictors of survival in patients with non-curative stage IV cancer and malignant bowel obstruction

PURPOSE

Malignant bowel obstruction (MBO) occurs in up to 15% of patients admitted to palliative care wards and management can be clinically challenging. Survival is generally poor with a reported median survival of 1-3 months; however, there are no studies describing predictors of survival for patients with MBO.

PATIENTS AND METHODS

All patients admitted to a tertiary care hospital with a MBO were approached between March 1, 2006 and March 31, 2008 to enter the study. Demographic, clinical, laboratory, and radiographic information were prospectively collected from patient charts and the patient's functional status (Eastern Cooperative Oncology Group score, ECOG) at admission was recorded. Follow-up was until death or the end of the study (August 2008). Survival was estimated using Kaplan-Meier plots and Cox regression models were used to evaluate prognostic factors for survival.

RESULTS

Thirty-five patients were recruited. Median patient age was 61% and 46% were female. Median survival of the cohort was 80 days (range 7-873). Median survival for patients with an ECOG performance status of 0-1 (n = 15) was 222 days, for ECOG 2 patients (n = 9), 63 days and for patients with an ECOG 3/4 score (n = 11) it was 27 days. ECOG status was the strongest predictor of survival on the multivariate analysis. In addition, a low blood urea nitrogen level or a high albumin on admission was also associated with prolonged survival.

CONCLUSION

An ECOG score of 0/1 for patients with MBO in the setting of Stage IV non-curative cancer is the strongest predictor of overall survival.

Surgical management for a malignant bowel obstruction with recurrent gastrointestinal carcinoma

BACKGROUND

A malignant bowel obstruction (MBO) is a common clinical complication in patients with recurrent gastrointestinal carcinoma, which has a poor prognosis and a limited life expectancy. This study considered the effectiveness of surgical management for MBO.

METHODS

This study reviewed the clinical course of 70 patients who underwent surgery for MBO and compared the outcomes in three groups: patients with (A) peritonitis carcinomatosis without manifest ascites, (B) peritonitis carcinomatosis with ascites, (C) local recurrence without peritonitis carcinomatosis.

RESULTS

The 1-year survival rate and median survival time (MST) in the patients in group A were 33.3% and 228 days, which was statistically longer than those (6.7% and 46 days) in the patients in group B (P = 0.026). The rate of the patients with possible oral intake of solid meals for 6 months and median oral intake periods were 45.4% and 161 days in patients in group A and 28.0% and 93 days in patients in group C. In contrast, 66.7% in group B could not take solid meals for more than 1 month, and five patients could not take solid meals at all.

CONCLUSION

Palliative operations for the patients with manifest ascites of MBO are risky and rarely effectively improve oral intake, but this is not considered to be a contraindication for surgical management. Informed consent is therefore important in the surgical management of MBO.

Multivisceral resection does not affect morbidity and survival after cytoreductive surgery and chemoperfusion for carcinomatosis from colorectal cancer

BACKGROUND

Carcinomatosis of colorectal origin is increasingly treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CS-HIPEC). This procedure commonly involves multivisceral resection (MVR) with potentially high morbidity. We analyzed the effect of MVR on the outcome after CS-HIPEC.

METHODS

All patients with colorectal carcinomatosis operated between June 2001 and June 2007 were included. MVR was defined as resection of two or more organs (n = 35). Patients without any or with a single visceral resection formed a control group (n = 30).

RESULTS

Sixty-five patients underwent 72 procedures. MVR was not strongly associated with the mortality, morbidity, reoperation, or readmission. Morbidity, but not mortality, was more common in patients requiring bowel anastomosis (36 of 51 vs. 7 of 21, P = .003). Median survival from the diagnosis of carcinomatosis was not significantly different between the MVR and controls (32.8 months vs. 20.0 months, P = .787). Similarly, the median survival from the time of cytoreduction was not significantly different (20.2 vs. 14.3 months; P = .436). Independent predictors of survival in the Cox regression model were presence of residual disease >5 mm (hazard ratio = 4.5, P = .048), evidence of carcinomatosis on preoperative computed tomographic scan (6.1, P = .008), and initial diagnosis of cancer as systemic (2.6, P = .049). MVR had no statistically significant effect on survival (.441, P = .133).

CONCLUSIONS

Increased risk of complications is associated with the number of intestinal anastomoses, but not with multivisceral resection in CS-HIPEC. Long-term survival is not affected by the number of resected organs.

(1)H NMR spectroscopy of ascitic fluid: discrimination between malignant and benign ascites and comparison of the results with conventional methods

It is often difficult to distinguish benign ascites from malignant ascites by conventional examination of ascitic fluid. Therefore, (1)H NMR spectroscopy of ascitic fluid specimens was explored as a one-shot experiment to identify potentially interesting metabolic indices that might help to differentiate between the two. Seventy ascitic fluid specimens (15 cytologically positive for malignant cells, eight cytologically negative for malignant cells but remaining suspicious for malignant ascites, and 47 due to liver cirrhosis) were subjected to (1)H NMR spectroscopy for quantitative estimation of 14 metabolites. Mean concentrations of the metabolites were compared with the Mann-Whitney U test. Multivariate discriminant function analysis was performed to determine important descriptors in the discrimination process. The sensitivity and specificity of the proposed model were compared with conventional methods using ascitic fluid protein and serum ascitic albumin gradient. Then, probable predictions for the doubtful cases were made using the proposed model. Patients with malignant ascites had significantly higher mean concentrations (microM) of beta-hydroxybutyrate (594 vs 61), lactate (5384 vs 2104), acetone (136 vs 69), and acetoacetate (122 vs 48) than patients with cirrhotic ascites, and significantly lower concentrations of glutamine (359 vs 615), citrate (62 vs 118), glucose (4933 vs 8411), tyrosine (44 vs 124), and phenylalanine (51 vs 93) (P < 0.05 for all). In the discriminant function analysis model, the best discrimination (P < 0.001) was achieved when beta-hydroxybutyrate, lactate, citrate and tyrosine were considered together as markers. Sensitivity and specificity of the proposed model, ascitic fluid protein and serum ascitic albumin gradient were found to be 100% and 97.9%, 53.3% and 76.6%, and 60% and 87.2%, respectively. The proposed model put five of the eight doubtful cases in the malignant group. This is encouraging and may provide useful information for clinical purposes.

Report of the clinical protocol committee: development of randomized trials for malignant bowel obstruction

Malignant bowel obstruction (MBO) is a commonly encountered palliative care problem. There have been very few comparative trials in this area, and consequently there is very little clinical evidence upon which therapy can be rationally based. The purpose of this paper is to highlight the discussion and decision-making process that was undertaken by the Clinical Protocol Subcommittee during the development of a proposed clinical trial of best medical care versus surgical or endoscopic treatment for MBO. The development of the proposed clinical trials followed an orderly process. The first step taken was a discussion of a specific definition for MBO. Once agreed upon, this definition helped identify inclusion and exclusion criteria for the proposed trial. This was followed by an extensive literature review, which helped define both surgical and endoscopic approaches to MBO as well as what constituted best medical care. An extensive discussion was then undertaken concerning the best outcome measure of success for medical, surgical, and endoscopic interventions. All of the above steps culminated in two proposed protocols, one for MBO of the small intestine distal to the ligament of Treitz and a second for colonic obstructions. The small intestinal trial is designed to compare surgical intervention versus best medical care, whereas the colonic trial seeks to compare surgery with endoscopically-placed intraluminal stents coupled with best medical care.

Symptom control in palliative care--Part I: oncology as a paradigmatic example

Achieving the best quality of life for patients and their families when a disease becomes progressive and no longer remains responsive to curative therapy is the primary goal of palliative care. A comprehensive care plan focusing on control of physical symptoms as well as psychological, social, and spiritual issues then becomes paramount in that context. Symptom assessment and treatment are a principle part of palliative care. This paper is the first of three in a series addressing non-pain symptoms, which are frequently encountered in the palliative care populations. The most frequent non-pain symptoms are constipation, chronic nausea and vomiting, anorexia, dyspnea, fatigue, and delirium. As symptoms are subjective, their expression varies from patient to patient, depending on the individual patient's perception and on other factors such as psychosocial issues. While symptoms are addressed individually, patients frequently have multiple coexisting symptoms. Generally told, once the intensity of a symptom has been assessed, it is necessary to assess the symptom in the context of other symptoms such as pain, appetite, fatigue, depression, and anxiety. Given that fact, adopting a multidimensional assessment allows for formulation of a more effective therapeutic strategy. More pertinently, this paper highlights the management of non-pain symptoms as an integral part of patient care and reviews the pathophysiologies, causes, assessment, and management of constipation, chronic nausea, and vomiting, each of which is common among the palliative care population.

Surgical palliation of bowel obstruction

MBO is a common but difficult problem for surgeons caring for cancer patients. Nonsurgical interventions should be considered in all patients who have MBO, especially in those with limited expected survival time or for whom surgery will have little effect on disease control. Surgical options can be helpful in the setting of MBO, as long as reasonable goals and realistic out-comes are clear. There is no defined algorithm for all patients with MBO, and decision-making is based on reasonable estimates of survival and treatment-related success. Therefore, better prospective data need to be collected for this population of patients. In addition, a randomized prospective trial comparing treatments based on the clinical scenario could help practitioners who care for patients with this condition.

Intraperitoneal heated chemotherapy affects healing of experimental colonic anastomosis: an animal study

BACKGROUND

The peritoneal spread of cancer is a well-known entity carrying a dismal prognosis. A new therapeutic approach is the combination of cytoreduction with heated intraperitoneal chemotherapy (HIPC). The risk of an intra-abdominal anastomosis in the presence of such chemotherapy is recognized clinically but the experimental data on the subject are lacking. The aim of this study is to examine the influence of chemotherapy and hyperthermia on the healing of colonic anastomosis.

MATERIALS AND METHODS

Colonic anastomosis were performed in four groups of male Wistar rats: (1) control (operation only), (2) HIPC with saline, (3) with mitomycin C (MMC), and (4) with cisplatinum. HIPC was performed using a closed circulation system at 40 degrees C over 20 min. Anastomotic strength was tested on day 4, 7, 10, and 21.

RESULTS

The bursting pressure of anastomoses in rats treated by HIPC was significantly lower than in controls. On day 4, it was 54.8 mm Hg, 38 mm Hg, 18 mm Hg, and 14.8 mm Hg in groups 1-4, respectively, while on day 7 it was 170 mm Hg, 188 mm Hg, 83 mm Hg, and 19 mm Hg, respectively (P < 0.01). The difference decreased on day 10 and almost vanished on day 21. HIPC with cisplatinum had the worst effect on anastomotic healing during the early postoperative period.

CONCLUSIONS

Cytoreduction and HIPC are gaining popularity. However, the use of heated chemotherapy has a detrimental effect on the strength of colonic anastomosis, especially during the early postoperative period (until day 10). This may cause anastomotic failure and postoperative morbidity. Therefore, careful selection and avoidance of unnecessary anastomoses are mandatory.

Surgical management of malignant bowel obstruction

MBO is a common but difficult problem for surgeons caring for cancer patients. Nonsurgical interventions should be considered in all patients with MBO, especially inpatients with limited survival or for whom surgery will have little effect on disease control. Although there is no algorithm for all patients with MBO, decision-making is based on reasonable expectations of survival and treatment-related success. Surgical options can be helpful in the setting of MBO as long as reasonable goals and realistic outcomes are clear.

Total abdominal colectomy, pelvic peritonectomy, and end-ileostomy for the surgical palliation of mucinous peritoneal carcinomatosis from non-gynecologic cancer

BACKGROUND AND OBJECTIVES

The optimal management of symptomatic advanced peritoneal carcinomatosis of non-gynecologic origin is not defined. Historic controls of surgical efforts report high postoperative mortality and morbidity rates with equivocal palliation. Novel surgical procedures need to be tested in terms of the impact on survival and quality of life.

STUDY DESIGN

We studied 46 consecutive patients who underwent total abdominal colectomy, pelvic peritonectomy with construction of an end-ileostomy for palliation of peritoneal carcinomatosis.

RESULTS

Total abdominal colectomy, pelvic peritonectomy, and end-ileostomy was successfully performed in 46 patients of median age of 54.4 years. Overall median survival was 10.7 months, with a mean follow-up period of 12 months. Patients with appendiceal malignancy had a median survival of 19.7 months. Prognosis was poorer for patients with colon cancer, who had a median survival of 7.0 months, while patients with primary peritoneal carcinomatosis had a median of 7.8 months. Postoperative morbidity and mortality rates were 19.5 and 8.6%, respectively.

CONCLUSIONS

Total abdominal colectomy, pelvic peritonectomy, and end-ileostomy is a technically feasible procedure and is advocated for the palliation of patients with peritoneal carcinomatosis of appendiceal origin. It is not clear if the procedure should be advocated for more invasive gastrointestinal malignancies.

Quality of life after intraperitoneal hyperthermic chemotherapy (IPHC) for peritoneal carcinomatosis

AIMS

This study assessed the functional status and quality of life (QOL) of patients with disseminated peritoneal cancer (DPC) before and after cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy (IPHC).

METHODS

Patients with confirmed or suspected diagnosis of gastro-intestinal cancer including stomach, pancreas, hepatobiliary and colorectal cancer with peritoneal implants were enrolled in the study. Sixty-four patients completed the Functional Assessment of Cancer Therapy-Colon (FACT-C) scale and several other instruments at baseline. Forty-eight, 40, 39 and 31 patients were assessed at approximately 2 weeks post-surgery, and 3, 6 and 12 months respectively.

RESULTS

There was a significant overall effect on the physical (P=0.0025), emotional (P<0.0001) and functional well-being (P=0.0044) subscales and the FACT-C (P=0.0076). Physical and functional well-being scores decreased at post-surgery follow-up and increased relative to baseline at 3, 6 and 12 months. Nineteen per cent, 46%, 59% and 74% of patients resumed greater than 50% of their normal activities post-operatively at 3, 6 and 12 months respectively. A percentage of patients reported depressive symptoms: baseline (28%), post-operatively (33%), 3 months (23%), 6 months (21%) and 12 months (29%).

CONCLUSIONS

Cytoreductive surgery followed by IPHC was well tolerated. Most patients returned to baseline or better levels of functioning within 3 months post-treatment.

Cytoreductive Surgery with Intraperitoneal Hyperthermic Chemotherapy for Disseminated Peritoneal Cancer of Gastrointestinal Origin

No standard effective treatment exists for peritoneal carcinomatosis of gastrointestinal origin. The pharmacokinetic advantage of intraperitoneal chemotherapy and the synergy of heat and certain anticancer agents have prompted researchers to investigate intraperitoneal hyperthermic chemotherapy in treating disseminated peritoneal cancers. We have conducted a large Phase II trial to determine the safety and efficacy of aggressive cytoreductive surgery and intraperitoneal hyperthermic chemotherapy (IPHC) in treating peritoneal carcinomatosis of gastrointestinal origin. Patients with disseminated peritoneal carcinomatosis of gastrointestinal origin with or without malignant ascites were eligible. After aggressive surgical debulking, patients were administered a 2-hour heated (40.5° C) intraperitoneal perfusion with mitomycin C. The major response variable monitored was overall survival. Patients were assessed for toxicity after IPHC administration using the National Cancer Institute Common Toxicity Criteria. Eighty-four patients with peritoneal carcinomatosis of gastrointestinal origin were evaluated for survival and toxicity (colon, n = 38; appendix, n = 22; stomach, n = 19; other gastrointestinal, n = 5). Thirty-nine (46%) patients had malignant ascites at the time of therapy. The operative mortality (30-day) was 6 per cent. Hematologic toxicity was the most common toxicity but was of mild to moderate severity (7 and 4% of patients had grade 3/4 white blood cell or platelet toxicity, respectively). The overall median survival was 14.3 months. The median survival of patients with peritoneal carcinomatosis of appendiceal, colorectal, and gastric origins were 31.1+, 14.6, and 10.1 months, respectively. Significant differences in median survival were seen in patients without and with malignant ascites (27.7 vs 7.6 months; P = 0.0004) and R0/R1 (complete gross tumor resection) versus R2 (gross residual tumor) surgical resection status (28.5+ vs 10.8 months, P = 0.0002). These data suggest that aggressive cytoreductive surgery with IPHC using mitomycin C is safe and effective in treating peritoneal carcinomatosis of gastrointestinal origin. Additional studies and broader applications of this treatment are encouraged.