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Yue TM, Sun BJ, Xu N, Ohkuma R, Fowler C, Lee B. Improved Postoperative Pain Management Outcomes After Implementation of Enhanced Recovery After Surgery (ERAS) Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC). Ann Surg Oncol 2024; 31:3769-3777. [PMID: 38466484 DOI: 10.1245/s10434-024-15120-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/14/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for patients with peritoneal carcinomatosis is promising but has potential for significant morbidity and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a standardized protocol designed to optimize perioperative care. This study describes trends in epidural and opioid use after implementing ERAS for CRS-HIPEC at a tertiary academic center. METHODS A retrospective analysis of patients undergoing CRS-HIPEC from January 2020 to September 2023 was conducted. ERAS was implemented in February 2022. Medication and outcomes data were compared before and after ERAS initiation. All opioids were converted to morphine milligram equivalents (MMEs). RESULTS A total of 136 patients underwent CRS-HIPEC: 73 (54%) pre- and 63 (46%) post-ERAS. Epidural usage increased from 63% pre-ERAS to 87% post-ERAS (p = 0.001). Compared with those without epidurals, patients with epidurals had decreased total 7-day oral and intravenous (IV) opioid requirements (45 MME vs. 316 MME; p < 0.001). There was no difference in 7-day opioid totals between pre- and post-ERAS groups. After ERAS, more patients achieved early ambulation (83% vs. 53%; p < 0.001), early diet initiation (81% vs. 25%; p < 0.001), and early return of bowel function (86% vs. 67%; p = 0.012). CONCLUSIONS ERAS implementation for CRS-HIPEC was associated with increased epidural use, decreased oral and IV opioid use, and earlier bowel function return. Our study demonstrates that epidural analgesia provides adequate pain control while significantly decreasing oral and IV opioid use, which may promote gastrointestinal recovery postoperatively. These findings support the implementation of an ERAS protocol for effective pain management in patients undergoing CRS-HIPEC.
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Affiliation(s)
- Tiffany M Yue
- Stanford University School of Medicine, Stanford, USA
| | - Beatrice J Sun
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, USA
| | - Nova Xu
- Stanford University School of Medicine, Stanford, USA
| | - Rika Ohkuma
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, USA
| | - Cedar Fowler
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, USA
| | - Byrne Lee
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, USA.
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Patrick-Brown TD, Mohamed F, Thrower A, Torgunrud A, Cosyns S, Canbay E, Villeneuve L, Flatmark K, Brandl A. Determining a minimum data set for reporting clinical and radiologic data for pseudomyxoma peritonei. Pleura Peritoneum 2023; 8:1-9. [PMID: 37020469 PMCID: PMC10067554 DOI: 10.1515/pp-2022-0200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/22/2023] [Indexed: 04/05/2023] Open
Abstract
Objectives Pseudomyxoma peritonei (PMP) is a rare cancer currently affecting over 11,736 patients across Europe. Since PMP is so uncommon, collaboration between scientific centers is key to discovering the mechanisms behind the disease, efficient treatments, and targets pointing to a cure. To date, no consensus has been reached on the minimum data that should be collected during PMP research studies. This issue has become more important as biobanking becomes the norm. This paper begins the discussion around a minimum data set that should be collected by researchers through a review of available clinical trial reports in order to facilitate collaborative efforts within the PMP research community. Content A review of articles from PubMed, CenterWatch, ClinicalTrials.gov and MedRxiv was undertaken, and clinical trials reporting PMP results selected. Summary There is a core set of data that researchers report, including age and sex, overall survival, peritoneal cancer index (PCI) score, and completeness of cytoreduction, but after this, reports become variable. Outlook Since PMP is a rare disease, it is important that reports include as large of a number of standardised data points as possible. Our research indicates that there is still much ground to cover before this becomes a reality.
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Affiliation(s)
| | - Faheez Mohamed
- Peritoneal Malignancy Institute, Basingstoke Hospital, Basingstoke, UK
| | - Andrew Thrower
- Hampshire Hospitals NHS Foundation, Basingstoke Hospital, Basingstoke, UK
| | - Annette Torgunrud
- Department of Tumour Biology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Sarah Cosyns
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Emel Canbay
- Department of General Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Türkiye
| | - Laurent Villeneuve
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Service de Recherche et d’Epidémiologie Cliniques, Hospices Civils de Lyon, Hôpital Lyon Sud, Université Lyon-1, Lyon, France
| | - Kjersti Flatmark
- Department of Tumour Biology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
- Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Andreas Brandl
- Department of Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Elgendy H, Iqbal M, Youssef T, Alzahrani A, Rugaan A. Optimizing risk factors influence Intensive Care stay after Hyperthermic Intraperitoneal Chemotherapy? An observational cohort study. Cancer Treat Res Commun 2022; 33:100653. [PMID: 36327575 DOI: 10.1016/j.ctarc.2022.100653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/20/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND It may be necessary to admit patients receiving Hyperthermic Intraperitoneal Chemotherapy (HIPEC) to the intensive care unit (ICU). They were required to evaluate the length of ICU stay (LOS) following HIPEC, as well as their survival rates and risk factors that influence LOS. METHODS 74 HIPEC patients were observed after being admitted to the ICU. Their assignments were made based on their LOS at the ICU. Short stay group, patients who stayed in the ICU for three days or less (S-group) and patients who stayed for three days or longer (L-group). RESULTS Survival rates for both groups were comparable. After HIPEC, they exhibited intraoperative hypotension (P = 0.015), hyopthermia (P = 0.014), and hyperglycemia (P = 0.010). Additionally, patients in group L underwent longer surgeries (P = 0.013), lost more blood (P = 0.043), and required more transfusions (P = 0.001). Subjects in group-L had higher SOFA, fentanyl, and vasopressor requirements (all P 0.001), higher ALT and AST levels, disrupted K, lower Na, and higher INR levels (all P 0.001), as well as a higher APACHE II score (P = 0.007). Preoperative BUN had an independent risk factor for LOS of 0.861; (95% CI), (0.742- 0.999); P = 0.048; and crystalloid transfusion had an independent risk factor of 1.000; (95% CI), (0.999- 1.000); P = 0.003. CONCLUSIONS Transfusions of crystalloids and BUN were independent risk factors for extended LOS. ICU LOS had no impact on survival. All measures should be taken to control hemostasis in vulnerable HIPEC participants.
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Affiliation(s)
- Hamed Elgendy
- Department of Anaesthesia, Assiut University Hospitals, Egypt; Department of Anaesthesia, Al Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar.
| | - Masood Iqbal
- Dept. Critical Care Medicine, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Talha Youssef
- Department of Internal Medicine, Nephrology, king Abdul-Aziz Medical City - Ministry of National Guard, Riyadh, Saudi Arabia
| | | | - Asia Rugaan
- Dept. Critical Care Medicine, King Abdullah Medical City, Makkah, Saudi Arabia
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Gangi A, Shah R. The Landmark Series: Appendiceal Primary Peritoneal Surface Malignancy. Ann Surg Oncol 2021; 29:2056-2068. [PMID: 34853944 DOI: 10.1245/s10434-021-10856-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/09/2021] [Indexed: 12/24/2022]
Abstract
Appendiceal primary peritoneal surface malignancies are rare and include a broad spectrum of pathologies ranging from indolent disease to aggressive disease. As such, the data that drive the management of appendiceal peritoneal surface malignancies is generally not based on prospective clinical trial data, but rather consists of level 1 data based on retrospective studies and high-volume institutional experiences. Complete surgical debulking typically offers the best chance for long-term survival. This review highlights the landmark articles on which management of primary appendiceal peritoneal surface malignancies are based.
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Affiliation(s)
- Alexandra Gangi
- Division of Surgical Oncology, Cedars Sinai Medical Center, Los Angeles, CA, USA.
| | - Rupen Shah
- Division of Surgical Oncology, Henry Ford Cancer Institute/Henry Ford Health System, Detroit, MI, USA
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Dranichnikov P, Mahteme H, Cashin PH, Graf W. Coagulopathy and Venous Thromboembolic Events Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2021; 28:7772-7782. [PMID: 33839978 PMCID: PMC8519924 DOI: 10.1245/s10434-021-09941-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 03/12/2021] [Indexed: 12/13/2022]
Abstract
Background Coagulopathy after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is recognized but few details have been studied. Objectives The aim of this study was to investigate changes in coagulation biomarkers and their predictive ability for venous thromboembolism (VTE). Methods Patients undergoing CRS and HIPEC at Uppsala University Hospital, Sweden, from 2004 to 2014 were included in a prospective study of coagulation biomarkers. Prothrombin time international normalized ratio (PT-INR), activated partial thromboplastin time (APTT), fibrinogen, antithrombin, D-dimer, and platelets were sampled on postoperative days 1, 2, 5, and 10. Logistic regression analysis was used to evaluate predictive capacity for coagulation-related complications. Results Overall, 380 patients were included (214 females, mean age 56 years); 38 patients had a history of thromboembolism and 57 were active smokers. Mean perioperative blood loss was 1228 mL and 231 (61%) received perioperative blood transfusions. PT-INR and APTT were elevated directly after surgery but returned to normal levels on postoperative day 5. Conversely, fibrinogen, platelet count, D-dimer, and antithrombin increased by postoperative day 5 and continued to increase up to day 10. There were 23 radiologically verified cases of VTE within 6 months. The multivariate analysis identified a completeness of cytoreduction score of 2–3 (p = 0.047) and day 2 D-dimer (p = 0.0082) as independent risk factors for postoperative VTE. Conclusion Significant postoperative changes in coagulation biomarkers occur with dynamic changes over 10 days postoperatively. The incidence of symptomatic VTE was low. Residual tumor at completion of surgery and elevated D-dimer on day 2 were independent risk factors for postoperative VTE.
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Affiliation(s)
- Paul Dranichnikov
- Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University, Uppsala, Sweden. .,Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University Hospital, Uppsala, Sweden.
| | - Haile Mahteme
- Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University, Uppsala, Sweden.,Department of Surgery and Centre for Clinical Research, Västmanland Hospital Västerås, Västerås, Sweden
| | - Peter H Cashin
- Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University, Uppsala, Sweden.,Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Wilhelm Graf
- Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University, Uppsala, Sweden.,Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University Hospital, Uppsala, Sweden
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Di Leo A, Corvasce A, Weindelmayer J, Mason EJ, Casella F, de Manzoni G. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in pseudomyxoma peritonei of appendiceal origin: result of a single centre study. Updates Surg 2020; 72:1207-1212. [PMID: 32410159 DOI: 10.1007/s13304-020-00788-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/02/2020] [Indexed: 12/25/2022]
Abstract
Pseudomyxoma peritonei (PMP) is a rare condition characterized by the intraperitoneal accumulation of mucus derived mostly by appendiceal mucinous neoplasm. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) can offer a favourable overall survival. In this study, we report a single-institute outcomes following CRS and HIPEC in patients with this condition. This is a review of prospectively collected data from 32 patients (11 men and 21 women) affected by PMP of appendiceal origin who underwent CRS and HIPEC from 2008 to 2016 in our Surgical Unit of General and Esophagogastric Surgery. The median age of the patients was 53 years (range 25-77 years). After CRS, all patients underwent HIPEC (mytomicin C 3.3 mg/m2/L and cisplatin 25 mg/m2/L at 41 °C for 60 min) with closed abdomen technique. The median (range) follow-up time for surviving patients was 43 (18-119) months. The median peritoneal cancer index (PCI) was 17. Complete cytoreductive surgery (CC0) was achieved in in 22 patients (69%). The majority of patients (88%) had grade I-II complications, 3 (9%) had grade III complications, and 1 (3%) patient had a grade IV complication. There were no perioperative mortalities. The median hospital stay was 9.5 (range 9-24) days. One year and 5-year overall survival (OS) were 90% and 58%, respectively. Regardless of histotype, disease-free survival was 95% at 1 year and 46% at 5 years. CRS in combination with HIPEC is a feasible treatment strategy and can achieve a satisfactory outcome in patients with PMP of appendiceal origin.
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Affiliation(s)
- Alberto Di Leo
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy.
| | - Arianna Corvasce
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy
| | - Jacopo Weindelmayer
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy
| | - Elena Jane Mason
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy
| | - Francesco Casella
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy
| | - Giovanni de Manzoni
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy
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The American Society of Colon and Rectal Surgeons, Clinical Practice Guidelines for the Management of Appendiceal Neoplasms. Dis Colon Rectum 2019; 62:1425-1438. [PMID: 31725580 DOI: 10.1097/dcr.0000000000001530] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Zaidi MY, Lee RM, Gamboa AC, Speegle S, Cloyd JM, Kimbrough C, Grotz T, Leiting J, Fournier K, Lee AJ, Dineen S, Dessureault S, Kelly KJ, Kotha NV, Clarke C, Gamblin TC, Patel SH, Lee TC, Hendrix RJ, Lambert L, Ronnekleiv-Kelly S, Pokrzywa C, Blakely AM, Lee B, Johnston FM, Fackche N, Russell MC, Maithel SK, Staley CA. Preoperative Risk Score for Predicting Incomplete Cytoreduction: A 12-Institution Study from the US HIPEC Collaborative. Ann Surg Oncol 2019; 27:156-164. [PMID: 31602579 DOI: 10.1245/s10434-019-07626-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND For patients with peritoneal carcinomatosis undergoing cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC), incomplete cytoreduction (CCR2/3) confers morbidity without survival benefit. The aim of this study is to identify preoperative factors which predict CCR2/3. METHODS All patients who underwent curative-intent CRS/HIPEC of low/high-grade appendiceal, colorectal, or peritoneal mesothelioma cancers in the 12-institution US HIPEC Collaborative from 2000 to 2017 were included (n = 2027). The primary aim is to create an incomplete-cytoreduction risk score (ICRS) to predict CCR2/3 CRS utilizing preoperative data. ICRS was created from a randomly selected cohort of 50% of patients (derivation cohort) and verified on the remaining patients (validation cohort). RESULTS Within our derivation cohort (n = 998), histology was low-grade appendiceal neoplasms in 30%, high-grade appendiceal tumor in 41%, colorectal tumor in 22%, and peritoneal mesothelioma in 8%. CCR0/1 was achieved in 816 patients and CCR 2/3 in 116 patients. On multivariable analysis, preoperative factors associated with incomplete cytoreduction were male gender [odds ratio (OR) 3.4, p = 0.007], presence of ascites (OR 2.8, p = 0.028), cancer antigen (CA)-125 ≥ 40 U/mL (OR 3.4, p = 0.012), and carcinoembryonic antigen (CEA) ≥ 4.2 ng/mL (OR 3.2, p = 0.029). Each preoperative factor was assigned a score of 0 or 1 to form an ICRS from 0 to 4. Scores were grouped as zero (0), low (1-2), or high (3-4). Incidence of CCR2/3 progressively increased by risk group from 1.6% in zero to 13% in low and 39% in high. When ICRS was applied to the validation cohort (n = 1029), this relationship was maintained. CONCLUSION The incomplete cytoreduction risk score incorporates preoperative factors to accurately stratify the risk of CCR2/3 resection in CRS/HIPEC. This score should not be used in isolation, however, to exclude patients from surgery.
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Affiliation(s)
- Mohammad Y Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Rachel M Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Adriana C Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Shelby Speegle
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Charles Kimbrough
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Travis Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Sophie Dessureault
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Kaitlyn J Kelly
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, USA
| | - Nikhil V Kotha
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, USA
| | - Callisia Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Laura Lambert
- Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Sean Ronnekleiv-Kelly
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Courtney Pokrzywa
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Andrew M Blakely
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Byrne Lee
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Nadege Fackche
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road, NE; Building C, 2nd Floor, Atlanta, GA, 30322, USA.
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Siddharthan R, Dewey E, Billingsley K, Gilbert E, Tsikitis VL. Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience. Am J Surg 2019; 219:1073-1075. [PMID: 31253353 DOI: 10.1016/j.amjsurg.2019.06.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 06/16/2019] [Accepted: 06/19/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is reported to have a prolonged length of stay (LOS). We incorporated an enhanced recovery after surgery (ERAS) protocol to examine whether we could reduce our LOS. METHODS Patients were identified who underwent CRS/HIPEC from 2015 to 2018 before and after initiation of ERAS protocol. The protocol included pre-operative, peri-operative and post-operative interventions. Primary end point was LOS. Secondary endpoints were morbidity and mortality. RESULTS Forty patients were identified, thirty-one of which underwent CRS/HIPEC: 16 before and 15 after ERAS. The median LOS prior to ERAS was 11 days (5-20) and 7 days (5-27) after ERAS (P < 0.05). There was no significant difference in 30-day morbidity (Clavien-Dindo ≥3) or mortality between the groups. CONCLUSIONS An ERAS protocol can safely be implemented in patients undergoing CRS/HIPEC with earlier return of bowel function and decrease in LOS without increasing morbidity or mortality.
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Affiliation(s)
| | - Elizabeth Dewey
- Oregon Health and Science Universtiy, Department of Surgery, United States
| | - Kevin Billingsley
- Oregon Health and Science Universtiy, Department of Surgery, United States
| | - Erin Gilbert
- Oregon Health and Science Universtiy, Department of Surgery, United States
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Votanopoulos KI, Shen P, Skardal A, Levine EA. Peritoneal Metastases from Appendiceal Cancer. Surg Oncol Clin N Am 2018; 27:551-561. [PMID: 29935689 DOI: 10.1016/j.soc.2018.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The early symptoms of appendiceal cancer may mimic the clinical picture of appendicitis. Most patients are diagnosed incidentally during surgical exploration or late when peritoneal or systemic dissemination has already occurred, as colonoscopy rarely will diagnose an appendiceal cancer. Systemic/extraperitoneal metastases are distinctly unusual for appendiceal mucinous lesions.
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Affiliation(s)
- Konstantinos I Votanopoulos
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
| | - Perry Shen
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Aleksander Skardal
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Edward A Levine
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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Morano WF, Khalili M, Chi DS, Bowne WB, Esquivel J. Clinical studies in CRS and HIPEC: Trials, tribulations, and future directions-A systematic review. J Surg Oncol 2017; 117:245-259. [PMID: 29120491 DOI: 10.1002/jso.24813] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 07/24/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The field of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has suffered from a lack of clinical trials to validate its expanding use. OBJECTIVE To evaluate published and ongoing clinical trials seeking to better define role of CRS/HIPEC in the treatment of peritoneal surface malignancies. METHODS Systematic review by PubMed search was performed using terms "Clinical trial," "intraperitoneal chemotherapy," and "HIPEC." ClinicalTrials.gov and EudraCT registries were searched for active clinical trials. Eligibility included CRS/HIPEC trials investigating adult patient populations from published clinical reports and/or trials currently accruing or at completion. RESULTS Thirteen published trials and 57 active clinical trials were included for review. CONCLUSIONS Published and ongoing U.S. and international clinical trials for CRS and HIPEC are defining important parameters that include improving patient selection, strategic sequences of treatment, cytoreductive strategies, chemotherapeutics, optimal hyperthermic temperature and timing, and toxicity profiles. Main barriers or limitations to trial development remain patient enrollment, trial design, and oncologic community collaboration. Overall progress is positive with increasing number of clinical trials throughout the world. Collaboration between surgeons and the wider oncologic community will be crucial to validate this important treatment strategy.
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Affiliation(s)
- William F Morano
- Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Marian Khalili
- Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Dennis S Chi
- Section of Ovarian Cancer Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Wilbur B Bowne
- Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jesus Esquivel
- Department of Surgery, Frederick Memorial Hospital, Frederick, Maryland
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Polanco PM, Ding Y, Knox JM, Ramalingam L, Jones H, Hogg ME, Zureikat AH, Holtzman MP, Pingpank J, Ahrendt S, Zeh HJ, Bartlett DL, Choudry HA. Outcomes of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion in Patients with High-Grade, High-Volume Disseminated Mucinous Appendiceal Neoplasms. Ann Surg Oncol 2015; 23:382-90. [DOI: 10.1245/s10434-015-4838-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Indexed: 12/18/2022]
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Randle RW, Votanopoulos KI, Shen P, Levine EA, Stewart JH. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Ahmed S, Stewart JH, Shen P, Votanopoulos KI, Levine EA. Outcomes with cytoreductive surgery and HIPEC for peritoneal metastasis. J Surg Oncol 2014; 110:575-84. [DOI: 10.1002/jso.23749] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 07/16/2014] [Indexed: 12/17/2022]
Affiliation(s)
- Shuja Ahmed
- Surgical Oncology Service; Department of General Surgery; Wake Forest Baptist Medical Center; Winston Salem North Carolina
| | - John H. Stewart
- Surgical Oncology Service; Department of General Surgery; Wake Forest Baptist Medical Center; Winston Salem North Carolina
| | - Perry Shen
- Surgical Oncology Service; Department of General Surgery; Wake Forest Baptist Medical Center; Winston Salem North Carolina
| | - Konstantinos I. Votanopoulos
- Surgical Oncology Service; Department of General Surgery; Wake Forest Baptist Medical Center; Winston Salem North Carolina
| | - Edward A. Levine
- Surgical Oncology Service; Department of General Surgery; Wake Forest Baptist Medical Center; Winston Salem North Carolina
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Blackham AU, Swett K, Eng C, Sirintrapun J, Bergman S, Geisinger KR, Votanopoulos K, Stewart JH, Shen P, Levine EA. Perioperative systemic chemotherapy for appendiceal mucinous carcinoma peritonei treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Surg Oncol 2014; 109:740-5. [PMID: 24375188 PMCID: PMC4010799 DOI: 10.1002/jso.23547] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 12/05/2013] [Indexed: 01/17/2023]
Abstract
BACKGROUND The role of systemic chemotherapy (SC) in conjunction with cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in appendiceal mucinous carcinoma peritonei (MCP) is unknown. METHODS A retrospective review (1999-2011) of MCP patients who had undergone CS/HIPEC with or without perioperative SC. RESULTS Twenty-two low-grade MCP patients treated with CS/HIPEC and SC were matched to patients who received CS/HIPEC alone. Median overall survival (OS) was 107 months for patients treated with perioperative SC compared to 72 without (P = 0.46). CS/HIPEC was performed on 109 patients with high-grade MCP: 70 were treated with perioperative SC, while 39 were not. Median OS (22.1 vs. 19.6 months, P = 0.74) and progression-free survival (PFS) (10.9 vs. 7.0 months, P = 0.47) were similar in patients treated with SC compared to CS/HIPEC alone. Progression while on pre-operative SC was seen in eight patients (17%), while four (8%) had a partial response. Treatment with post-operative SC was associated with longer PFS (13.6 months) compared to pre-operative SC (6.8 months, P < 0.01) and CS/HIPEC alone (7.0 months, P = 0.03). CONCLUSIONS Post-operative SC appears to improve PFS in patients with high-grade appendiceal MCP treated with CS/HIPEC. In contrast, there is no evidence to support the routine use of perioperative SC in low-grade disease.
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Affiliation(s)
- Aaron U. Blackham
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Katrina Swett
- Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Cathy Eng
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph Sirintrapun
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Simon Bergman
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kim R Geisinger
- Piedmont Pathology Associates, Hickory, North Carolina
- Department of Pathology and Laboratory Medicine, The University of North Carolina, Chapel Hill, North Carolina
| | | | - John H. Stewart
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Perry Shen
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Edward A. Levine
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Amini A, Masoumi-Moghaddam S, Ehteda A, Morris DL. Secreted mucins in pseudomyxoma peritonei: pathophysiological significance and potential therapeutic prospects. Orphanet J Rare Dis 2014; 9:71. [PMID: 24886459 PMCID: PMC4013295 DOI: 10.1186/1750-1172-9-71] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 04/22/2014] [Indexed: 12/22/2022] Open
Abstract
Pseudomyxoma peritonei (PMP, ORPHA26790) is a clinical syndrome characterized by progressive dissemination of mucinous tumors and mucinous ascites in the abdomen and pelvis. PMP is a rare disease with an estimated incidence of 1-2 out of a million. Clinically, PMP usually presents with a variety of unspecific signs and symptoms, including abdominal pain and distention, ascites or even bowel obstruction. It is also diagnosed incidentally at surgical or non-surgical investigations of the abdominopelvic viscera. PMP is a neoplastic disease originating from a primary mucinous tumor of the appendix with a distinctive pattern of the peritoneal spread. Computed tomography and histopathology are the most reliable diagnostic modalities. The differential diagnosis of the disease includes secondary peritoneal carcinomatoses and some rare peritoneal conditions. Optimal elimination of mucin and the mucin-secreting tumor comprises the current standard of care for PMP offered in specialized centers as visceral resections and peritonectomy combined with intraperitoneal chemotherapy. This multidisciplinary approach has reportedly provided a median survival rate of 16.3 years, a median progression-free survival rate of 8.2 years and 10- and 15-year survival rates of 63% and 59%, respectively. Despite its indolent, bland nature as a neoplasm, PMP is a debilitating condition that severely impacts quality of life. It tends to be diagnosed at advanced stages and frequently recurs after treatment. Being ignored in research, however, PMP remains a challenging, enigmatic entity. Clinicopathological features of the PMP syndrome and its morbid complications closely correspond with the multifocal distribution of the secreted mucin collections and mucin-secreting implants. Novel strategies are thus required to facilitate macroscopic, as well as microscopic, elimination of mucin and its source as the key components of the disease. In this regard, MUC2, MUC5AC and MUC5B have been found as the secreted mucins of relevance in PMP. Development of mucin-targeted therapies could be a promising avenue for future research which is addressed in this article.
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Affiliation(s)
- Afshin Amini
- Department of Surgery, St George Hospital, The University of New South Wales, Level 3, Clinical Sciences (WR Pitney) Building, Gray Street, Kogarah, Sydney, NSW 2217, Australia
| | - Samar Masoumi-Moghaddam
- Department of Surgery, St George Hospital, The University of New South Wales, Level 3, Clinical Sciences (WR Pitney) Building, Gray Street, Kogarah, Sydney, NSW 2217, Australia
| | - Anahid Ehteda
- Department of Surgery, St George Hospital, The University of New South Wales, Level 3, Clinical Sciences (WR Pitney) Building, Gray Street, Kogarah, Sydney, NSW 2217, Australia
| | - David Lawson Morris
- Department of Surgery, St George Hospital, The University of New South Wales, Level 3, Clinical Sciences (WR Pitney) Building, Gray Street, Kogarah, Sydney, NSW 2217, Australia
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Arjona-Sanchez A, Muñoz-Casares FC, Casado-Adam A, Sánchez-Hidalgo JM, Ayllon Teran MD, Orti-Rodriguez R, Padial-Aguado AC, Medina-Fernández J, Ortega-Salas R, Pulido-Cortijo G, Gómez-España A, Rufián-Peña S. Outcome of patients with aggressive pseudomyxoma peritonei treated by cytoreductive surgery and intraperitoneal chemotherapy. World J Surg 2014; 37:1263-70. [PMID: 23532601 DOI: 10.1007/s00268-013-2000-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pseudomyxoma peritonei (PMP) is a rare disease with an incidence rate of approximately 1 per million a year. During the past few years, there has been a survival benefit for these patients treated by complete cytoreduction and perioperative chemotherapy. Better survival rates were found in the adenomucinosis group than the carcinomatosis group. The purpose of our study was to analyze the outcome and the prognosis factors of only high-grade PMP. METHODS We selected 38 patients from a prospective database of 59 with high-grade PMP from appendiceal origin who were treated by cytoreduction surgery and HIPEC at the Hospital University Reina Sofia (Cordoba, Spain) between 1998 and July 2012. Clinical, surgical, analytical, radiological, and histological data were obtained prospectively. Survival curves were calculated using the Kaplan-Meier method, a univariate analysis was performed and the log rank-test was used to analyze the effects of several clinical and pathologic factors on overall survival (OS) and disease-free survival (DFS). RESULTS Median follow-up time was 32 months (range, 2-170). Median age at diagnosis was 57 years (range, 32-77). In 89.5 % of patients, optimal cytoreduction CC-0 (57.9 %) and CC-1 (31.6 %) was achieved. In the remaining 10.5 %, cytoreduction was classified as CC-2. The median PCI score was 21 (range, 4-38). Morbidity complications ≥ Grade 3 in the CTCAE v 3.0 classification was 18.4 %. One patient died 45 days postsurgery. Median OS at the end of follow-up was 36 months (range, 9-83); overall 5-year survival rate was 58.7 %. In the univariate analysis for OS, significant values were obtained for lymph-node involvement and suboptimal cytoreduction. The 5-year OS was 64.5 % when an optimal cytoreduction was achieved. Median DFS was 36 months (17-54); 3-year DFS rate was 49.1 %. Neoadjuvant therapy did not affect the survival of these patients; there was no difference in the 5-year OS (43 % vs. 75 %, p = 0.068). CONCLUSIONS In aggressive PMP, cytoreduction with peritonectomy procedure plus HIPEC is a safe procedure that suggests an improvement to the survival rates. Because optimal cytoreduction is a primary prognostic factor for survival rates, this procedure would have to be performed in an experienced center with a low morbidity. Neoadjuvant chemotherapy has not demonstrated benefits in these patients and further research will be required.
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Corbella D, Piraccini E, Finazzi P, Brambillasca P, Prussiani V, Corso MR, Germandi C, Agnoletti V. Anesthetic management of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedures. World J Obstet Gynecol 2013; 2:129-136. [DOI: 10.5317/wjog.v2.i4.129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 04/07/2013] [Accepted: 05/19/2013] [Indexed: 02/05/2023] Open
Abstract
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure are performed with increasing frequency to treat patients with diffused peritoneal carcinomatosis. These procedures have showed to increase life expectancy in what was previously considered a “terminal condition”. Anyway patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Despite the need of an advanced organ monitoring and support all these derangements seem to be mild and short-lived when timely addressed, at least in the majority of patients. Intensive care physicians are involved in providing surveillance and organ support till the patient is effectively weaned after the operation. Moreover, the anesthesiologist as perioperative physician is involved in pain control, metabolic and nutritional support of this cohort of patients. This task can be challenging considering that part of the patients are already on a long list of pain control medication after previous surgery or chemotherapy. A malnourished state is common too and it is secondary to difficult feeding, wasting syndrome from the tumor and massive ascites. The last issue the anesthesiologists need to be aware of is the impact over the quality of life (QoL) of this procedure. The patient’s underlying pathology is unlikely to be definitively cured so no treatment is an acceptable choice. The possibility to withhold the treatments must be part of the consultation process like the discussion about the QoL in the immediate, as well as in the long-term, after the operation. Careful monitoring and treatment of every aspect that can impact the QoL must be taken and the efforts to be poured into an effective preservation of the QoL must be doubled when compared with a patient scheduled for major abdominal surgery.
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Flatmark K, Guldvik IJ, Svensson H, Fleten KG, Flørenes VA, Reed W, Giercksky KE, Fodstad Ø, Andersson Y. Immunotoxin targeting EpCAM effectively inhibits peritoneal tumor growth in experimental models of mucinous peritoneal surface malignancies. Int J Cancer 2013; 133:1497-506. [PMID: 23494569 DOI: 10.1002/ijc.28158] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 02/11/2013] [Accepted: 03/01/2013] [Indexed: 11/10/2022]
Abstract
Cytoreductive surgery and intraperitoneal (i.p.) chemotherapy constitute a curative treatment option in mucinous peritoneal surface malignancies of intestinal origin, but treatment outcome is highly variable and the search for novel therapies is warranted. Immunotoxins are attractive candidates for targeted therapy in the peritoneal cavity because of direct cytotoxicity, distinct mechanisms of action and tumor cell selectivity. The MOC31PE immunotoxin targets the tumor-associated adhesion protein EpCAM (Epithelial Cell Adhesion Molecule), and has been administered safely in early clinical trials. In our work, the efficacy of i.p. administration of MOC31PE alone and together with mitomycin C (MMC) was investigated in unique animal models of human mucinous peritoneal surface malignancies. In initial model validation experiments, clear differences in efficacy were demonstrated between MMC and oxaliplatin, favoring MMC in five investigated tumor models. Subsequently, MOC31PE and MMC were given as single i.p. injections alone and in combination. In the PMCA-2 model, moderate growth inhibition was obtained with both drugs, while the combination resulted in at least additive effects; whereas the PMP-2 model was highly sensitive to both drugs separately and in combination and intermediate sensitivity was found for the PMCA-3 model. Furthermore, results from ex vivo experiments on freshly obtained mucinous tumor tissue from animals and patients suggested that classic mechanisms of immunotoxin activity were involved, i.e., inhibition of protein synthesis and induction of apoptosis. The present results suggest that adding MOC31PE to MMC-based i.p. chemotherapy should be further explored for EpCAM-expressing peritoneal surface malignancies, and a phase I trial is in preparation.
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Affiliation(s)
- Kjersti Flatmark
- Department of Tumor Biology, Norwegian Radium Hospital, Oslo University Hospital, Montebello, Oslo, Norway.
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20
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McBride K, McFadden D, Osler T. Improved survival of patients with pseudomyxoma peritonei receiving intraperitoneal chemotherapy with cytoreductive surgery: a systematic review and meta-analysis. J Surg Res 2013; 183:246-52. [DOI: 10.1016/j.jss.2012.12.040] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 12/05/2012] [Accepted: 12/14/2012] [Indexed: 11/30/2022]
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Losa F, Barrios P, Salazar R, Torres-Melero J, Benavides M, Massuti T, Ramos I, Aranda E. Cytoreductive surgery and intraperitoneal chemotherapy for treatment of peritoneal carcinomatosis from colorectal origin. Clin Transl Oncol 2013; 16:128-40. [DOI: 10.1007/s12094-013-1053-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 05/08/2013] [Indexed: 12/16/2022]
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22
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Turner KM, Hanna NN, Zhu Y, Jain A, Kesmodel SB, Switzer RA, Taylor LM, Richard Alexander H. Assessment of neoadjuvant chemotherapy on operative parameters and outcome in patients with peritoneal dissemination from high-grade appendiceal cancer. Ann Surg Oncol 2013; 20:1068-73. [PMID: 23456383 DOI: 10.1245/s10434-012-2789-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Indexed: 12/30/2022]
Abstract
BACKGROUND High-grade appendiceal adenocarcinoma is a rare malignancy with propensity for peritoneal metastases (PM). The impact of neoadjuvant chemotherapy on operative cytoreduction (CRS) and intraperitoneal chemotherapy (HIPEC) and patient survival was reviewed. METHODS A total of 45 patients with PM from high-grade appendiceal adenocarcinoma were identified from a prospective database. All patients had laparotomy with intent to undergo CRS and HIPEC. Operative parameters, complications, and survival outcomes were analyzed. RESULTS Of the 45 patients (male: 27, female: 18; median age: 55 years), 26 received neoadjuvant chemotherapy ± bevacizumab. Of the 26, 15 (58 %) had a response based on improvement in imaging, biomarkers, or both and 9 (34 %) had stable disease. The median peritoneal cancer index (PCI) was 27. Also, 30 (67 %) had a completeness of cytoreduction score (CCR) of ≤1 and 37 (82 %) received HIPEC. There were no differences in PCI, CCR score, operative blood loss, or major organ resection between those who received or did not receive neoadjuvant chemotherapy. Operative time was significantly shorter in those who did not receive neoadjuvant chemotherapy. Major complications and length of hospital stay were similar between the groups. The median actuarial overall survival calculated from the date of initial therapeutic intervention was not different in those treated with or without neoadjuvant therapy. CONCLUSIONS Neoadjuvant chemotherapy has marked clinical activity in patients with PM from high-grade appendiceal adenocarcinoma and does not adversely affect operative outcomes. These data support conducting a prospective clinical trial to define the role of neoadjuvant chemotherapy in this clinical setting.
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Affiliation(s)
- Keli M Turner
- Division of General and Oncologic Surgery, Department of Surgery and the Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Ba MC, Long H, Cui SZ, Tang YQ, Wu YB, Zhang XL, Tang HS, Bai SX. Multivariate comparison of B-ultrasound guided and laparoscopic continuous circulatory hyperthermic intraperitoneal perfusion chemotherapy for malignant ascites. Surg Endosc 2013; 27:2735-43. [PMID: 23392978 DOI: 10.1007/s00464-013-2800-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 01/07/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Clinical efficacy of B-ultrasound-guided and laparoscopy-assisted continuous hyperthermic intraperitoneal perfusion chemotherapy (CHIPC) for treatment of malignant ascites was investigated. METHODS Sixty-two patients with malignant ascites induced by ovarian or gastrointestinal cancers were randomly treated with B-ultrasound-guided CHIPC (therapeutic group) or laparoscopy-assisted CHIPC (control group) performed at the same center. Hospitalization costs and surgical duration were evaluated. Follow-up was conducted for 21 months with B-ultrasound or computed tomography at least once per month for assessment of ascites amount and tumor progression. Clinical efficacy was assessed by modified World Health Organization criteria. Survival time, Karnofsky performance score (KPS) of quality of life (QOL), and complications were recorded for all patients. RESULTS Overall condition, primary disease type, and ascites amounts were comparable between groups. Significantly shorter mean duration of perfusion catheter placement (35 vs. 85 min) and mean hospitalization cost (36,000 vs. 55,000 ¥/patient) were observed in the therapeutic group than the control group (P < 0.01). Significantly different KPS scores were not observed before or after CHIPC (23.13 vs. 22.64 %) in both groups (P > 0.05). No significant differences in objective remission rates of malignant ascites (93.75 vs. 93.34 %), median survival times (9 vs. 8 months), or stamp hole metastasis rates (18.75 vs. 18.15 %) were observed between groups (P > 0.05). CONCLUSIONS B-ultrasound-guided and laparoscopy-assisted CHIPC have similar clinical efficacy for improving QOL and prolonging patient survival. B-ultrasound-guided CHIPC may, however, shorten operation times and reduce hospitalization costs, making the treatment available to a broader patient population, although port hole metastasis remains an issue.
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Affiliation(s)
- Ming-Chen Ba
- Intracelom Hyperthermic Perfusion Therapy Center, Cancer Hospital of Guangzhou Medical College, Guangzhou 510095, China.
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Votanopoulos KI, Shen P, Stewart JH, Levine EA. Current Status and Future Directions in Appendiceal Cancer with Peritoneal Dissemination. Surg Oncol Clin N Am 2012; 21:599-609. [DOI: 10.1016/j.soc.2012.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Wagner PL, Austin F, Sathaiah M, Magge D, Maduekwe U, Ramalingam L, Jones HL, Holtzman MP, Ahrendt SA, Zureikat AH, Pingpank JF, Zeh HJ, Bartlett DL, Choudry HA. Significance of serum tumor marker levels in peritoneal carcinomatosis of appendiceal origin. Ann Surg Oncol 2012; 20:506-14. [PMID: 22941175 DOI: 10.1245/s10434-012-2627-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Indexed: 01/16/2023]
Abstract
BACKGROUND The significance of tumor markers in patients with appendiceal carcinomatosis is poorly defined. We determined preoperative and postoperative tumor marker levels in patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemoperfusion (HIPEC) and examined their association with clinicopathologic features and survival. METHODS A total of 176 patients undergoing attempted CRS/HIPEC for appendiceal carcinomatosis had at least 1 tumor marker measured. Marker levels were correlated with tumor characteristics and oncologic outcomes. Kaplan-Meier curves and multivariate Cox regression models were used to identify prognostic factors affecting progression and survival. RESULTS At least 1 marker was elevated prior to CRS/HIPEC in 70 % of patients (CEA, 54.1 %; CA19-9, 47.7 %; CA-125, 47.2 %). Among patients with elevated preoperative marker levels, normalization occurred postoperatively in 79.4 % for CEA, 92.3 % for CA19-9, and 60 % for CA-125. Absolute preoperative tumor marker levels correlated with peritoneal carcinomatosis index (PCI) (p < .0002), and the number of elevated markers was associated with PCI and progression-free survival (PFS). Elevated postoperative CEA level was associated with decreased PFS (median, 13 vs 36 months, p = .0008). On multivariate Cox regression analysis, elevated preoperative CA19-9 was associated with shorter PFS (hazard ratio [HR] 2.9, 95 % confidence interval [95 % CI] 1.5-5.3, p = .0008), whereas elevated CA-125 was associated with shorter overall survival (HR 2.6, 95 % CI 1.3-5.4, p = .01). CONCLUSIONS Most patients with appendiceal carcinomatosis will have at least 1 elevated tumor marker and will normalize following CRS/HIPEC, allowing for ongoing surveillance. CA19-9 is a promising biomarker for early progression following CRS/HIPEC, whereas CA-125 is associated with shorter survival.
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Affiliation(s)
- Patrick L Wagner
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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26
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Austin F, Mavanur A, Sathaiah M, Steel J, Lenzner D, Ramalingam L, Holtzman M, Ahrendt S, Pingpank J, Zeh HJ, Bartlett DL, Choudry HA. Aggressive management of peritoneal carcinomatosis from mucinous appendiceal neoplasms. Ann Surg Oncol 2012; 19:1386-93. [PMID: 22302270 DOI: 10.1245/s10434-012-2241-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Indexed: 01/01/2023]
Abstract
BACKGROUND Peritoneal carcinomatosis (PC) in the setting of mucinous appendiceal neoplasms is characterized by the intraperitoneal accumulation of mucinous ascites and mucin-secreting epithelial cells that leads to progressive compression of intra-abdominal organs, morbidity, and eventual death. We assessed postoperative and oncologic outcomes after aggressive surgical management by experienced surgeons. METHODS We analyzed clinicopathologic, perioperative, and oncologic outcome data in 282 patients with PC from appendiceal adenocarcinomas between 2001 and 2010 from a prospective database. Kaplan–Meier survival curves and multivariate Cox-regression models were used to identify prognostic factors affecting oncologic outcomes. RESULTS Adequate cytoreduction was achieved in 82% of patients (completeness of cytoreduction score (CC)-0: 49%; CC-1: 33%). Median simplified peritoneal cancer index (SPCI), operative time, and estimated blood loss were 14 (range, 0–21), 483.5 min (range, 46–1,402), and 800 ml (range, 0–14,000), respectively. Pathology assessment demonstrated high-grade tumors in 36% of patients and lymph node involvement in 23% of patients. Major postoperative morbidity occurred in 70 (25%) patients. Median overall survival was 6.72 years (95% confidence interval (CI), 4.17 years not reached), with 5 year overall survival probability of 52.7% (95% CI, 42.4, 62%). In a multivariate Cox-regression model, tumor grade, age, preoperative SPCI and chemo-naïve status at surgery were joint significant predictors of overall survival. Tumor grade, postoperative CC-score, prior chemotherapy, and preoperative SPCI were joint significant predictors of time to progression. CONCLUSIONS Aggressive management of PC from mucinous appendiceal neoplasms, by experienced surgeons, to achieve complete cytoreduction provides long-term survival with low major morbidity.
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Affiliation(s)
- Frances Austin
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
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27
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Zhong Y, Deng M, Xu R, Kokudo N, Tang W. Pseudomyxoma peritonei as an intractable disease and its preoperative assessment to help improve prognosis after surgery: A review of the literature. Intractable Rare Dis Res 2012; 1:115-21. [PMID: 25343082 PMCID: PMC4204597 DOI: 10.5582/irdr.2012.v1.3.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 07/29/2012] [Accepted: 08/01/2012] [Indexed: 01/05/2023] Open
Abstract
Pseudomyxoma peritonei (PMP) is a rare and intractable disease with an estimated incidence of one per million population per year. Many aspects of PMP need to be fully and precisely understood; these include its preoperative assessment, i.e. diagnosis, early diagnosis, pathologic classification, and staging according to the peritoneal cancer index, and its surgical treatment. This review focuses on elements of preoperative assessment and surgery using the Sugarbaker procedure to help improve the prognosis for patients with PMP. Accurate data on the incidence of PMP must be based on large populations rather than estimates, and much work needs to be done especially in China. Special attention should be paid to its preoperative assessment. Also proposed here are steps to manage PMP with an emphasis on preoperative assessment.
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Affiliation(s)
- Yuesi Zhong
- Department of Hepatobiliary Surgery, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Meihai Deng
- Department of Hepatobiliary Surgery, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ruiyun Xu
- Department of Hepatobiliary Surgery, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Norihiro Kokudo
- Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Wei Tang
- Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Address correspondence to: Dr. Wei Tang, Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan. E-mail:
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Choudry HA, O'Malley ME, Guo ZS, Zeh HJ, Bartlett DL. Mucin as a therapeutic target in pseudomyxoma peritonei. J Surg Oncol 2012; 106:911-7. [PMID: 22585683 DOI: 10.1002/jso.23146] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 04/16/2012] [Indexed: 11/09/2022]
Abstract
Pseudomyxoma peritonei (PMP) is characterized by intraperitoneal dissemination of mucinous ascites. This malignancy frequently recurs despite aggressive locoregional therapies, demonstrates chemo-insensitivity and lacks targeted therapies. This review addresses some intriguing questions in PMP; what role does mucin play in this malignancy?; what genetic alterations and dysregulated signaling pathways lead to a putative goblet cell-lineage differentiation or mucin overexpression?; are targeted therapies against known transcriptional pathways for mucin production a novel therapeutic strategy in this malignancy?
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Affiliation(s)
- Haroon A Choudry
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15261, USA.
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Hasovits C, Clarke S. Pharmacokinetics and Pharmacodynamics of Intraperitoneal Cancer Chemotherapeutics. Clin Pharmacokinet 2012; 51:203-224. [DOI: 10.2165/11598890-000000000-00000] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Early postoperative intraperitoneal chemotherapy following cytoreductive surgery for appendiceal mucinous neoplasms with isolated peritoneal metastasis. Dis Colon Rectum 2012; 55:407-15. [PMID: 22426264 DOI: 10.1097/dcr.0b013e3182468330] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although cytoreductive surgery and intraperitoneal chemotherapy have been advocated as standard treatment for appendiceal neoplasms with isolated peritoneal metastasis, the optimal method of chemotherapy administration has not been established. At our institution, patients undergoing complete cytoreduction in this setting typically receive multiple cycles of early postoperative intraperitoneal chemotherapy. OBJECTIVES The aim of this study was to describe patients with appendiceal neoplasms and peritoneal dissemination treated with complete cytoreductive surgery and early postoperative intraperitoneal chemotherapy and to document associated time to progression and morbidity. DESIGN This is a retrospective study at a single specialty institution. Hospital and departmental databases were searched for patients presenting with primary appendiceal neoplasms undergoing cytoreductive surgery, placement of intraperitoneal port, and subsequent intraperitoneal chemotherapy from June 1995 to September 2009. SETTINGS This study was conducted at Memorial Sloan-Kettering Cancer Center. PATIENTS We identified 50 patients (30 female), median age 48 (range, 26-66) who met the criteria. INTERVENTIONS Cytoreductive surgery, placement intraperitoneal port, and intraperitoneal chemotherapy were performed. RESULTS All patients underwent intraperitoneal catheter placement after complete cytoreductive surgery, followed by a median of 4 cycles (range, 1-9) intraperitoneal 5-fluoro-2'-deoxyuridine (1000 mg/m daily for 3 days) plus leucovorin (240 mg/m). The median hospital length of stay was 9 days (maximum, 29). Thirty-four percent of the patients experienced complications; 12% experienced major complications (3 abdominal abscesses, 1 deep vein thrombosis, 1 abdominal hemorrhage, and 1 intraperitoneal port malfunction). There were no 30-day mortalities. Five-year recurrence-free interval was observed in 43%. Among 23 patients with recurrence, 18 had a recurrence only within the peritoneum. The median overall survival was 9.8 years. LIMITATIONS This is a retrospective study. Many patients had surgery first at other institutions; therefore, pathologic examination of resected material was not possible in every case. Other factors possibly impacting time to recurrence (ie, preoperative chemotherapy, duration between onset of disease and presentation to our institution) varied among patients and were not controlled for. In the absence of a control arm undergoing complete cytoreduction without early postoperative intraperitoneal chemotherapy, we did not ascertain whether intraperitoneal chemotherapy confers additional benefit. CONCLUSIONS Cytoreductive surgery plus multiple cycles of early postoperative intraperitoneal chemotherapy is safe, achieving survival results similar to published outcomes of other protocols (including hyperthermic intraperitoneal chemotherapy). Prospective trials are warranted to compare various methods of intraperitoneal chemotherapy in this setting.
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Pillai K, Akhter J, Chua TC, Morris DL. Potential mucolytic agents for mucinous ascites from pseudomyxoma peritonei. Invest New Drugs 2012; 30:2080-6. [PMID: 22359216 DOI: 10.1007/s10637-012-9797-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 01/20/2012] [Indexed: 11/24/2022]
Abstract
Pseudomyxoma peritonei is a disease characterised by the accumulation of mucinous ascites. Thus far, cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to be effective at eradicating disease. Chemotherapy has been less effective, providing disease stabilization but not demonstrating significant treatment responses. Mucolytic is a potential class of drug that may be exploited in the chemical management of this disease. A variety of potential mucolytic agents are explored in this review providing evidence of basic biochemical evidence of its efficacy with potential translational application.
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Affiliation(s)
- Krishna Pillai
- Department of Surgery Cancer Research Laboratories, University of New South Wales, Sydney, Australia
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Cooksley TJ, Haji-Michael P. Post-operative critical care management of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC). World J Surg Oncol 2011; 9:169. [PMID: 22182345 PMCID: PMC3261105 DOI: 10.1186/1477-7819-9-169] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 12/19/2011] [Indexed: 12/15/2022] Open
Abstract
Background Cytoreductive surgery (CRS) and Heated Intraperitoneal Chemotherapy (HIPEC) results in a number of physiological changes with effects on the cardiovascular system, oxygen consumption and coagulation. The Critical Care interventions required by this cohort of patients have not yet been quantified. Methods This retrospective audit examines the experience of a Specialist Tertiary Centre in England over an 18 month period (January 2009-June 2010) during which 69 patients underwent CRS and HIPEC. All patients were extubated in the operating theatre and transferred to the Critical Care Unit (CCU) for initial post-operative management. Results Patients needed to remain on the CCU for 2.4 days (0.8-7.8). There were no 30 day mortalities. The majority of patients (70.1%) did not require post-operative organ support. 2 patients who developed pneumonia post-operatively required respiratory support. 18 (26.1%) patients required vasopressor support with norepinephrine with a mean duration of 13.94 hours (5-51 hours) and mean dose of 0.04 mcg/kg/min. Post-operative coagulopathy peaked at 24 hours. A significant drop in serum albumin was observed. Conclusion The degree of organ support required post-operatively is minimal. Early extubation is efficacious with the aid of epidural analgesia. Critical Care monitoring for 48 hours is desirable in view of the post-operative challenges.
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Arjona-Sánchez Á, Muñoz-Casares FC, Rufián-Peña S, Díaz-Nieto R, Casado-Adam Á, Rubio-Pérez MJ, Ortega-Salas R. Pseudomyxoma peritonei treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: results from a single centre. Clin Transl Oncol 2011; 13:261-7. [PMID: 21493187 DOI: 10.1007/s12094-011-0651-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pseudomyxoma peritonei (PMP) is a rare, slowly progressive disease whose prognosis depends primarily on the completeness of cytoreduction. The value of intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) and of additional factors predicting long-term outcome and disease-free survival (DFS) remains poorly understood. This study aims to analyse survival rates and prognostic factors in patients undergoing maximal cytoreduction and HIPEC. METHODS Thirty patients were selected from a prospective database of records for patients undergoing cytoreduction and HIPEC with mitomycin C or paclitaxel. Overall survival (OS), DFS, and the prognostic factors influencing them, were examined using multivariate analysis. RESULTS Median follow-up was 44 months (range, 8-144). Histological classification of PMPs was DPAM in 6/30 of cases, PMCA-I in 10/30 and PMCA in 14/30. Complete cytoreduction (CC-0 and CC-1) was achieved in 28/30 of patients and CC-2 in 2/30. Median OS was 111 months (range 0-230) and five-year OS rate was 67%. Median DFS was 53.5 months (range 0-120) and 5-year DFS rate was 44%. Incomplete cytoreduction, lymph node involvement and PCI>20 were associated with poor prognosis for OS, while lymph node involvement, elevated CA-125 levels, unfavourable histology and previous chemotherapy were associated with poor outcomes for DFS. There was morbidity of Grade 3 or higher in 9/30. Post-operative mortality occurred in 1 case. CONCLUSION Cytoreduction plus peritonectomy procedures combined with HIPEC is a safe treatment and could improve survival rates. Since the optimal cytoreduction is the primary prognostic factor, patients should be centralised under the care of experienced teams.
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Affiliation(s)
- Álvaro Arjona-Sánchez
- Department of General Surgery, Unit of Surgical Oncology, Hospital Universitario Reina Sofía, Córdoba, Spain
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Youssef H, Newman C, Chandrakumaran K, Mohamed F, Cecil TD, Moran BJ. Operative findings, early complications, and long-term survival in 456 patients with pseudomyxoma peritonei syndrome of appendiceal origin. Dis Colon Rectum 2011; 54:293-9. [PMID: 21304299 DOI: 10.1007/dcr.0b013e318202f026] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pseudomyxoma peritonei syndrome is a clinical entity characterized by mucinous ascites usually originating from a perforated mucinous appendiceal tumor. Currently optimal therapy is considered complete macroscopic tumor removal (complete cytoreduction) combined with heated intraperitoneal chemotherapy. When complete cytoreduction is not achievable, major tumor debulking is undertaken. The long-term follow-up of patients undergoing surgery for perforated appendiceal tumors in a national pseudomyxoma center is reported. METHODS Between March 1994 and July 2009, 456 patients with pseudomyxoma peritonei syndrome from perforated appendiceal tumors underwent surgery. The treatment strategy involved a combination of cytoreductve surgery aiming for macroscopic tumor removal, combined with hyperthermic intraperitoneal chemotherapy with mitomycin C. Where complete tumor removal was not possible, maximal tumor debulking was performed. Perioperative outcomes and predicted 5- and 10-year survival are reported. RESULTS Overall 15 of 456 (3%) tumors were not resectable at laparotomy. Of the 441 patients who had resection, 289 (66%) had complete cytoreduction and 152 (34%) had major tumor debulking. Postoperative in-hospital mortality was 1.6% and grade 3/4 morbidity was 7%. The Kaplan-Meier method predicted 5- and 10-year overall survival of 69% and 57%, respectively. Five- and 10-year predicted survival was 87% and 74% for the 289 patients who had complete cytoreduction compared with 34% and 23% for the 152 who had major tumor debulking. CONCLUSION Complete tumor removal was achieved in 289 of 441 (66%) patients with peritoneal dissemination from perforated appendiceal tumors with good long-term survival and probable cure in more than two-thirds.
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Affiliation(s)
- Haney Youssef
- Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, UK
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Mohr Z, Hirche C, Liebeskind U, Rau B, Hünerbein M. Feasibility of Delayed Hyperthermic Intraperitoneal Chemotherapy in Case of Unforeseen Complications. Eur Surg Res 2011; 47:19-25. [DOI: 10.1159/000327397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 03/08/2011] [Indexed: 11/19/2022]
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Alves S, Mohamed F, Yadegarfar G, Youssef H, Moran B. Prospective longitudinal study of quality of life following cytoreductive surgery and intraperitoneal chemotherapy for pseudomyxoma peritonei. Eur J Surg Oncol 2010; 36:1156-61. [PMID: 20864306 DOI: 10.1016/j.ejso.2010.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 08/22/2010] [Accepted: 09/02/2010] [Indexed: 01/14/2023] Open
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Evolution of locoregional treatment for peritoneal carcinomatosis: single-center experience of 308 procedures of cytoreductive surgery and perioperative intraperitoneal chemotherapy. Am J Surg 2010; 201:149-56. [PMID: 20832051 DOI: 10.1016/j.amjsurg.2010.02.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 02/15/2010] [Accepted: 02/15/2010] [Indexed: 11/23/2022]
Abstract
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.
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Chua TC, Al-Zahrani A, Saxena A, Liauw W, Zhao J, Morris DL. Secondary cytoreduction and perioperative intraperitoneal chemotherapy after initial debulking of pseudomyxoma peritonei: a study of timing and the impact of malignant dedifferentiation. J Am Coll Surg 2010; 211:526-35. [PMID: 20729102 DOI: 10.1016/j.jamcollsurg.2010.06.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Revised: 05/27/2010] [Accepted: 06/07/2010] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cytoreductive surgery and perioperative intraperitoneal chemotherapy (PIC) is recognized as an effective treatment modality for patients with pseudomyxoma peritonei. This study investigates its role as a secondary definitive treatment procedure after earlier primary treatments. STUDY DESIGN Patients with pseudomyxoma peritonei undergoing secondary cytoreduction combined with PIC were identified from a prospective database. Retrospective analysis investigated the outcomes, prognostic factors, critical time points, and impact of malignant dedifferentiation. Survival analysis was performed via the Kaplan-Meier method and compared via the log-rank test. RESULTS The median time to progression after secondary cytoreduction was 28 months (95% CI 14 to 41 months), median survival was 97 months (95% CI 82 to 113 months), and 10-year survival was 25%. Median overall survival from initial diagnosis was 17 years and 10-year survival rate was 75%. Forty-five patients remained disease free (63%). Requiring an urgent treatment (waiting time < 60 days) after disease progression (p = 0.045) and having moderate or severe symptoms (p = 0.033) were associated with a shorter time to progression. Improved survival was associated with patients who had low-grade tumors (p = 0.029), and those who required less urgent treatment (wait > 30 days) after disease progression (waiting up to 15 days, p = 0.010; waiting up to 30 days, p = 0.005). Malignant dedifferentiation appeared to affect survival from initial diagnosis (p = 0.062) and after secondary cytoreduction (p = 0.006). CONCLUSIONS Secondary cytoreduction with PIC achieves long-term survival. Tumors that undergo malignant dedifferentiation appear to adversely affect survival, and this may support the rationale for early definitive treatment with cytoreduction and PIC.
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Affiliation(s)
- Terence C Chua
- Department of Surgery, University of New South Wales, Kogarah, Sydney, Australia
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Winder T, Lenz HJ. Mucinous adenocarcinomas with intra-abdominal dissemination: a review of current therapy. Oncologist 2010; 15:836-44. [PMID: 20656916 DOI: 10.1634/theoncologist.2010-0052] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas Winder
- Division of Medical Oncology, University of Southern California, Norris Comprehensive Cancer Center, Keck School of Medicine, 1441 Eastlake Avenue, Los Angeles, CA 90033, USA
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Liu L, Sun L, Wang J, Ji G, Chen B, Zhang H. Ovarian cystadenocarcinoma and pseudomyxoma peritonei. BMJ Case Rep 2010; 2010:2010/jun28_1/bcr0620080137. [PMID: 22753161 DOI: 10.1136/bcr.06.2008.0137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Mucoceles resulting from cystadenomas of the ovary are uncommon. Although rare, rupture of the mucoceles can occur without causing any abdominal issue. This report concerns an unusual and interesting case of the right ovary associated with liver, spleen and kidney cysts. CASE PRESENTATION A case of ruptured mucocele resulting from cystadenoma of the ovary occurred in a 63-year-old woman. The patient underwent x-ray, ultrasound and a CT scan. Localised pseudomyxoma peritonei associated with adenocarcinoma of the right ovary was diagnosed. The patient underwent resection of the ovary, uterus, uterine tube and appendix with excision of the mesenteric lymph nodes and removal of about 5000 ml of yellowish mucoid jelly. She was free of symptoms at 1-year follow-up. CONCLUSIONS Pseudomyxoma peritonei may occur in patients with ovarian cystadenocarcinoma. In such patients, the ovary should be investigated and transvaginal ultrasound can be carefully performed in cases of ruptured mucoceles and localised pseudomyxoma peritonei. Surgical intervention is the current choice of management.
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Affiliation(s)
- Lili Liu
- Institute of Digestive Diseases Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Anoop TM, John TM, Fukunaga N. Pseudomyxoma peritonei. Indian J Surg 2010; 72:353-4. [DOI: 10.1007/s12262-010-0109-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 11/17/2009] [Indexed: 11/28/2022] Open
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Martínez A, Ferron G, Mery E, Gladieff L, Delord JP, Querleu D. Peritoneal pseudomyxoma arising from the urachus. Surg Oncol 2010; 21:1-5. [PMID: 20189378 DOI: 10.1016/j.suronc.2009.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Accepted: 12/29/2009] [Indexed: 12/13/2022]
Abstract
Pseudomyxoma peritonei (PMP) arising from urachal tumors is extremely rare. To our knowledge, natural history, tumor biological behaviour, morbidity, treatment, and prognosis of PMP arising from the urachus are determined by the associated PMP. Management of urachal tumors with associated PMP should be based on aggressive locorregional therapy with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, similar to PMP arising from other origins.
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Affiliation(s)
- Alejandra Martínez
- Institut Claudius Regaud, Surgery, 20-24, Rue du Pont Saint Pierre, 31052 Toulouse, France.
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Bevan KE, Mohamed F, Moran BJ. Pseudomyxoma peritonei. World J Gastrointest Oncol 2010; 2:44-50. [PMID: 21160816 PMCID: PMC2999154 DOI: 10.4251/wjgo.v2.i1.44] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 12/24/2009] [Accepted: 12/31/2009] [Indexed: 02/05/2023] Open
Abstract
Pseudomyxoma peritonei (PMP) is an uncommon “borderline malignancy” generally arising from a perforated appendiceal epithelial tumour. Optimal treatment involves a combination of cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC). Controversy persists regarding the pathological classification and its prognostic value. Computed tomography scanning is the optimal preoperative staging technique. Tumour marker elevations correlate with worse prognosis and increased recurrence rates. Following CRS with HIPEC, 5-year survival ranges from 62.5% to 100% for low grade, and 0%-65% for high grade disease. Treatment related morbidity and mortality ranges from 12 to 67.6%, and 0 to 9%, respectively. Surgery and HIPEC are the optimal treatment for PMP which is at best a “borderline” peritoneal malignancy.
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Affiliation(s)
- Katharine E Bevan
- Katharine E Bevan, Faheez Mohamed, Brendan J Moran, Pseudomyxoma Peritonei Centre, Basingstoke and North Hampshire Hospital Foundation Trust, Aldermaston Road, Basingstoke, Hampshire RG24 9NA, United Kingdom
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Cotte E, Passot G, Isaac S, Gilly FN, Glehen O. Tumeurs malignes primitives du péritoine. Presse Med 2009; 38:1814-22. [DOI: 10.1016/j.lpm.2008.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 09/25/2008] [Accepted: 10/06/2008] [Indexed: 12/29/2022] Open
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Rout S, Renehan AG, Parkinson MF, Saunders MP, Fulford PE, Wilson MS, O'Dwyer ST. Treatments and outcomes of peritoneal surface tumors through a centralized national service (United kingdom). Dis Colon Rectum 2009; 52:1705-14. [PMID: 19966601 DOI: 10.1007/dcr.0b013e3181b5504e] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Treatment of peritoneal surface malignancies with combined cytoreductive surgery and heated intraperitoneal chemotherapy may improve oncologic outcome. To better define treatment pathways, five-year results in patients referred to one of two centralized national treatment centers in the United Kingdom were analyzed. METHODS A prospective database of patients referred to the Manchester Peritoneal Tumor Service, established in 2002, was analyzed. Outcomes were evaluated using Kaplan-Meier life tables and Cox models. RESULTS Two hundred seventy-eight patients (median age, 56.9 (range, 16-86) years) were considered by a dedicated multidisciplinary team and tracked on seven clinical pathways. Among the 118 surgically treated, the most common diagnosis was pseudomyxoma peritonei (101 patients, 86%). Major complications occurred in 11 patients (9%); there was no 30-day mortality. Where complete cytoreduction was achieved, three-year and five-year tumor-related survival rates were 94% and 86%, respectively. In the Cox model, incompleteness of cytoreduction (P = 0.001) and high-grade tumor (P < 0.0001) were independent prognosticators of poor outcome. CONCLUSION The establishment of a national treatment center has allowed refinement of techniques to achieve internationally recognized results. Having achieved low levels of morbidity and mortality in the treatment of mainly pseudomyxoma peritonei of appendiceal origin, the technique of cytoreductive surgery and heated intraperitoneal chemotherapy may be considered for peritoneal carcinomatosis of colorectal origin.
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Affiliation(s)
- S Rout
- Peritoneal Tumour Service, Department of Surgery, the Christie NHS Foundation Trust, Manchester, United Kingdom
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Slim K, Blay JY, Brouquet A, Chatelain D, Comy M, Delpero JR, Denet C, Elias D, Fléjou JF, Fourquier P, Fuks D, Glehen O, Karoui M, Kohneh-Shahri N, Lesurtel M, Mariette C, Mauvais F, Nicolet J, Perniceni T, Piessen G, Regimbeau JM, Rouanet P, sauvanet A, Schmitt G, Vons C, Lasser P, Belghiti J, Berdah S, Champault G, Chiche L, Chipponi J, Chollet P, De Baère T, Déchelotte P, Garcier JM, Gayet B, Gouillat C, Kianmanesh R, Laurent C, Meyer C, Millat B, Msika S, Nordlinger B, Paraf F, Partensky C, Peschaud F, Pocard M, Sastre B, Scoazec JY, Scotté M, Triboulet JP, Trillaud H, Valleur P. [Digestive oncology: surgical practices]. ACTA ACUST UNITED AC 2009; 146 Suppl 2:S11-80. [PMID: 19435621 DOI: 10.1016/s0021-7697(09)72398-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- K Slim
- Chirurgien Clermont-Ferrand.
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Morbidity and mortality with cytoreductive surgery and intraperitoneal chemotherapy: the importance of a learning curve. Cancer J 2009; 15:196-9. [PMID: 19556904 DOI: 10.1097/ppo.0b013e3181a58d56] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Evidence for the efficacy of cytoreductive surgery, combined with hyperthermic intraperitoneal chemotherapy (HIPEC), in the treatment of peritoneal carcinomatosis is accumulating. Many centers around the world now have considerable experience of the complex techniques required to achieve complete cytoreduction with the administration of HIPEC. Procedure-related morbidity ranges from 12% to 67.6% and mortality from 0% to 9% in recent studies of cytoreductive surgery and HIPEC for pseudomyxoma peritonei. A number of specialized centers have studied the factors that influence perioperative complications and mortality and have demonstrated impressive reductions in morbidity and mortality over time. However, for this treatment to be accepted as standard of care, teams undertaking this treatment strategy must aim to minimize morbidity and mortality by learning from the experience of established centers and using the "global learning curve."
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Brouquet A, Goéré D, Lefèvre JH, Bonnet S, Dumont F, Raynard B, Elias D. The second procedure combining complete cytoreductive surgery and intraperitoneal chemotherapy for isolated peritoneal recurrence: postoperative course and long-term outcome. Ann Surg Oncol 2009; 16:2744-51. [PMID: 19626375 DOI: 10.1245/s10434-009-0611-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 04/15/2009] [Accepted: 04/15/2009] [Indexed: 12/26/2022]
Abstract
BACKGROUND Complete cytoreductive surgery (CCRS) with intraperitoneal chemotherapy (IPC) is becoming the gold-standard treatment for resectable peritoneal carcinomatosis, when feasible. However, this approach has not yet been evaluated for isolated peritoneal re-recurrences after previous IPC. The aim of this study was to evaluate the postoperative course and long-term outcome after repeat (re-)CCRS + IPC. METHODS From 1996 to 2007, 25 re-CCRS + IPC were performed in 20 patients with isolated peritoneal re-recurrences, among 393 CCRS + IPC performed during the same period in the department. Selection was based on the supposedly limited extent of the peritoneal disease and an interval of more than 12 months between the first CCRS + IPC procedure and recurrence. After a re-CCRS, we used re-IPC modalities (method and/or drug) that were systematically different from those of the first IPC. The origins of the tumors were pseudomyxoma (n = 12), colorectal cancer (n = 4), mesothelioma (n = 3), and carcinoid tumor (n = 1). RESULTS At laparotomy, mean peritoneal index was 7.6 +/- 4.8. Among the 25 procedures, hyperthermic intraperitoneal chemotherapy was used in 15 cases and early postoperative intraperitoneal chemotherapy in 10 cases. The postoperative mortality rate was 4% (n = 1) and six grade 3-4 postoperative complications occurred. The overall 5- and 10-year actuarial survival rates were 72.5% and 58%, respectively. The 5-year disease-free survival rate was 19%. The long-term outcome was not different, whatever the type of primary tumor. CONCLUSION Re-CCRS + IPC is feasible and yields prolonged survival in highly selected patients. Also, the switch to another type of IPC or regimen may have contributed to this prolonged survival.
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Affiliation(s)
- Antoine Brouquet
- Department of Surgical Oncology, Gustave Roussy Cancer Institute, Villejuif Cédex, France
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Stewart JH, Levine EA, Shen P. The Current Role of Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Dissemination of Appendiceal Tumors. Curr Probl Cancer 2009; 33:142-53. [DOI: 10.1016/j.currproblcancer.2009.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Chua TC, Yan TD, Smigielski ME, Zhu KJ, Ng KM, Zhao J, Morris DL. Long-term survival in patients with pseudomyxoma peritonei treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy: 10 years of experience from a single institution. Ann Surg Oncol 2009; 16:1903-11. [PMID: 19387742 DOI: 10.1245/s10434-009-0341-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Revised: 12/29/2008] [Accepted: 12/30/2008] [Indexed: 01/23/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) has been recognized as a treatment option for pseudomyxoma peritonei. This study reports the survival outcomes, clinicopathological prognostic factors, and a learning curve from a single institution's experience. METHODS Patients with pseudomyxoma peritonei underwent CRS and PIC, which was comprised of hyperthermic intraperitoneal chemotherapy (HIPEC) and/or early postoperative intraperitoneal chemotherapy (EPIC), according to a standardized treatment protocol in our institution. Clinicopathological factors were analyzed to determine their prognostic value for survival using univariate and multivariate analysis. Time period comparison was performed to study the effect of a learning curve. RESULTS A total of 106 patients (43 men and 63 women) were treated. The mortality rate was 3% and severe morbidity rate was 49%. The median follow-up was 23 (range, 0-140) months. The overall median survival was 104 months with a 5-year survival rate of 75%. The progression-free survival was 40 months with a 1-year progression-free survival rate of 71%. Factors influencing survival include histopathological type of tumor, use of both HIPEC and EPIC, peritoneal cancer index, completeness of cytoreduction, and severe morbidity. The results demonstrate a learning curve where patients with a higher peritoneal cancer index (PCI) were treated, reduced amount of blood products required, more patients undergoing HIPEC and the combined HIPEC and EPIC, more redo-procedures performed, and a longer progression-free survival. CONCLUSIONS This report demonstrates long-term survival outcomes, acceptable perioperative outcomes, and a learning curve associated with the treatment of patients with pseudomyxoma peritonei.
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Affiliation(s)
- Terence C Chua
- Department of Surgery, St George Hospital, University of New South Wales, Sydney, NSW, Australia.
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