Single-incision flexible endoscopy (SIFE) for detection and staging of peritoneal carcinomatosis

A prediction model to refine the timing of an early second-look laparoscopic exploration in patients with colon cancer at high risk of early peritoneal metastasis recurrence

BACKGROUND

In patients at high risk of peritoneal metastasis (PM) recurrence following surgical treatment of colon cancer (CC), second-look laparoscopic exploration (SLLE) is mandatory; however, the best timing is unknown. We created a tool to refine the timing of early SLLE in patients at high risk of PM recurrence.

METHODS

This international cohort study included patients who underwent CC surgery between 2009 and 2020. All patients had PM recurrence. Factors associated with PM-free survival (PMFS) were assessed using Cox regression. The primary endpoint was early PM recurrence defined as a PMFS of <6 months. A model (logistic regression) was fitted and corrected using bootstrap.

RESULTS

In total, 235 patients were included. The median PMFS was 13 (IQR, 8-22) months, and 15.7% of the patients experienced an early PM recurrence. Synchronous limited PM and/or ovarian metastasis (hazard ratio [HR]: 2.50; 95% confidence interval [CI]: [1.66-3.78]; p < 0.001) were associated with a very high-risk status requiring SLLE. T4 (HR: 1.47; 95% CI: [1.03-2.11]; p = 0.036), transverse tumor localization (HR: 0.35; 95% CI: [0.17-0.69]; p = 0.002), emergency surgery (HR: 2.06; 95% CI: [1.36-3.13]; p < 0.001), mucinous subtype (HR: 0.50; 95% CI [0.30, 0.82]; p = 0.006), microsatellite instability (HR: 2.29; 95% CI [1.06, 4.93]; p = 0.036), KRAS mutation (HR: 1.78; 95% CI: [1.24-2.55]; p = 0.002), and complete protocol of adjuvant chemotherapy (HR: 0.93; 95% CI: [0.89-0.96]; p < 0.001) were also prognostic factors for PMFS. Thus, a model was fitted (area under the curve: 0.87; 95% CI: [0.82-0.92]) for prediction, and a cutoff of 150 points was identified to classify patients at high risk of early PM recurrence.

CONCLUSION

Using a nomogram, eight prognostic factors were identified to select patients at high risk for early PM recurrence objectively. Patients reaching 150 points could benefit from an early SLLE.

Poorly cohesive cells gastric carcinoma including signet-ring cell cancer: Updated review of definition, classification and therapeutic management

While the incidence of gastric cancer (GC) in general has decreased worldwide in recent decades, the incidence of diffuse cancer historically comprising poorly cohesive cells-GC (PCC-GC) and including signet ring cell cancer is rising. Literature concerning PCC-GC is scarce and unclear, mostly due to a large variety of historically used definitions and classifications. Compared to other histological subtypes of GC, PCC-GC is nevertheless characterized by a distinct set of epidemiological, histological and clinical features which require a specific diagnostic and therapeutic approach. The aim of this review was to provide an update on the definition, classification and therapeutic strategies of PCC-GC. We focus on the updated histological definition of PCC-GC, along with its implications on future treatment strategies and study design. Also, specific considerations in the diagnostic management are discussed. Finally, the impact of some recent developments in the therapeutic management of GC in general such as the recently validated taxane-based regimens (5-Fluorouracil, leucovorin, oxaliplatin and docetaxel), the use of hyperthermic intraperitoneal chemotherapy as well as pressurized intraperitoneal aerosol chemotherapy and targeted therapy have been reviewed in depth for their relative importance for PCC-GC in particular.

Bidirectional chemotherapy combining intraperitoneal docetaxel with intravenous 5-fluorouracil and oxaliplatin for patients with unresectable peritoneal metastasis from gastric cancer: the first study in Western countries

Background

A new treatment using bidirectional intraperitoneal (IP) and intravenous (IV) chemotherapy developed by Asiatic surgeons improves outcomes in patients with synchronous peritoneal metastasis (PM) from gastric cancer (GC).

Methods

We enrolled six consecutive patients with unresectable PM from GC who underwent bidirectional chemotherapy using IP docetaxel and IV FOLFOX or LV5FU2. In one course, IP docetaxel 30 mg/m² was administrated on days 1, 8 and 15, and IV FOLFOX or LV5FU2 was administered on days 1 and 15, followed by 7 days of rest. Before and after a complete bidirectional cycle of three courses, the peritoneal cancer index (PCI) was evaluated by laparoscopy. The primary endpoint was to evaluate the feasibility and safety of bidirectional chemotherapy. Secondary endpoints were overall survival (OS), and the success of the therapeutic strategy was reflected by a decrease of 25% of the initial PCI.

Results

All patients completed one bidirectional cycle. The regimen was well tolerated. The median OS was 13 months [range 5–18], and the 1-year OS rate was 67%. After the first bidirectional cycle, the PCI decrease ≥25% of the initial value in four patients. A major histological response was observed in four patients.

Conclusions

This is the first Western study and confirms the feasibility and safety of bidirectional treatment using IP and IV chemotherapy for patients with unresectable PM from GC, resulting in a 13-month median OS with limited morbidity. The decrease in PCI after one bidirectional cycle is promising.

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy by laparoscopy via a single-port approach for low-grade peritoneal malignancy

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a long and complex procedure. A minimal invasive approach is rarely performed. The feasibility of laparoscopic CRS and HIPEC via a single port (SP) approach is unknown. The aim of this study was to assess the feasibility of CRS and HIPEC with a SP approach.

METHODS

This study is IDEAL stage I-IIa. Patients with low grade and limited peritoneal malignancy were included in a tertiary care cancer center. Intra- and post-operative adverse events were recorded and classified according to medical and surgical dedicated classifications. The main objective measurement to assess feasibility was the conversion to open or multiport surgery.

RESULTS

A total of 12 highly selected patients were assessed. The median operating time was 240 min (range, 180-360) and two near miss events were reported. Two conversions to open and multiport surgery occurred. The median comprehensive complication index was 0 (range, 0-42.6) with two severe adverse events (Clavien-Dindo or CTC-AE ≥ 3). The median length of stay was 8.5 days (range, 5-13).

CONCLUSION

CRS and HIPEC via a laparoscopic SP approach are feasible and safe in the short term. The next step should be a prospective development study.

The role of single-incision laparoscopic peritoneal exploration in the management of patients with peritoneal metastases

BACKGROUND

The outcome of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) depends on the extent of peritoneal metastases (PM) and the completeness of cytoreduction (CCR). The role of preoperative assessment of PM is to identify potential candidates for CRS/HIPEC and to prevent unwarranted laparotomy for those who are not. Laparoscopy has been utilized for that purpose but with concerns related to technical difficulties and risk of trocar site metastases. Single-incision laparoscopic peritoneal exploration (SILPE) has not yet been evaluated in this setting.

METHODS

This single-center retrospective study examined patients from January 2011 to December 2015 who underwent SILPE for diagnosis and staging of PM. Preoperative, intraoperative, and postoperative data were collected. For the patients who underwent subsequent laparotomy, a comparison between SILPE and laparotomy findings was made.

RESULTS

A total of 183 SILPE were performed. Primary sites were mostly colorectal in 72 cases (39.3%) and gastric in 47 (25.7%). Overall, 157 patients (85.8%) had at least one prior abdominal surgery and 48 (26.2%) had 3 or more. SILPE was successfully achieved in 90.2% of the cases. Two (1.2%) intraoperative complications and five (3%) postoperative complications were observed. Eighty-one patients had laparotomy, with a median of 27 days between SILPE and laparotomy (4-162 days). The peritoneal carcinomatosis index PCI was 9.7 ± 7.5 at SILPE, and 13.5 ± 9.6 at laparotomy. The positive predictive value of SILPE to predict CCR was 79.5%. SILPE sensitivity was 75% and specificity 97%. The lowest sensitivity was in regions 9-12 ranging from 44 to 53%.

CONCLUSION

SILPE can be safely incorporated in the management of patients with PM. It is a safe and feasible staging tool, allowing for preventing unwarranted laparotomy for patients not deemed candidate for CRS/HIPEC. Even though it may underestimate PCI, SILPE accurately predicts the possibility of CCR.

Strategies for Managing Intraoperative Discovery of Limited Colorectal Peritoneal Metastases

BACKGROUND

Management of limited synchronous colorectal peritoneal metastases (CRPM) is critical to outcome. Resection of the primary tumor and CRPM can be performed concurrently, followed by hyperthermic intraperitoneal chemotherapy (HIPEC) either immediately, during the same procedure (one-stage), or during a systematic second-stage procedure (two-stage).

OBJECTIVE

The aim of this study was to compare these two strategies for morbidity, mortality, and survival.

METHODS

All patients presenting with limited (initial Peritoneal Cancer Index [PCI] ≤ 10) synchronous CRPM who had undergone complete cytoreductive surgery plus HIPEC between 2000 and 2016 were selected from a prospectively maintained institutional database.

RESULTS

Overall, 74 patients were included-31 in the one-stage group and 43 in the two-stage group. During second-stage surgery, a peritoneal recurrence was diagnosed in 37 (86%) patients, 12 of whom had a PCI > 10 (28%) and 2 of whom had unresectable disease (5%). Among the one-stage group, peritoneal recurrence occurred in 29% of patients after a median delay of 23 months. Overall survival at 1, 3, and 5 years was similar between the two groups, i.e. 96%, 59%, and 51% for the one-stage group, and 98%, 77%, and 61% for the two-stage group. A PCI > 10 at the time of HIPEC, as well as liver metastases, were independent negative prognostic factors.

CONCLUSIONS

For incidental limited CRPM diagnosed during primary tumor resection, one-stage curative treatment is preferable, avoiding a supplementary surgical procedure. Given the critical issues associated with completeness of resection, patients should be referred to centers specialized in peritoneal surgery.

Preoperative assessment of peritoneal carcinomatosis of colorectal origin

The goal of preoperative assessment of patients with peritoneal carcinomatosis (PC) from colorectal origin is to select candidates for curative surgery by evaluating the possibility of complete resection, and to plan the surgical procedure. Quantitative and qualitative evaluation of lesional localization remains difficult even with current technical progress in imaging. Computed tomography (CT), the reference imaging technique, allows detection of both peritoneal and extra-peritoneal lesions. Sensitivity and specificity for detecting PC are 83% (95%CI: 79-86%) and 86% (95%CI: 82-89%), respectively. Functional imaging, with diffusion-weighted magnetic resonance imaging (MRI) and positron emission tomography PET-CT allows efficient exploration of peritoneal lesions. MRI is operator-dependent, with a long learning curve, and is, at present, essentially used only in expert centers. A standardized protocol provided by the radiologists working with the French National Center for rare peritoneal tumors RENA-RAD (http://www.renape-online.fr/fr/espace-professionnel/rena-rad.html) is however available on line. PET-CT is particularly useful for identifying and defining extra-peritoneal disease. Combining imaging techniques, particular CT with MRI, seems to improve the calculation of the Peritoneal Cancer Index compared to CT alone. Surgical exploration is the reference technique to evaluate PC. Currently, the literature cannot confirm whether laparoscopy performs as well as laparotomy, but laparoscopy is, de facto, the fundamental tool to decrease the number of unnecessary laparotomies in these patients. To optimize the pre-, intra- and postoperative reporting of the extent of PC, the French National Network for management of PC (RENAPE and BIG-RENAPE: http://www.e-promise.org/) has offered on-line a free-of-charge, standardized, multidisciplinary and transversal software.

Multicentre study of laparoscopic or open assessment of the peritoneal cancer index (BIG-RENAPE)

Background

The peritoneal cancer index (PCI) is a comparative prognostic factor for colorectal peritoneal metastasis (CRPM). The ability of laparoscopy to determine the PCI in consideration of cytoreductive surgery remains undetermined, and this study was designed to compare it with laparotomy.

Methods

A prospective multicentre study was conducted for patients with no known CRPM, but at risk of peritoneal disease. Surgery began with laparoscopic exploration followed by open exploration to determine the PCI. Concordance between laparoscopic and open assessment was evaluated for the diagnosis of CRPM and for the PCI.

Results

Among 50 patients evaluated, CRPM recurrence was found in 29 (58 per cent) and 34 (68 per cent) at laparoscopic and open surgery respectively. Laparoscopy was feasible in 88 per cent (44 of 50) and deemed satisfactory by the surgeon in 52 per cent (26 of 50). Among the 25 evaluable patients with satisfactory laparoscopy, there was concordance of 96 per cent (24 of 25 patients) and 38 per cent (10 of 25) for laparoscopic and open assessment of CRPM and the PCI respectively. Where there were discrepancies, it was laparoscopy that underestimated the PCI.

Conclusion

Laparoscopy may underestimate the extent of CRPM.

Prediction of Resectability in Pseudomyxoma Peritonei with a New CT Score

BACKGROUND

Curative treatment of pseudomyxoma peritonei (PMP) is complete cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC).

OBJECTIVE

The aim of this study was to build and evaluate a preoperative imaging score to predict resectability.

PATIENTS AND METHODS

Between 2007 and 2014, all PMP patients in two tertiary reference centers who underwent laparotomy with intent to undergo CRS and HIPEC were included in this study retrospectively. Thickness of tumor burden was measured on preoperative multidetector-row computed tomography (MDCT) by two radiologists blinded to surgical results in five predetermined areas. Patients were divided into two cohorts with the same resectability rate (building and validation). The performances of the scores were assessed using receiver operating characteristic (ROC) curve analyses.

RESULTS

Overall, 126 patients were included, with compete CRS being achieved in 91/126 patients (72.2%). Two cohorts of 63 patients matched by age, sex, burden of disease, resectability rate, and pathological grade were constituted. The MDCT score was the sum of the five measures, and was higher in unresectable disease [median 46.2 mm (range 27.9-74.6) vs. 0.0 mm (range 0.0-14.0), p < 0.001]. Area under the ROC curve was 0.863 (range 0.727-0.968) and 0.801 (range 0.676-0.914) in the building and validation cohorts, respectively. A threshold of 28 mm yielded a sensitivity, specificity, positive predictive and negative predictive value of 94, 81, 81 and 94% in the building cohort, and 80, 68, 59 and 85% in the validation cohort, respectively. Using our score, overall and disease-free survival were increased in the group classified as resectable.

CONCLUSION

A simple preoperative MDCT score measuring tumor burden in the perihepatic region is able to predict resectability and survival of PMP patients.

Evaluation of the peritoneal carcinomatosis index with CT and MRI

BACKGROUND

The aim was to determine the incremental value of MRI compared with CT in the preoperative estimation of the peritoneal carcinomatosis index (PCI).

METHODS

CT and MRI examinations of patients with peritoneal carcinomatosis were evaluated. CT images were first analysed by two observers who determined a first PCI (PCI_CT ). Then, the two observers reviewed MRI examinations in combination with CT and determined a second PCI (PCI_CT+MRI ). The sensitivity and negative predictive value of the two imaging sets were determined using surgery as a reference standard (PCI_Ref ).

RESULTS

CT plus MRI was more accurate in predicting the surgical PCI than CT alone. The absolute difference between PCI_CT+MRI and PCI_Ref was lower than that between PCI_CT and PCI_Ref (mean(s.d.) 3·96(4·10) versus 4·89(4·73); P = 0·010). The number of true-positive findings increased from 106 to 125 for reader 1 and from 117 to 132 for reader 2 with the adjunct of MRI. For both readers, an increased sensitivity was obtained when both MRI and CT were used (from 63 to 81 per cent for reader 1; from 44 to 81 per cent for reader 2). The increase in sensitivity was greater for patients with a moderate volume of disease.

CONCLUSION

The combination of CT and MRI improved the preoperative estimation of PCI compared with CT alone.

Specific computed virtual chromoendoscopy for detection of peritoneal carcinomatosis: an animal study

BACKGROUND

Detection of an incipient Peritoneal Carcinomatosis (PC) is still challenging, and there is a crucial need for technological improvements in order to diagnose and to treat early this condition. The aim of this study was to create a murine model of incipient PC and to explore the PC with Fujinon Intelligent Chromo Endoscopy (FICE) in order to determine the wavelengths of the white light (WL) spectre that offer the highest contrast between PC nodules and surrounding peritoneum.

METHODS

Eighteen BALB/c mice had intraperitoneal injection of murine colonic cancer CT26 cells. Peritoneal exploration with FICE was performed at different times. For each PC nodule, 1 WL and 10 FICE images were recorded. Each image was then divided into its elementary red, green and blue band images. Depending on the FICE channel, each elementary image corresponds to a specific wavelength of the WL spectre. Through numerical analysis of these images, the value of the nodule and the background peritoneum were obtained, and the contrast value was calculated. Contrast values obtained with the different wavelengths were then compared.

RESULTS

PC grew in all the mice. The number as well as the size of PC nodules was increasingly high depending on the day of exploration. Mean PCI was 1.6 ± 1.2 at day 5, 7.7 ± 2.6 at day 8 and 15.0 ± 7.3 at day 10. A total number of 1805 elementary images of PC nodules were analysed. The wavelength that offered the best contrast between PC nodules and background peritoneum was 460 nm with a mean contrast value of 0.240 ± 0.151 (p < 0.0001).

CONCLUSION

This murine model of incipient PC is effective, reliable and reproducible. A monochromatic light with a wavelength at 460 nm offers the highest contrast between PC nodules and background peritoneum, allowing a better detection of PC.

Strategies to prevent peritoneal carcinomatosis arising from colorectal cancer

In the last decades, cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy became a curative option for peritoneal metastases in selected patients, otherwise considered for palliative therapy alone. Better knowledge of physiopathology of peritoneal spread and identification of predictive factors for peritoneal relapse prompted specialized centers to investigate the role of a 'proactive approach' in order to early detect peritoneal metastasis. These encouraging data could justify an active attitude in selected patients at high risk of peritoneal recurrence after curative resection of primary tumor. Selection criteria and the timing of complementary hyperthermic intraperitoneal chemotherapy remain important points of discussion. In this article, we will discuss treatment principles and future perspectives to early treat and, if possible, to prevent peritoneal dissemination after curative treatment of colorectal cancer.

A feasibility study of the use of computed virtual chromoendoscopy for laparoscopic evaluation of peritoneal metastases

BACKGROUND

Detection of an incipient peritoneal carcinomatosis (PC) is still challenging, and there is a crucial need for technological improvements in order to diagnose and to treat early this condition. Fujinon Intelligent Chromo Endoscopy (FICE) is a spectral image processing technology that enhances the contrast of the target tissue. The aim of this study is to investigate the usefulness of FICE system during peritoneal endoscopy and to establish the optimal FICE preset(s) for peritoneal exploration and PC detection.

METHODS

A total of 561 images corresponding to 51 different areas of PC nodules and normal peritoneum were recorded during peritoneal endoscopies (For each area, one white light endoscopy (WLE) image and 10 FICE images). Three groups of 5 evaluators each: senior surgeons, surgical residents and medical students assessed these images. In a first questionnaire, the evaluators gave a score ranging from 1 to 10 to each image, and the three best FICE channels were determined. In a second questionnaire, five criteria were studied specifically: contrast, brightness, vascular architecture, differentiation between organs and detection of PC. The evaluators ranked the WLE and the three best FICE channel images according to these criteria.

RESULTS

The three best FICE channels were channels 6, 2 and 9 with mean scores of 6.21 ± 1.59, 6.17 ± 1.48 and 6.06 ± 1.52, respectively. FICE Channel 2 was superior to WLE and other FICE channels, in terms of contrast (p < 10^-4), visualization of vascular architecture (p < 10^-4), differentiation between organs (p < 10^-4) and detection of PC (p < 10^-4); and ranked first in 38.8, 41.5, 31 and 46.9 % of the cases, respectively.

CONCLUSION

FICE system provides adequate illumination of the abdominal cavity and a unique contrast that enhances the vascular architecture. FICE Channel 2 is the optimal channel for peritoneal exploration and could be a useful tool for the diagnosis of PC during peritoneal explorations.