Cytoreductive Surgery plus HIPEC for Peritoneal Metastases from Colorectal Cancer

Insight into Predictors of Cytoreduction Score Following Cytoreductive Surgery-Hyperthermic Intraperitoneal Chemotherapy for Gastric Peritoneal Carcinomatosis Improves Patient Selection and Prognostic Outcomes

BACKGROUND

Peritoneal metastases due to gastric adenocarcinoma (GCPM) carry a dismal prognosis. A promising treatment strategy is cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), but clear eligibility criteria for GCPM are lacking. We sought to identify factors associated with overall survival (OS) following CRS-HIPEC for GCPM to help optimize patient selection and clinical outcomes.

PATIENTS AND METHODS

In this single-center retrospective cohort study, we examined CRS-HIPEC outcomes for patients with GCPM between 2001 and 2021. After analyzing patient demographic, clinicopathologic, and perioperative variables, we applied multivariable Cox hazard models to assess factors associated with OS. We then assessed associations between baseline predictors and prognostically important variables using multivariable logistic regression.

RESULTS

We analyzed 55 patients with GCPM who underwent CRS-HIPEC. Median age was 54 years and 42% were female. Median peritoneal carcinomatosis index (PCI) was 8, and 75% of patients achieved a cytoreduction completeness score (CC score) of 0. Median progression-free survival (PFS) was 6.9 months, and median OS was 14.1 months. On adjusted analysis, a CC score > 0 (HR 2.3, p = 0.02) was significantly associated with worse OS. A peritoneal carcinomatosis index greater than 13 (OR 52.6, p = 0.001) and fewer lymph nodes (especially < 18) resected with the primary tumor (OR 0.86, p = 0.042) in the metachronous setting were significantly associated with incomplete macroscopic cytoreduction (CC score > 0).

CONCLUSIONS

We demonstrated that PCI > 13 and primary lymph nodes harvested < 18 in metachronous tumors are associated with CC score > 0, which in turn portends a worse OS. Although these results warrant prospective validation, they provide insight into improved selection of patients with GCPM for CRS-HIPEC.

Prognostic Value of Immune Scoring System for Colorectal Cancer Patients with Peritoneal Metastasis

Background and Objectives: There is no reliable immune scoring system that can help us predict the postoperative outcomes of colorectal cancer patients with peritoneal metastases after cytoreductive surgery. In this cohort, the aims were (1) to evaluate the postoperative morbidity, mortality and surgical oncological outcomes in colorectal cancer patients with peritoneal metastasis; (2) to compare oncological and postoperative outcomes of colon cancer patients with peritoneal metastasis and rectal cancer patients with peritoneal metastasis; and (3) to assess the prognostic value of the modified Glasgow Prognostic Score (mGPS) and the CRP-albumin ratio (CAR). Materials and Methods: A prospectively maintained database of 258 patients who underwent cytoreductive surgery for peritoneal metastases of colorectal origin between 2007 and 2024 was analyzed. According to the anatomical location of the primary tumor, two different groups were created: rectum cancer patients with peritoneal metastasis (Group A) and colon cancer patients with peritoneal metastasis (Group B). All standard clinico-pathological characteristics, operative findings, morbi-mortality results, and final oncologic outcomes were compared between Groups A and B. We evaluated whether CAR and mGPS could predict postoperative morbi-mortality and overall survival in the two groups or not. Results: No significant difference was detected between Groups A and B in terms of clinical-demographic characteristics. In both groups, the preoperative mGPS and CAR values were statistically significantly higher in those who developed postoperative high-grade complications (C-D grade III/IV) (p < 0.001) and those who died perioperatively (p = 0.001 and p = 0.002). Conclusions: In multivariate Cox analysis, the CAR was found to be an independent prognostic factor for overall survival in this cohort. CAR and mGPS predicted high-grade complications and postoperative mortality in both groups.

Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy applications in upper and lower gastrointestinal cancer, a review

Peritoneal metastases (PM) are the spread of tumor forms into the peritoneum as metastases from another organ. PM is a frequent condition in metastatic gastrointestinal cancer (colorectal, gastric, pancreatic, appendiceal, and cholangiocarcinoma); their presence confers a poor prognosis, reducing patient survival. The standard treatment consists of systemic chemotherapy according to current guidelines. In recent years, scientific evidence has shown how combined cytoreductive surgery (CRS) techniques followed by hyperthermic intraperitoneal chemotherapy (HIPEC) can improve survival in this patient population. Despite the results still obtained, using this combined technique is still under discussion. This review aims to highlight the benefits and limitations of this combined procedure, which is already widely used to treat peritoneal metastases in gynecological tumors.

Clinical and Radiologic Predictors of a Pathologic Complete Response to Neoadjuvant Chemotherapy (NACT) in Patients Undergoing Cytoreductive Surgery for Colorectal Peritoneal Metastases: Results of a Prospective Multi-center Study

BACKGROUND

Patients undergoing cytoreductive surgery for colorectal peritoneal metastases who have a pathologic complete response (pCR) to neoadjuvant chemotherapy experience a significantly longer survival than those with residual disease. This response is known only after surgery. This study aimed to examine clinical and radiologic predictors of a pCR.

METHODS

From July 2018 to December 2019, the study prospectively enrolled 120 patients. The clinical and radiologic findings were compared between patients with and without a pCR. A protocol for pathologic evaluation was followed.

RESULTS

A pCR was observed in 34 patients (28.3%). Receiver operating characteristic (ROC) curves showed that patients with a surgical Peritoneal Cancer Index (sPCI) of 3 or lower had an 80% probability of experiencing a pCR, and that patients with a radiologic PCI (rPCI) of 2 or lower had a 70% probability of experiencing a pCR. A pCR was correctly predicted for 47% of the patients by imaging and for 44.4% of the patients by surgical evaluation. The site of primary tumor, the timing of peritoneal metastasis (PM), histology, tumor marker positivity, and mutations in known poor prognostic genes (KRAS) did not differ between the patients with and those without pCR. The primary tumor showed residual disease in 23.5% and regional nodes in 26.4% of the patients with pCR.

CONCLUSIONS

The rPCI and sPCI concurred with a pCR in less than 50% of the patients. The patients with a lower PCI had greater concordance. An sPCI of 3 or lower was predictive of a pCR in 80% of the patients. The impact of KRAS mutations on pCR should be evaluated in a larger series. The predictors of pCR and response to systemic chemotherapy should be incorporated in prognostic scores used to select patients for surgery.

Hepatic resection and blood transfusion increase morbidity after cytoreductive surgery and HIPEC for colorectal carcinomatosis

BACKGROUND AND OBJECTIVES

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but complex treatment for peritoneal metastasis (PM). Our objective was to identify risk factors for postoperative morbidity and mortality following CRS-HIPEC.

METHODS

Retrospective study of prospectively collected data of patients undergoing CRS-HIPEC for PM arises from colorectal cancer between January 2008 and December 2017. Perioperative variables were correlated with morbidity outcomes using a logistic regression model.

RESULTS

Sixty-seven patients underwent CRS-HIPEC, and overall morbidity and mortality were 31.3% and 4.5% respectively. Major morbidity rate was 19.4%; 7.5% of patients were re-operated. Intraoperative blood transfusion (p = 0.01), liver resection (p < 0.01), and intestinal anastomosis (p < 0.01) were associated with a higher morbidity in univariate analysis. A multivariate analysis identified blood transfusion and liver resection as independent risk factors (OR 3.66, IC 1.13-16.54; OR 4.33, IC 1.17-11.46, respectively). Extension of visceral resection did not correlate with morbidity. Patients with lymph-node infiltration had a higher major complication rate (p = 0.01).

CONCLUSIONS

CRS-HIPEC is a feasible treatment for colorectal PM with an acceptable morbi-mortality rate in experienced centers. In our study, digestive anastomosis, perioperative blood transfusion, hepatic resection, and lymph-node infiltration were associated with higher morbidity rates.

Cytoreductive surgery and HIPEC for malignant ascites from colorectal cancer - a randomized study

INTRODUCTION

The efficacy of different timings of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in controlling malignant ascites caused by peritoneal carcinomatosis of colorectal cancer (CRC) is not well defined. The study aims to investigate the clinical efficacy and safety of different timings of CRS with HIPEC for malignant ascites caused by peritoneal carcinomatosis from CRC.

MATERIALS AND METHODS

This was a preliminary randomized controlled study performed at the Intracelom Hyperthermic Perfusion Therapy Center of the Cancer Hospital of Guangzhou Medical University (China) from December 2008 to December 2016. The patients were randomized to: CRS, followed by HIPEC (CRS+HIPEC; n = 14), and ultrasound-guided HIPEC, followed by CRS 1 to 2 weeks later (HIPEC+ delayed cytoreductive surgery (dCRS) group, n = 14). The endpoints were complete remission rate of ascites, successful complete CRS rate, and overall survival.

RESULTS

Malignant ascites in all patients showed complete remission; the total effective rate was 100%. Complete CRS was not feasible in any patient. The median follow-up of the 2 groups was 41.9 and 42.3 months in the CRS+HIPEC and HIPEC+dCRS groups, respectively. Overall survival was 14.5 (95%CI: 7-19 months) and 14.3 months (95%CI: 4-21 months) (P > .05). The adverse effects of HIPEC were manageable.

CONCLUSIONS

CRS+HIPEC and HIPEC+dCRS have the same efficacy in controlling malignant ascites caused by CRC and peritoneal carcinomatosis. The timing of CRS and HIPEC does not prolong the survival of patients with peritoneal carcinomatosis from CRC, even when a complete CRS is not feasible.

Clinical outcomes of complete cytoreduction with concurrent liver resection followed by hyperthermic intraperitoneal chemotherapy for synchronous peritoneal and liver metastatic colorectal cancer

Background

This study aimed to evaluate the clinical outcomes of concurrent liver resection with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in colorectal cancer patients with synchronous liver and peritoneal metastases.

Methods

Patients with colorectal liver and peritoneal metastasis who underwent complete cytoreduction and hyperthermic intraperitoneal chemotherapy with concurrent liver surgery between September 2014 and July 2018 were included. Perioperative outcomes, overall survival, and progression-free survival were analyzed retrospectively.

Results

In total, 22 patients were included. The median peritoneal cancer index was 13 (range, 0–26), and the median number of liver metastases was 3 (range, 1–13). The mean total operative time was 11.4 ± 2.6 h. Minor postoperative complications (Clavien-Dindo grade I–II) were reported in 10 patients (45.5%), and major postoperative complications (grade III–V) were reported in five patients (22.7%), including one mortality patient. The median overall survival since diagnosis with metastasis was 27.4 months. The median overall survival since surgical intervention and the progression-free survival were 16.7 months and 7.1 months, respectively.

Conclusions

This short-term follow-up study showed that, in an experienced center, combined resection with hyperthermic intraperitoneal chemotherapy for colorectal liver and peritoneal metastases was feasible and safe with acceptable oncologic outcomes.

Patients with extensive regional lymph node involvement (pN2) following potentially curative surgery for colorectal cancer are at increased risk for developing peritoneal metastases: a retrospective single-institution study

AIM

Our goal was to determine the incidence and clinical behaviour of peritoneal metastases (PM) in patients with colorectal cancer undergoing potentially curative surgery, comparing patients with extensive locoregional lymph node involvement (pN2) with those who have serosal involvement (pT4), a known risk factor for developing PM.

METHOD

A retrospective analysis of a prospectively maintained database was performed. All patients with pT4 and pN2 were included in the analysis. The diagnostic criteria were the finding of PM during surgery with biopsy confirmation as well as imaging features suggestive of PM, including ovarian metastases and omental deposits.

RESULTS

Two hundred and fourteen patients treated between May 2010 and October 2015 were included. Of these, 110 (51.4%) had pT4 and 131 (61.2%) pN2 tumours: 17.2% of patients with pT4 tumours and 20.2% of patients with pN2 tumours developed PM (P = 0.53). The median time to detection of PM was 16.6 months and 11.8 months for pT4 and pN2 tumours, respectively. PM were isolated in 51.8% of patients with pN2 tumours. Nonperitoneal metastases developed in 37.5% of patients with pN2 tumours. In pN2 tumours, the incidence of PM was higher in signet ring cell and mucinous tumours (P < 0.01), positive surgical margins (P = 0.02), colonic versus rectal tumours (P = < 0.01) and right colon primary tumours (P = 0.01).

CONCLUSION

Patients with pN2 tumours are at an increased risk of developing PM, which is similar to the risk in pT4 tumours. pN2 tumours should be included in clinical trials evaluating preventive/proactive strategies. There is a need to identify predictive biomarkers for the development of PM versus other sites of metastasis.

Cytoreductive surgery and heated intraperitoneal chemotherapy for peritoneal carcinomatosis from rare etiologies

BACKGROUND

Cytoreductive surgery and heated intraperitoneal chemotherapy (CRS/HIPEC) are commonly used in the treatment of peritoneal carcinomatosis (PC) originating from colorectal, appendiceal and ovarian cancers. It is unclear what benefit CRS/HIPEC might have for PC from uncommon etiologies, therefore we sought to describe local practice patterns and evaluate overall survival (OS).

METHODS

All patients who had CRS/HIPEC between 2000 and 2016 were identified using our institutional cancer database. Patients with appendiceal, colorectal, and ovarian pathologies were excluded. Kaplan-Meier curves were used to estimate and demonstrate 5-year OS. Cox regression analysis was performed to determine factors associated with OS.

RESULTS

Of all patients treated with CRS/HIPEC at our institution, 38 were treated for PC of rare origin. Etiologies included 23 patients with mesothelioma, 8 with primary peritoneal carcinoma, 4 with small bowel tumours and 3 with gastric cancer. Median OS of 35.4, 20.8, 25.4, and 20.2 months were obtained for each group respectively. 5-year OS for each pathology was 8.7%, 0.0%, 25.0%, and 33.3% respectively with corresponding mean PCI of 31.3, 23.6, 21.5, and 12.7. No independent prognostic factors were significant on Cox regression analysis. Median length of stay was 19 days. Readmission rate within 30 days of discharge was 7.9%. Rate of Grade III/IV complications was 34.2%. No thirty-day mortality.

CONCLUSION

Survivals beyond 20 months can be obtained with the use of CRS/HIPEC for rare PC etiologies aligning with results of other groups. CRS/HIPEC in well-selected patients demonstrates a clinical benefit and this could be confirmed with a multi-institutional study.

The Current Status of Peritoneal Surface Oncology in India

With the increasing acceptance of cytoreductive surgery and HIPEC as a potentially curative treatment for primary and secondary peritoneal surface malignancies, peritoneal surface oncology has emerged as a distinct sub-specialty of surgical oncology. In the last 10 years, the acceptance of a conceptually different approach towards the management of peritoneal metastases has increased in India. During this period, over 1000 combined procedures have been performed in the country and most of the major cities have centers performing offering this treatment. Indian surgeons have formed collaborative groups to promote research and development of this specialty across the country. This article provides a detailed account of current practices pertaining to peritoneal surface oncology in the country and a future perspective.

Current practice in cytoreductive surgery and HIPEC for metastatic peritoneal disease: Spanish multicentric survey

INTRODUCTION

Radical Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC), has been proposed as the current standard of treatment for metastatic peritoneal disease by several tumors. Despite its widely utilization, there seems to be a great variability in their organization, clinical practice, and safety among centers.

AIM OF THE STUDY

To obtain updated information on clinical practice in different perioperative areas of the CRS-HIPEC.

PATIENTS AND METHODS

All 25 members of the Spanish Surface Peritoneal Malignancy (GECOP), were invited to answer an online survey, to describe their usual practice in different perioperative areas of the CRS-HIPEC.

RESULTS

Survey was responded by 100% of centers. This study represents more than 800 patients treated annually. Seventy per cent of respondents perform CRS-HIPEC for more than 5 years. The most frequent technique was Coliseum (88%). Routinely non-invasive monitoring of cardiac output is used by 92% of centers. More than 50% of centers administer oxaliplatin (74%), or mitomycin-C (65%) in colorectal cancer; cisplatin in gastric cancer (73%) and mesothelioma (74%). Ovarian cancer is treated with cisplatin and various combinations, in 64% or paclitaxel in 54.5%. Spillage protocol was available in 100% centers.

CONCLUSIONS

Data showed an important variability in volume of patients per center, selection of cytostatic agents, professional training and safety measures applied. The standardization of CRS/HIPEC procedures based on the best available evidence, the individualization of patients and the consensus among professionals, constitute an important part of the basis that will allow us to improve results of this complex procedure.

From utopia to reality: increased survival in peritoneal carcinomatosis treated with cytoreduction and hyperthermic intraperitoneal chemotherapy

We have read with great interest the article by Illán et al.1 entitled "Long survival in a patient with metastatic colorectal carcinoma: reality or utopia?" This article describes the case of a 42 year old patient with mucinous-type colon adenocarcinoma who had tumor recurrence with peritoneal metastases 18 months after resection of the primary tumor and adjuvant chemotherapy. After multiple metastasectomies and several lines of chemotherapy, the patient died 27 months after the recurrence.

Multidisciplinary Treatment for Colorectal Peritoneal Metastases: Review of the Literature

Peritoneum is one of the common sites of metastasis in advanced stage colorectal cancer patients. Colorectal cancer patients with peritoneal metastases (PM) are traditionally believed to have poor prognosis, which indicates it is of no value to adopt surgical treatment. With the advancement of surgical techniques, hyperthermic intraperitoneal chemotherapy (HIPEC), and multidisciplinary treatment in recent years, the cognition and treatment strategies of colorectal peritoneal metastases (CPM) have changed dramatically. In terms of prognosis, CPM under the palliative systemic treatment shows an inferior outcome compared with nonperitoneal metastasis. Nevertheless, some CPM patients amenable to the complete peritoneal cytoreductive surgery (CRS) combined with HIPEC may achieve long-term survival. The prognostic factors of CPM comprise peritoneal carcinomatosis index (PCI), completeness of cytoreduction score (CC score), the presence of extraperitoneal metastasis (liver, etc.), Peritoneal Surface Disease Severity Score (PSDSS), Japanese peritoneal staging, and so forth. Taken together, literature data suggest that a multimodality approach combining complete peritoneal CRS plus HIPEC, systemic chemotherapy, and targeted therapy may be the best treatment option for PM from colorectal cancer.

Recent insights into nanotechnology development for detection and treatment of colorectal cancer

The global incidence of colorectal cancer (CRC) is 1.3 million cases. It is the third most frequent cancer in males and females. Most CRCs are adenocarcinomas and often begin as a polyp on the inner wall of the rectum or colon. Some of these polyps become malignant, eventually. Detecting and removing these polyps in time can prevent CRC. Therefore, early diagnosis of CRC is advantageous for preventive and instant action interventions to decrease the mortality rates. Nanotechnology has been enhancing different methods for the detection and treatment of CRCs, and the research has provided hope within the scientific community for the development of new therapeutic strategies. This review presents the recent development of nanotechnology for the detection and treatment of CRC.