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Pacelli F, Gerardi C, Rulli E, Abatini C, Rotolo S, Garattini S, Melotti G, Torri V, Galli F, Rulli E, Di Giorgio A. Prophylactic surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC CO2) versus standard surgery in colorectal carcinoma at high risk of peritoneal carcinomatosis: short-term and long-term outcomes from the CHECK study - protocol for a randomised, multicentre, phase 3 trial. BMJ Open 2022; 12:e051324. [PMID: 35914916 PMCID: PMC9345052 DOI: 10.1136/bmjopen-2021-051324] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Up to one-fifth of patients with colorectal cancer will develop peritoneal metastases, frequently without other districts' involvement. Despite the recent unsuccesses of hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer peritoneal metastases treatment, the rationale in the prophylactic setting remains strong. Several clinical and pharmacokinetic data suggest that the efficacy of intraperitoneal chemotherapy is highest when the disease is microscopic. However, robust evidence demonstrating whether the addition of HIPEC for high-risk colorectal cancers offers better control of local recurrence is lacking. METHODS AND ANALYSIS This is a multicentre randomised phase 3 trial comparing prophylactic surgery plus HIPEC CO2 with mitomycin, over standard surgical excision in patients with colorectal cancer at high risk of peritoneal carcinomatosis; 388 patients will be included in this study. The primary objective is to compare the efficacy of prophylactic surgery (radical colorectal resection, omentectomy, appendectomy, round ligament of the liver resection and bilateral adnexectomy) plus HIPEC CO2 with mitomycin and standard surgery in terms of local recurrence-free survival. The main secondary endpoints are disease-free survival (DFS), overall survival (OS) and safety. The primary endpoint will be described with a cumulative incidence function and will be analysed with Grey test to take account of the competing risks. DFS and OS will be described with the Kaplan-Meier method. ETHICS AND DISSEMINATION This trial has been evaluated by the Italian Medicines Agency, local ethics committees and will be submitted to the Ministry of Health to notify the start of the trial according to the regulation of trials on devices with CE mark/certification.The results will be submitted for presentation at academic meetings and for publication in a peer-reviewed journal, whatever the findings. TRIAL REGISTRATION NUMBER NCT03914820.
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Affiliation(s)
- Fabio Pacelli
- Chirurgia del Peritoneo e del Retroperitoneo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Chiara Gerardi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Eliana Rulli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Carlo Abatini
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Stefano Rotolo
- Chirurgia del Peritoneo e del Retroperitoneo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
- Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche (Di.Chir.On.S.), Università degli Studi di Palermo, Palermo, Italy
| | - Silvio Garattini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | | | - Valter Torri
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Fabio Galli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Erica Rulli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Andrea Di Giorgio
- Chirurgia del Peritoneo e del Retroperitoneo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
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Feingold PL, Klemen ND, Kwong MLM, Hashimoto B, Rudloff U. Adjuvant intraperitoneal chemotherapy for the treatment of colorectal cancer at risk for peritoneal carcinomatosis: a systematic review. Int J Hyperthermia 2017; 34:501-511. [PMID: 29214884 DOI: 10.1080/02656736.2017.1401742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The peritoneal surface is the second most common site of disease recurrence, after the liver, following definitive surgery for colorectal cancer. Adjuvant intraperitoneal (IP) chemotherapy delivered at time of surgical resection has the potential to delay or prevent future spread to the peritoneal surface and improve clinical outcome. The exact role of adjuvant IP chemotherapy in colorectal cancer, including its associated morbidity and mortality, is not well defined. STUDY DESIGN Systematic review and pooled random effect analysis of comparative trials examining the addition of adjuvant IP chemotherapy compared to surgery alone in colorectal cancer. The primary outcome was overall survival, and the secondary outcomes were of post-operative morbidity and mortality. RESULTS In nine colorectal cancer studies identified, seven were two-arm trials comparing adjuvant IP chemotherapy to surgery alone. Of these, four trials had outcome reporting and met criteria that allowed inclusion into a random effects model. Heterogeneity was measured by Cochran's Q-test (Q = 13.9; p = 0.01) and random effect models were utilised. Pooling eligible trials together revealed a 0.55 odds ratio of death associated with the administration of IP chemotherapy compared to surgery alone (CI = 0.31, 0.98; p = 0.04). Trials selecting patients at elevated risk for the development of peritoneal carcinomatosis by clinicopathological biomarkers for administration of adjuvant IP chemotherapy reported more favourable overall outcomes. There was no increase in mortalities or IP chemotherapy-related abdominal complication rates among patients undergoing IP chemotherapy (OR = 1.4; CI = 0.52, 3.8; p = 0.5). CONCLUSIONS This systematic review supports the use of adjuvant IP chemotherapy in resectable colorectal cancer at risk for peritoneal spread. Future trials should seek to standardise inclusion criteria and IP chemotherapy modalities to better define the role of this treatment in patients with resectable colorectal cancer.
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Affiliation(s)
- Paul L Feingold
- a Thoracic and Gastrointestinal Oncology Branch , National Cancer Institute, National Institutes of Health , Bethesda , MD , USA
| | - Nicholas D Klemen
- a Thoracic and Gastrointestinal Oncology Branch , National Cancer Institute, National Institutes of Health , Bethesda , MD , USA
| | - Mei Li M Kwong
- a Thoracic and Gastrointestinal Oncology Branch , National Cancer Institute, National Institutes of Health , Bethesda , MD , USA
| | - Barry Hashimoto
- b Department of International Studies , American University of Sharjah, Sharjah, UAE
| | - Udo Rudloff
- a Thoracic and Gastrointestinal Oncology Branch , National Cancer Institute, National Institutes of Health , Bethesda , MD , USA
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Gelli M, Huguenin JF, Cerebelli C, Benhaim L, Honoré C, Elias D, Goéré D. Strategies to prevent peritoneal carcinomatosis arising from colorectal cancer. Future Oncol 2017; 13:907-918. [PMID: 28052691 DOI: 10.2217/fon-2016-0389] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Maximiliano Gelli
- Department of Surgical Oncology, Gustave Roussy, Université Paris-Saclay, F-94805 Villejuif, France
| | - Janina Fl Huguenin
- Department of Surgical Oncology, Gustave Roussy, Université Paris-Saclay, F-94805 Villejuif, France
| | - Cecilia Cerebelli
- Department of Surgical Oncology, Gustave Roussy, Université Paris-Saclay, F-94805 Villejuif, France
| | - Léonor Benhaim
- Department of Surgical Oncology, Gustave Roussy, Université Paris-Saclay, F-94805 Villejuif, France
| | - Charles Honoré
- Department of Surgical Oncology, Gustave Roussy, Université Paris-Saclay, F-94805 Villejuif, France
| | - Dominique Elias
- Department of Surgical Oncology, Gustave Roussy, Université Paris-Saclay, F-94805 Villejuif, France
| | - Diane Goéré
- Department of Surgical Oncology, Gustave Roussy, Université Paris-Saclay, F-94805 Villejuif, France
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Klaver CEL, Musters GD, Bemelman WA, Punt CJA, Verwaal VJ, Dijkgraaf MGW, Aalbers AGJ, van der Bilt JDW, Boerma D, Bremers AJA, Burger JWA, Buskens CJ, Evers P, van Ginkel RJ, van Grevenstein WMU, Hemmer PHJ, de Hingh IHJT, Lammers LA, van Leeuwen BL, Meijerink WJHJ, Nienhuijs SW, Pon J, Radema SA, van Ramshorst B, Snaebjornsson P, Tuynman JB, Te Velde EA, Wiezer MJ, de Wilt JHW, Tanis PJ. Adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with colon cancer at high risk of peritoneal carcinomatosis; the COLOPEC randomized multicentre trial. BMC Cancer 2015; 15:428. [PMID: 26003804 PMCID: PMC4492087 DOI: 10.1186/s12885-015-1430-7] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 05/13/2015] [Indexed: 12/17/2022] Open
Abstract
Background The peritoneum is the second most common site of recurrence in colorectal cancer. Early detection of peritoneal carcinomatosis (PC) by imaging is difficult. Patients eventually presenting with clinically apparent PC have a poor prognosis. Median survival is only about five months if untreated and the benefit of palliative systemic chemotherapy is limited. Only a quarter of patients are eligible for curative treatment, consisting of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CR/HIPEC). However, the effectiveness depends highly on the extent of disease and the treatment is associated with a considerable complication rate. These clinical problems underline the need for effective adjuvant therapy in high-risk patients to minimize the risk of outgrowth of peritoneal micro metastases. Adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) seems to be suitable for this purpose. Without the need for cytoreductive surgery, adjuvant HIPEC can be performed with a low complication rate and short hospital stay. Methods/Design The aim of this study is to determine the effectiveness of adjuvant HIPEC in preventing the development of PC in patients with colon cancer at high risk of peritoneal recurrence. This study will be performed in the nine Dutch HIPEC centres, starting in April 2015. Eligible for inclusion are patients who underwent curative resection for T4 or intra-abdominally perforated cM0 stage colon cancer. After resection of the primary tumour, 176 patients will be randomized to adjuvant HIPEC followed by routine adjuvant systemic chemotherapy in the experimental arm, or to systemic chemotherapy only in the control arm. Adjuvant HIPEC will be performed simultaneously or shortly after the primary resection. Oxaliplatin will be used as chemotherapeutic agent, for 30 min at 42-43 °C. Just before HIPEC, 5-fluorouracil and leucovorin will be administered intravenously. Primary endpoint is peritoneal disease-free survival at 18 months. Diagnostic laparoscopy will be performed routinely after 18 months postoperatively in both arms of the study in patients without evidence of disease based on routine follow-up using CT imaging and CEA. Discussion Adjuvant HIPEC is assumed to reduce the expected 25 % absolute risk of PC in patients with T4 or perforated colon cancer to a risk of 10 %. This reduction is likely to translate into a prolonged overall survival. Trial registration number NCT02231086 (Clinicaltrials.gov)
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Affiliation(s)
- Charlotte E L Klaver
- Department of surgery, Academic Medical Centre, University of Amsterdam, Post box 22660, 1105AZ, Amsterdam, The Netherlands.
| | - Gijsbert D Musters
- Department of surgery, Academic Medical Centre, University of Amsterdam, Post box 22660, 1105AZ, Amsterdam, The Netherlands.
| | - Willem A Bemelman
- Department of surgery, Academic Medical Centre, University of Amsterdam, Post box 22660, 1105AZ, Amsterdam, The Netherlands.
| | - Cornelis J A Punt
- Department of oncology, Academic Medical Centre, University of Amsterdam, Post box 22660, Amsterdam, The Netherlands.
| | - Victor J Verwaal
- Department of Surgery, Antoni van Leeuwenhoek hospital/the Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Marcel G W Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Post box 22660, 1105AZ, Amsterdam, The Netherlands.
| | - Arend G J Aalbers
- Department of Surgery, Antoni van Leeuwenhoek hospital/the Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Jarmila D W van der Bilt
- Department of surgery, Academic Medical Centre, University of Amsterdam, Post box 22660, 1105AZ, Amsterdam, The Netherlands.
| | - Djamila Boerma
- Department of surgery, St. Antonius Hospital, Post box 2500, 3430 EM, Nieuwegein, The Netherlands.
| | - Andre J A Bremers
- Department of surgery, Radboud University Medical Centre, Geert Grooteplein-Zuid 22, 6525 GA, Nijmegen, The Netherlands.
| | - Jacobus W A Burger
- Department of surgery, Erasmus Medical Centre/Daniel den Hoed, Post box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Christianne J Buskens
- Department of surgery, Academic Medical Centre, University of Amsterdam, Post box 22660, 1105AZ, Amsterdam, The Netherlands.
| | - Pauline Evers
- Dutch Cancer Patient Organization 'Leven met Kanker', Utrecht, the Netherlands.
| | - Robert J van Ginkel
- Department of surgery, University Medical Centre, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | | | - Patrick H J Hemmer
- Department of surgery, University Medical Centre, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Ignace H J T de Hingh
- Department of surgery, Catharina Ziekenhuis, Post box 1350, 5602 ZA, Eindhoven, The Netherlands.
| | - Laureen A Lammers
- Department of pharmacy, Academic Medical Centre, University of Amsterdam, Post box 22660, 1105AZ, Amsterdam, The Netherlands.
| | - Barbara L van Leeuwen
- Department of surgery, University Medical Centre, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Wilhelmus J H J Meijerink
- Departement of surgery, Vrije University Medical Center, Post box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Simon W Nienhuijs
- Department of surgery, Catharina Ziekenhuis, Post box 1350, 5602 ZA, Eindhoven, The Netherlands.
| | - Jolien Pon
- Society of patients with cancer of the gastrointestinal tract (SPKS), Darmkanker Nederland, Utrecht, the Netherlands.
| | - Sandra A Radema
- Department of oncology, Radboud University Medical Centre, Geert Grooteplein-Zuid 22, 6525 GA, Nijmegen, The Netherlands.
| | - Bert van Ramshorst
- Department of surgery, St. Antonius Hospital, Post box 2500, 3430 EM, Nieuwegein, The Netherlands.
| | - Petur Snaebjornsson
- Department of pathology, Antoni van Leeuwenhoek hospital/the Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Jurriaan B Tuynman
- Departement of surgery, Vrije University Medical Center, Post box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Elisabeth A Te Velde
- Departement of surgery, Vrije University Medical Center, Post box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Marinus J Wiezer
- Department of surgery, St. Antonius Hospital, Post box 2500, 3430 EM, Nieuwegein, The Netherlands.
| | - Johannes H W de Wilt
- Department of surgery, Radboud University Medical Centre, Geert Grooteplein-Zuid 22, 6525 GA, Nijmegen, The Netherlands.
| | - Pieter J Tanis
- Department of surgery, Academic Medical Centre, University of Amsterdam, Post box 22660, 1105AZ, Amsterdam, The Netherlands.
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Sloothaak DAM, Gardenbroek TJ, Crezee J, Bemelman WA, Punt CJA, Buskens CJ, Tanis PJ. Feasibility of adjuvant laparoscopic hyperthermic intraperitoneal chemotherapy in a short stay setting in patients with colorectal cancer at high risk of peritoneal carcinomatosis. Eur J Surg Oncol 2014; 40:1453-8. [PMID: 25073662 DOI: 10.1016/j.ejso.2014.06.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/12/2014] [Accepted: 06/26/2014] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Treatment of peritoneal carcinomatosis (PC) of colorectal cancer (CRC) origin is relatively ineffective and associated with morbidity. This raises the question whether we should focus on prevention of the development of PC. We determined the feasibility of adjuvant laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) in a short stay setting. METHODS A prospective single centre pilot study was conducted between January 2011 and July 2012. Ten patients at risk of developing PC of CRC origin were included. Laparoscopic HIPEC using Mitomycin-C (90 min; inflow temperature 42-43 °C) was performed within several weeks after primary resection of CRC and was considered feasible when postoperative hospital stay was three days or shorter in at least six patients, and if a maximum of one conversion and one re-admission within 30 days occurred. RESULTS HIPEC was performed after a median of 6 weeks (range 3-9 weeks). Postoperatively, five patients were discharged at day one, four patients at day two and one patient at day three. Laparoscopic adhesiolysis resulted in small bowel injury in one patient, but no conversion to open surgery and no postoperative complications were observed. One patient was readmitted within 30 days due to a clostridium infection. The postoperative course was uneventful for the remaining patients. CONCLUSION Adjuvant laparoscopic HIPEC appeared to be feasible in a short stay setting based on this small pilot study. The necessity of adhesiolysis determines the complexity of the procedure and requires an operating team with experience in minimally invasive abdominal surgery.
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Affiliation(s)
- D A M Sloothaak
- Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - T J Gardenbroek
- Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - J Crezee
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - W A Bemelman
- Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - C J A Punt
- Medical Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - C J Buskens
- Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - P J Tanis
- Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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