Adjuvant hyperthermic intraperitoneal chemotherapy in patients with locally advanced colon cancer (COLOPEC): a multicentre, open-label, randomised trial

Underdiagnosis of positive resection margins and synchronous peritoneal metastases in locally advanced colon cancer: histopathological reassessment of primary resection in the COLOPEC trial

The aim of this study was to perform histopathological reassessment of primary resections of locally advanced colon cancer (CC) within a randomized controlled trial, with specific focus on surgical margins and synchronous locoregional peritoneal metastases (SL-PM), and to provide learning points for both surgeons and pathologists. All histopathological slides of patients with c/pT4N0-2M0 or perforated CC included in the COLOPEC trial were reassessed and correlated with surgical reports. The COLOPEC trial originally determined the value of prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC). Frequency of positive margins (R +), R + subtypes, and SL-PM and the association with 5-year peritoneal recurrence were analyzed. Histopathological slides of 199 patients were reassessed. R + was present in 28 patients (14.1%), of which 8 occurred at the site of adhesiolysis (originally classified as pT4a in 6). SL-PM was present in 11 cases (5.5%), of which 9 were not recognized or misclassified. Both R + and SL-PM were associated with 5-year peritoneal metastases in cox regression analysis (HR 2.38, 95% CI 1.12-5.04 and HR 5.98, 95% CI 2.69-13.29, respectively). Of 9 patients with peritoneal recurrences detected during re-exploration at 5-8 weeks after primary tumor resection for intended HIPEC, 5 demonstrated either R + and/or SL-PM. This study brings to light previously unnoticed but clinicopathologically relevant aspects of CC pathology retaining to underdetected SL-PM and new R + types. Underrecognition until now probably relates to the complexity of advanced CC specimens, poor communication between surgeons and pathologists, and the low incidence among high volumes of CC specimens. Trial registration: NCT02231086 (Clinicaltrials.gov).

Peritoneal reflection involvement as a prognostic factor in rectal cancer. Long-term oncological outcomes from a prospective study

PURPOSE

To assess the relevance of peritoneal reflection involvement in long-term oncological outcomes in patients with rectal cancer.

METHODS

Prospective observational study from a specialized colorectal unit that included a consecutive series of patients undergoing mesorectal excision for rectal cancer. Peritoneal reflection (PR) involvement was evaluated on pathological examination using Shepherd's classification. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) were assessed.

RESULTS

One hundred sixty patients were included in the present analysis. Peritoneal involvement was present in 28.2% of the 85 tumors above or at the level of PR. There were no differences in OS, DFS, or LR according to tumor's height location. The 5-year OS, DFS, and LR for tumors involving PR were 58.3%, 61.7%, and 30.3%, respectively. Patients with peritoneal involvement had a higher LR rate (p = 0.02) and shorter OS (p = 0.04). Shepherd's grade 4 peritoneal involvement was an independent risk factor for OS (HR 2.9; 95% CI 1.1-9.5, p = 0.04) and LR (HR 4.2; 95% CI 1.2-16.9, p = 0.04).

CONCLUSION

After rectal cancer resection, peritoneal involvement is an independent risk factor for local recurrence and poor survival.

Hyperthermic intraperitoneal chemotherapy after upfront cytoreductive surgery for stage III epithelial ovarian cancer: Follow-up of long-term survival

INTRODUCTION

The survival benefit of hyperthermic intraperitoneal chemotherapy (HIPEC) has been well defined at the time of interval cytoreductive surgery, but the role of HIPEC remains uncertain for patients with newly diagnosed advanced ovarian cancer in the upfront setting. The present study aimed to report the updated long-term survival outcomes after 5 years of follow-up from our previous multicenter retrospective cohort study to compare primary cytoreductive surgery (PCS) plus HIPEC with PCS alone among women with stage III epithelial ovarian cancer.

MATERIAL AND METHODS

This study was conducted at five high-volume gynecological medical centers in China from January 2010 to May 2017. Eligible patients with complete data were treated with either PCS combined with HIPEC or PCS alone. The 5-year overall survival (OS) rate was updated to compare PCS plus HIPEC with PCS alone. The inverse probability of treatment weighting (IPTW) method based on a propensity score model for each patient was used to control the confounding factors and evaluate the effect of HIPEC.

RESULTS

Data from 789 patients, a total of 584 eligible stage III epithelial ovarian cancer patients were ultimately included in the analysis (PCS-plus-HIPEC group, n = 425; PCS-alone group, n = 159). After IPTW adjustment, the median OS was 44.5 (95% CI, 40.1-49.1) months in the PCS-plus-HIPEC group and 32.4 (95% CI, 28.8-40.3) months in the PCS-alone group (weighted hazard ratio, 0.74; 95% CI, 0.59-0.93; p = 0.006). At 5 years, the OS rates were 37.9% (95% CI, 33.0%-42.8%) in the PCS-plus-HIPEC group and 26.4% (95% CI, 18.9%-34.6%) in the PCS-alone group (p = 0.007). After stratification into optimal and suboptimal cytoreduction subgroups, patients in the PCS-plus-HIPEC group maintained a greater association with improved OS than those in the PCS-alone group. Among the women who underwent optimal cytoreduction in the PCS-plus-HIPEC group and PCS-alone group, the median OS was 49.9 (95% CI, 45.2-58.4) months and 37.8 (95% CI, 30.5-53.0) months (p = 0.042) while the 5-year OS rate was 43.7% (95% CI, 37.7%-49.6%) and 33.2% (95% CI, 23.3%-43.5%), respectively (p = 0.040). Meanwhile, for those treated with suboptimal cytoreduction subgroup in the PCS-plus-HIPEC and PCS-alone groups, the median OS was 28.4 (95% CI, 22.2-39.9) months and 20.6 (95% CI, 10.6-32.4) months (p = 0.099) while the 5-year OS rate was 22.4% (95% CI, 15.1%-30.5%) and 12.2% (95% CI, 4.4%-24.2%), respectively (p = 0.060). The median follow-up period was 87.2 (95% CI, 85.1-92.7) months.

CONCLUSIONS

The updated results indicate that the addition of HIPEC is associated with improved long-term survival outcomes beyond 5 years for patients with stage III epithelial ovarian cancer in the upfront setting.

Challenges of Nontherapeutic Laparotomy in Patients with Peritoneal Surface Malignancies Selected for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

This study aimed to analyze the morbidity, mortality, and survival outcomes in patients with peritoneal surface malignancies who were initially considered candidates for cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) but were found to have unresectable disease, resulting in nontherapeutic exploratory laparotomy.

PATIENTS AND METHODS

We evaluated data from our referral center for the treatment of peritoneal surface malignancies between January 2008 and December 2022. Adverse events following nontherapeutic laparotomy were classified using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0.

RESULTS

Among a cohort of 486 patients with peritoneal surface malignancies initially considered candidates for CRS + HIPEC, 46 cases (9.4%) were aborted due to the disease being deemed unresectable during exploratory laparotomy. The primary reasons for unresectability included extensive disease spread, observed in 28 patients, with massive small intestine involvement detected in 13 of these cases. The median duration of surgery was 90 min (range: 60-180 min). Postoperative complications occurred in 10 patients (22%), with a mortality rate of 4.3% (2 patients). Survival was significantly lower in patients who did not receive adjuvant systemic chemotherapy with palliative intent (4 months vs. 15 months, p < 0.01).

CONCLUSIONS

Exploratory laparotomy in patients with peritoneal surface malignancies considered for CRS with HIPEC carries a substantial risk of complications. Improved preoperative staging using advanced technologies such as radiomics and laparoscopy is expected to reduce the number of patients undergoing nontherapeutic laparotomy.

The Mitomycin versus Oxaliplatin debate on HIPEC in colorectal cancers - An updated systematic review and Meta-analysis

INTRODUCTION

Following the PRODIGE-7 trial, surgeons have shifted to the use of Mitomycin-based HIPEC from Oxaliplatin for colorectal peritoneal metastasis. While preclinical studies have demonstrated the superiority of Mitomycin over oxaliplatin, clinical studies report variable results. The objective of the meta-analysis was to determine the most efficacious drug after cytoreduction for colorectal peritoneal metastasis.

METHODS

he databases searched were PubMed, Cochrane Library, Scopus, CINHAL (EBSCO), and Google Scholar based on the following concepts: colorectal, peritoneal, cytoreduction, Mitomycin, and Oxaliplatin. The risk of bias was assessed using the Newcastle-Ottawa scale and certainty of the evidence was assessed using the GRADE Pro tool. The analysis was carried out using the log hazard ratio as the outcome measure for survival data. All syntheses used the Random-effects model and were reported for Oxaliplatin-based HIPEC with MMC as the reference.

RESULTS

Thirteen studies with 3406 patients were included in the quantitative meta-analysis. The pooled hazard ratio for overall survival was 1.03 (95 % CI: 0.786-1.349) from ten studies. Six studies reported disease-free survival and the pooled hazard ratio was 0.941 (95 % CI: 0.683-1.297). Both survival estimates had moderate statistical heterogeneity. The evidence was of very low certainty for all the outcomes due to the non-randomized nature of studies, clinical and statistical heterogeneity, serious risk of bias due to uncontrolled measured confounding, selection bias, and unequal follow-up durations.

CONCLUSION

Our systematic review and meta-analysis found no significant difference in survival outcomes or postoperative morbidity between MMC and Oxaliplatin-based HIPEC.

The Role of Prophylactic or Adjuvant Hyperthermic Intraperitoneal Therapy in Appendiceal and Colorectal Cancer Peritoneal Metastasis

Appendiceal neoplasms and colorectal cancer have a propensity to develop peritoneal metastases. Despite advancements in systemic therapy and surgical management, the development and management of peritoneal metastases remains a challenging problem. Utilization of adjuvant or prophylactic hyperthermic intraperitoneal chemotherapy has been described, with varying quality of data and reported outcomes. The utilization of prophylactic or adjuvant hyperthermic intraperitoneal chemotherapy in patients with appendiceal neoplasms and colorectal cancer remains an active area of exploration.

Application of computed tomography body composition in patients with locally progressive gastric cancer undergoing radical surgery combined with prophylactic hyperthermic intraperitoneal chemotherapy

OBJECTIVES

Radical resection combined with prophylactic hyperthermic intraperitoneal chemotherapy (p-HIPEC) is a promising treatment for locally advanced gastric cancer (LAGC), though factors influencing its long-term benefits remain unclear. This study aimed to assess the impact of computed tomography (CT)-based body composition parameters on survival in patients undergoing this combination treatment, exploring nutritional factors affecting long-term survival and developing a prognostic model.

METHODS

We retrospectively analyzed clinical and CT data from 230 patients with LAGC who underwent radical resection with p-HIPEC between January 2017 and December 2020. Cox regression and Kaplan-Meier analysis were used to identify independent risk factors, and nomograms were constructed based on significant predictors. The models' accuracy was evaluated using receiver operating characteristic (ROC) curves and calibration plots.

RESULTS

Of the 230 patients, the 3-year survival rate was 56.1%, with a median overall survival of 49.7 months. Multivariate analysis identified sarcopenia (hazard ratio [HR], 3.078; p < 0.001), low subcutaneous adipose tissue index (HR, 1.739; p = 0.002), high visceral-to-subcutaneous adipose tissue ratio (HR, 1.746; p = 0.002), pT stage (p < 0.001), pN stage (N3: p = 0.004; N2: p = 0.049), and vascular invasion (p < 0.001) as independent risk factors for poor survival. Nomograms incorporating body composition and tumor features predicted 1-, 3-, and 5-year overall survival with high accuracy (AUC >0.7).

CONCLUSIONS

Body composition and tumor characteristics are independent predictors of overall survival in LAGC patients. Nomograms integrating these factors provide reliable prognostic predictions.

Diagnostic Advances and Novel Therapeutics in Peritoneal Metastasis

Appropriate assessment of disease burden in patients with peritoneal surface malignancy (PSM) is critical for treatment decision-making, and conventional cross-sectional imaging (computed tomography and/or MRI) often underestimates burden of disease. Advances in imaging for PSM include novel functional imaging modalities that target cells unique to the tumor microenvironment. Novel alternative methods of diagnosis and disease monitoring are also potentially applicable to management of PSM. These include forms of "liquid biopsy" targeting circulating tumor DNA. Novel regional therapies include both new therapeutic agents (immune-based and nanoparticle-based), as well as new methods of delivery such as pressurized intraperitoneal aerosolized chemotherapy.

Clinical and Pathological Risk Factors for Peritoneal Metastases in a Surgical Series of T4 Colorectal Cancers

Background: T4 colorectal cancer (CRC) is associated with an increased risk of peritoneal metastases (PM), but it is currently not possible to accurately predict which patients with T4 CRC develop PM. We investigated the occurrence and risk factors for PM in these patients. Methods: A mono-institutional prospective database of 352 patients undergoing T4 primary CRC resection from 2012 to 2021 was reviewed. Clinico-pathological variables potentially associated with synchronous or metachronous PM were tested by univariate and multivariate analyses. Results: The prevalence of synchronous PM was 73/352 (20.7%) and was significantly associated with age (p = 0.037), primary site (p = 0.002), positive nodes (p = 0.005), elevated CA19.9 (p = 0.001), and non-intestinal histology (p = 0.001). After a median follow-up of 35.9 months (95% confidence interval [CI] = 29.5-44.9), metachronous CRC-PM occurred in 36/164 patients (22.0%) with available data, accounting for a three-year cumulative incidence of 21.5% (95% CI = 14.3-28.1). Metachronous CRC-PM occurred in 3/48 patients (6.2%) with negative nodes and normal CEA, as compared with 33/116 patients (28.4%) with positive nodes and/or elevated CEA (p < 0.001). Combined nodal and CEA status (hazard ratio [HR] = 1.27; 95% CI = 1.02-1.59; p = 0.033), postoperative chemotherapy (HR= 0.51; 95% CI = 0.33-0.77; p = 0.001), and positive resection margins (HR = 2.01; 95% CI = 1.20-3.39; p = 0.008) were significantly associated with PM. Conclusions: The peritoneum is a major site for treatment failure in T4 CRC. Patients with normal CEA and negative lymph nodes are associated with a significantly lower risk for metachronous CRC-PM. These findings may help in refining patient selection for integrated approaches aiming at the prevention or early treatment of CRC-PM, which are pending validation in prospective studies.

An Organoid Model for the Therapeutic Effect of Hyperthermic Intraperitoneal Chemotherapy for Colorectal Cancer

BACKGROUND

Consensus regarding the hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer (CRC) regimen remains elusive. In this study, patient-derived tumor organoids from CRC were utilized as a preclinical model for in vitro drug testing of HIPEC regimens commonly used in clinical practice. This approach was used to facilitate the clinical formulation of HIPEC.

METHOD

Tumor tissues and corresponding clinical data were obtained from patients diagnosed with CRC at the Sixth Affiliated Hospital of Sun Yat-Sen University. Qualified samples were cultured and passaged. We aimed to assess the sensitivity of in vitro hyperthermic perfusion using five different regimens, i.e. mitomycin C, mitomycin C combined with cisplatin, mitomycin C combined with 5-fluorouracil, oxaliplatin, and oxaliplatin combined with 5-fluorouracil.

RESULTS

Tumor organoids obtained from 46 patients with CRC were cultured, and in vitro hyperthermic perfusion experiments were conducted on 42 organoids using five different regimens. The average inhibition rate of mitomycin C was 85.2% (95% confidence interval [CI] 80.4-89.9%), mitomycin C combined with cisplatin was 85.5% (95% CI 80.2-90.7%), mitomycin C combined with 5-fluorouracil was 65.6% (95% CI 59.6-71.6%), oxaliplatin was 37.9% (95% CI 31.5-44.3%), and oxaliplatin combined with 5-fluorouracil was 40.7% (95% CI 33.9-47.5%).

CONCLUSION

In vitro hyperthermic perfusion demonstrates that the inhibition rate of mitomycin C, both alone and in combination with cisplatin, surpasses that of the combination of mitomycin C with 5-fluorouracil and oxaliplatin. In clinical practice, the combination of mitomycin C and cisplatin can be regarded as the optimal choice for HIPEC in CRC.

Appendiceal adenocarcinoma-patterns of tumor spread and prognosis

INTRODUCTION

Appendiceal adenocarcinoma represents a diagnostic and therapeutic challenge since it is prone to early lymphatic and peritoneal spread. We aimed to analyze the proportion of lymph node metastases in completion right hemicolectomy specimens, risk factors for peritoneal metastases (PM), and prognosis after definitive treatment.

METHODS

Ninety-three patients with appendiceal adenocarcinoma scheduled for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) in Uppsala 2004-2020 were identified from a prospectively maintained registry. Risk factors for PM were assessed based on the presence (CT + group, n = 55) or absence (CT - group, n = 37) of visible PM at baseline CT scan. Prognostic factors were analyzed based on the actual presence (PM group, n = 66) or absence (no PM group, n = 27) of PM.

RESULTS

The median age was 60 (26-78). Forty-eight patients were women. Resection of PM at initial surgery indicated an 80 % risk of finding PM at a follow-up exploration. R1 appendectomy and perforated appendix had a similar risk for PM (24 %,26 %) which increased to 38 % if both were present. Regional lymph node metastases occurred in 31 % in the CT + group vs. 14 % in the CT - group (p = 0.005) and was associated with poor survival HR 5.16 (1.49-17.81). The 5-year OS and DFS rates were 54 % and 29 % in the PM group.

CONCLUSIONS

Patients with certain risk factors have a high likelihood of PM despite a normal CT scan, which justifies selective exploration at a HIPEC center. Regional lymph node spread supports the current practice of completion right hemicolectomy and is a significant prognostic factor.

Prospects of the surgical management of colorectal peritoneal metastasis

BACKGROUND

Colorectal cancer (CRC) is a common malignancy with the propensity to metastasize. Common sites of metastasis include the liver, lungs, and peritoneum, with peritoneal metastases (PMs) having the worst prognosis. Unfortunately, systemic chemotherapy is often less effective in the treatment of PMs. Therefore, removal of all visible tumor via cytoreductive surgery along with intraperitoneal (IP) therapies has been used.

METHODS

A comprehensive review of the literature was conducted using MEDLINE/PubMed and Web of Science with an end date of September 1, 2024, regarding cytoreductive surgery and heated IP chemotherapy for CRC PMs.

RESULTS

Recent studies have called into question the utility of IP chemotherapy in the treatment of CRC PMs. However, regardless of IP chemotherapy, cytoreductive surgery has demonstrated an additional survival benefit for patients with PM secondary to CRC.

DISCUSSION

This study reviews the pathophysiology of CRC PM, the current treatment paradigms, and a pathway for improving outcomes in patients with CRC PM.

Predictors of Recurrence in Nonmetastatic Appendiceal Epithelial Cancers: An Updated Single-Center Experience Over 25 Years

BACKGROUND

Appendiceal epithelial tumors are rare and encompass a broad set of adenocarcinoma histologies, including mucinous (mAC), colonic-type (cAC), and goblet cell (GCA) adenocarcinomas. It has previously been reported that nodal disease predicted recurrence in patients with nonmetastatic appendiceal adenocarcinomas, supporting diagnostic laparoscopy with right hemicolectomy for staging and assessment for risk of recurrence. In this update, we sought to identify predictors of nodal disease on initial diagnostic pathology in nonmetastatic adenocarcinomas.

METHODS

Patients with nonmetastatic appendiceal adenocarcinoma at a single institution from 1994 to 2020 were included. Clinicopathologic characteristics that predict recurrence and lymph node metastasis were analyzed. Workup included staging laparoscopy with right hemicolectomy, seriel imaging and biochemical monitoring.

RESULTS

A total of 147 patients with mAC (18%), cAC (22%), and GCAs (59%) were included. After median follow-up of 53 months, 23 (16%) patients recurred, most commonly in the peritoneal cavity (17/23, 74%). Recurrence rates were higher among node-positive patients (59% vs. 5%, P < 0.001). Nodal disease was more common in mAC (27%) and cAC (37%) than in GCA (11%); however, adenocarcinoma grade was not associated with nodal involvement.

CONCLUSIONS

Nodal metastasis was more common in mAC and cAC compared with GCA and was the only significant predictor of recurrence in appendix cancer.

Computational Evaluation of Improved HIPEC Drug Delivery Kinetics via Bevacizumab-Induced Vascular Normalization

Background: Oxaliplatin-based hyperthermic intraperitoneal chemotherapy (HIPEC) using the original 30 min protocol has shown limited benefits in patients with peritoneal metastasis of colorectal cancer (PMCRC), likely due to the short duration, which limits drug penetration into tumor nodules. Bevacizumab, an antiangiogenic antibody that modifies the tumor microenvironment, may improve drug delivery during HIPEC. This in silico study evaluates the availability of oxaliplatin within tumor nodules when HIPEC is performed after bevacizumab treatment. Methods: Using a computational fluid dynamics (CFD) model of HIPEC, the temperature and oxaliplatin distribution within the rat abdomen were calculated, followed by a model of drug transport within tumor nodules located at various sites in the peritoneum. The vascular normalization effect of the bevacizumab treatment was incorporated by adjusting the biophysical parameters of the tumor nodules. The effective penetration depth values, including the thermal enhancement ratio of cytotoxicity, were then compared between HIPEC alone and HIPEC combined with the bevacizumab treatment. Results: After bevacizumab treatments at doses of 0.5 mg/kg and 5 mg/kg, the oxaliplatin availability increased by up to 20% and 45% when HIPEC was performed during the vascular normalization phase, with the penetration depth increasing by 1.5-fold and 2.3-fold, respectively. Tumors with lower collagen densities and larger vascular pore sizes showed higher oxaliplatin enhancement after the combined treatment. Bevacizumab also enabled a reduction in the oxaliplatin dose (up to half at 5 mg/kg bevacizumab) while maintaining effective drug levels in the tumor nodules, potentially reducing systemic toxicity. Conclusions: These findings suggest that administering oxaliplatin-based HIPEC during bevacizumab-induced vascular normalization could significantly improve drug penetration and enhance treatment efficacy.

Advances in pharmacotherapy for the treatment of peritoneal metastases from colorectal cancer

INTRODUCTION

Patients with peritoneal metastasis (PM) from colorectal cancer (CRC) typically have a poor prognosis with historically few treatment options. Cytoreductive surgery (CRS) is the mainstay of treatment to remove macrometastases into the peritoneum, but residual micrometastases are often left behind. Systemic chemotherapy remains a cornerstone of treatment for micrometastases, but intraperitoneal therapy offers advantages including higher local dose concentration with fewer systemic side effects from treatment.

AREAS COVERED

This review covers advancements in the routes and types of pharmacotherapies for PM in CRC.

EXPERT OPINION

More evidence is needed to justify HIPEC with CRS as the standard of care treatment modality for patients with resectable PM in CRC. New therapies such as oncolytic viruses, biologics, and small-molecule inhibitors may become additional treatment modalities for PM.

Effectiveness of hyperthermic intraperitoneal chemotherapy during primary curative resection for colorectal carcinoma

PURPOSE

Peritoneal metastasis (PM) is the life-threatening cause of colorectal cancer patients (CRC). Adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) plus cytoreductive surgery exhibited promising effects in preventing recurrence and increasing the survival of CRC patients. However, the outcomes of HIPEC on treating advanced CRC with risk of PM are still controversial. Here, we retrospectively examined the impact of HIPEC on preventing PM and its overall effects on patients with locally advanced CRC who underwent primary curative resection at our center.

METHODS

We retrospectively analyzed 45 patients diagnosed with locally advanced colorectal cancer (CRC) who underwent primary curative laparoscopic surgery with proactive hyperthermic intraperitoneal chemotherapy (HIPEC), in conjunction with adjuvant systemic chemotherapy at our center between 2019 and 2022. An additional 55 patients with locally advanced CRC who underwent similar surgery and received adjuvant systemic chemotherapy but did not undergo HIPEC during the same period were selected as the control group. Disease-free survival (DFS), overall survival (OS), and PM incidence were compared between patients with and without HIPEC.

RESULTS AND CONCLUSIONS

The cumulative PM incidence was 2.2% in the HIPEC group and 14.5% in the control group(P = 0.0347). No significant adverse effects were observed in the HIPEC group. Furthermore, Kaplan-Meier survival analysis showed that the HIPEC correlated to better DFS [hazard ratio (HR) 0.4670, 95% confidence interval (CI) 0.2305-0.9462; P = 0.0345] and extended the overall survival of CRC patients [hazard ratio (HR) 0.3978, 95% confidence interval (CI) 0.1684-0.9395; P = 0.0355]. Therefore, our data supports that adjuvant HIPEC can prevent peritoneal failure in CRC patients and improve both PFS and OS survival following primary curative resection.

INDEPSO-ISPSM Consensus on Peritoneal Malignancies: Management of Colorectal Peritoneal Metastases

PURPOSE

This manuscript reports the results of the Indian Network for Development of Peritoneal Surface Oncology and Indian Society of Peritoneal Surface Malignancies (INDEPSO-ISPSM) consensus that aimed to provide recommendations for some important aspects management of patients with colorectal peritoneal metastases (CPM) and address some issues unique to India.

METHODS

The modified Delphi technique was used with two rounds of voting. There were 29 questions on nine main topics-the role of cytoreductive surgery (CRS), patient selection for CRS, preoperative workup, role of systemic chemotherapy (SC), CPM with other visceral metastases, molecular profile, hyperthermic intraperitoneal chemotherapy (HIPEC) and other modalities of intraperitoneal chemotherapy (IPC), prophylactic/preventive strategies, and surveillances after CRS. A consensus was achieved if anyone option received >70 votes (strong consensus >90%).

RESULTS

Forty-eight surgical (n = 41) and gastrointestinal (n = 7) oncologists were invited; 44 agreed to participate. The response rate was 95.4% (42/44) in round 1 and 93.1% (41/44) in round 2. Overall, a consensus was achieved on 23/29 (79.3%) questions (strong consensus on 6/29 [20.6%]). The panel strongly recommended considering surgery for limited CPM with limited liver metastases (92.5%), not altering the surgical approach in patients with KRAS mutations (91.67%), and limiting the use of IPC for unresectable CPM outside clinical trials (95%). Adjuvant SC was recommended for all patients undergoing CRS (89.47%). CRS is a therapeutic option for selected patients with CPM including those with metachronous CPM (79.49) and signet ring cell cancers (76.92%). HIPEC was recommended outside clinical trials only for patients with peritoneal cancer index 11-15(80%).

CONCLUSION

The panel recommended CRS for most indications but was very selective in recommending HIPEC and IPC outside clinical trials. These recommendations should be a useful resource in clinical decision making for clinicians treating CPM in India and regions with a similar sociodemographic background.

Peritoneal Carcinomatosis in Colorectal Cancer: Review and Update of Current Clinical Data

The peritoneal metastasized colorectal cancer (pmCRC) represents a serious health problem worldwide with a special emphasis in the developed countries. Several guidelines recognize the role of multimodal therapy consisting of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of pmCRC. New data suggests that some other factors, eg, tumor biology, immune profile, neoadjuvant chemotherapy may play a predictive role for the oncological outcome of these patients.

The safety and effectiveness of prophylactic hyperthermic intraperitoneal chemotherapy in patients with pathological T3-4 locally advanced colon cancer

INTRODUCTION

The safety and effectiveness of prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) in pathological T3-4 locally advanced (pT3N + M0 and pT4NxM0) colon cancer (CC) patients with radical resection need further study.

METHODS

Clinical and pathological information of pT3-4 locally advanced CC patients who received radical surgery in our hospital from January 2018 to December 2020 were analyzed. The prognosis of patients was estimated using Cox proportional hazards regression analysis and Kaplan-Meier method.

RESULTS

Among 927 patients, 10.4% (96/927) received prophylactic HIPEC based on 5-FU, 4.6% (43/927) received prophylactic HIPEC based on lobaplatin, 85.0% (788/927) received conventional therapy. The incidence of metachronous peritoneal carcinomatosis (mPC) was 9.4%. Complications occurred in 32 patients (4.1%) in the conventional therapy group, 6 patients (6.3%) in the prophylactic HIPEC group based on 5-FU and 3 patients (7.0%) in the prophylactic HIPEC group based on lobaplatin within 30 days after surgery (5-FU vs. conventional therapy group, p = 0.464; Lobaplatin vs. conventional therapy group, p = 0.591). Multivariate Cox regression analysis revealed that prophylactic HIPEC based on either 5-FU or lobaplatin regimen could not effectively improve mPC-free survival (5-FU: p = 0.020, HR = 1.927, 95% CI, 1.111-3.343; Lobaplatin: p = 0.167, HR = 0.247, 95% CI, 0.034-1.796), overall survival (5-FU: p = 0.361, HR = 1.360, 95% CI, 0.703-2.634; Lobaplatin: p = 0.780, HR = 0.816, 95% CI, 0.195-3.416) and disease-free survival (5-FU: p = 0.525, HR = 1.149, 95% CI, 0.749-1.760; Lobaplatin: p = 0.117, HR = 0.488, 95% CI, 0.199-1.198).

CONCLUSION

Early prophylactic HIPEC based on 5-FU or lobaplatin subsequent to radical resection for patients with pT3-4 locally advanced CC is safe, but not effective in reducing the risk for mPC.

Preoperative chemotherapy response and survival in patients with colorectal cancer peritoneal metastases

Treatment guidelines provided by PRODIGE-7 recommend perioperative systemic chemotherapy before cytoreductive surgery (CRS) for colorectal cancer peritoneal metastases (CRPM). Toxicity with multimodal treatment needs to be better defined. Chemotherapy response and impact on survival have not been reported. We assessed CRPM patients who received systemic oxaliplatin/irinotecan before CRS (preoperative) with Mitomycin C (35 mg/m2, 90 min) or Oxaliplatin (368 mg/m2, 30 min) heated intraperitoneal chemotherapy (HIPEC). Secondary analysis was performed from a prospective database. Overall survival (OS) in chemotherapy responders (R) and nonresponders (NR) was compared. Toxicity was assessed by rate of adverse events (AEs). From April 2005 to April 2021, 436 patients underwent CRS + HIPEC; 125 (29%) received preoperative chemotherapy. The 112 (90%) received oxaliplatin (64, 57%) or irinotecan (48, 43%). R, defined as complete (CR) or partial response on preoperative imaging and/or postoperative histology, was seen in 71, 63% (53.8-72.3); 16, 14% (8.4-22.2) had CR. Median OS in R versus NR was 43.7 months (37.9-49.4) versus 23.9 (16.3-31.4) p = 0.007, HR 0.51 (0.31-0.84). OS multivariable analysis showed HR 0.48 (0.25-0.95), p = 0.03 for chemotherapy response corrected by peritoneal cancer index, completeness of cytoreduction score. CRS led to 21% grade 3-4 AEs versus 4% for preoperative chemotherapy. HIPEC grade 3-4 AEs were 0.5%. Preoperative chemotherapy response is an independent predictor for OS in CRPM.

Intraperitoneal administration of a thermogel combined with an anticancer agent for the prevention of peritoneal carcinomatosis in a pig model

BACKGROUND

Surgeons may discover perioperative clinical situations associated with an increased risk of peritoneal carcinomatosis recurrence after primary resection. We developed a thermogel that can be used as a drug carrier to deliver an anticancer agent in the peritoneal cavity as a rescue solution. The spatial distribution of the thermogel and pharmacokinetics of chemotherapy have been studied in pigs. The safety of the thermogel was assessed based on the healing of bowel sutures.

METHODS

Nine pigs received gel with oxaliplatin at 130 mg/200 mL (TG-Ox group), and 4 pigs received the gel alone (TG group). Digestive tract and bladder wounds were made and sutured. Pigs were sacrificed at different times after surgery to monitor the distribution of the thermogel and to detect the occurrence of bowel fistulas. Oxaliplatin plasma and tissue concentrations were determined via mass spectrometry.

RESULTS

After 3 h, 100 % of the regions of interest were covered by the gel, 78 % were covered after 2 days, and 38 % were covered after 4 days. The thermogel delayed the release of oxaliplatin into the systemic circulation and significantly prolonged tissue impregnation. Anastomotic fistulas were observed in the TG-Ox group (10 %) versus 0 % in the TG group (p = 0.31).

CONCLUSIONS

A homogeneous distribution of the thermogel throughout the peritoneal cavity was observed, and the thermogel fulfilled its functions as a drug carrier, including ensuring safety and delaying chemotherapy delivery. Treatment-induced toxicity due to oxaliplatin was identified. The concept of a rescue solution being available in operating rooms was demonstrated.

Guidelines for the Prophylaxis and Treatment of Peritoneal Metastases From Colorectal Cancer: A GRADE-Approach for Evidence Evaluation and Recommendations

Colorectal peritoneal metastases (CPM) are common in colorectal cancer patients. This article aims to provide GRADE guidelines for the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in two clinical situations: (1) To determine the value of adjuvant HIPEC for the prevention of CPM in high-risk colorectal cancer patients; (2) to determine the impact on survival of cytoreductive surgery and HIPEC followed by adjuvant systemic chemotherapy as compared to systemic chemotherapy alone in patients with CPM.

Size-dependent translocation and lymphatic transportation of polymeric nanocarriers post intraperitoneal administration

Intraperitoneal (i.p.) administered nanomedicine has been widely applied in the clinical treatment of intra-abdominal diseases and preclinical pharmacological investigations. However, current understandings about the in vivo fate of i.p.-administered drug remains controversial owing to lack of reliable investigation tools. This work presents a nanoparticle-labeling strategy based on aggregation-caused quenching (ACQ) probes in the second near-infrared (NIR-II) window, which can eliminate the interference of unbound probes and allow for non-invasive tracking of nanoparticles in deep tissues. Our results strongly evidence a size-dependent absorption and biodistribution of the i.p.-administered polymeric nanocarriers (PNs) with particle sizes ranging from 30 to 1000 nm both in vivo and ex vivo, and moreover provide a clear visualization of lymphatic transportation and lymph node retention of integral PNs. Importantly, our findings suggest that small particles (≤30 nm) are favorable in systemic therapies due to their rapid absorption and high concentration (>19 %ID mL-1) in circulation, while large particles (over 1000 nm) are meant for localized treatment of abdominal diseases. Besides, the high retention of 200 nm nanoparticles within lymph nodes indicates their promising role in cancer vaccines and lymphatic diseases including lymph node metastasis.

Staging Paradox and recurrence pattern among stage IIB, IIC, and IIIA Colon cancers: a retrospective cohort study

PURPOSE

The survival rates of patients with stage IIB and IIC colon cancer are paradoxically inferior to that of patients with stage IIIA colon cancer. This study aimed to examine the oncological outcomes and investigate the factors that could affect the staging paradox among stage IIB, IIC, and IIIA colon cancers based on a 9-year cancer database.

METHODS

Patients with stage IIB (pT4aN0M0), IIC (pT4bN0M0), or IIIA (pT1-2N1M0) colon cancer were retrospectively selected from a prospectively maintained medical database from January 2011 to December 2019. Factors that might influence the staging paradox, including radicality, harvested lymph nodes, and chemotherapy administration, were examined.

RESULTS

A total of 282 patients (stage IIB, n = 59; stage IIC, n = 46; and stage IIIA, n = 177) were enrolled. Patients with stage IIB/C cancer demonstrated higher carcinoembryonic antigen levels, larger tumor size, more frequent tumor obstruction, and higher locoregional recurrence than those with stage IIIA cancer. With respect to 10-year locoregional recurrence-free survival and cancer-specific survival, patients with stage IIB and IIC cancers had significantly lower survival rates than did those with stage IIIA cancer (73.7% vs. 66.3% vs. 91.2%, P = 0.0003; 5.4% vs. 10.9% vs. 11.2%, P = 0.0023). The staging paradox persisted in patients who underwent R0 resection, had harvested lymph nodes ≥ 12, and received chemotherapy, as confirmed by multivariate regression analysis.

CONCLUSIONS

Based on the inferior oncological outcomes and higher locoregional recurrence rate, this study highlighted the need for intensified cytotoxic chemotherapy specific to this recurrence pattern for patients with stage IIB/C colon cancer.

Genomic landscape defines peritoneal metastatic pattern and related target of peritoneal metastasis in colorectal cancer

The primary objective of this study is to develop a prediction model for peritoneal metastasis (PM) in colorectal cancer by integrating the genomic features of primary colorectal cancer, along with clinicopathological features. Concurrently, we aim to identify potential target implicated in the peritoneal dissemination of colorectal cancer through bioinformatics exploration and experimental validation. By analyzing the genomic landscape of primary colorectal cancer and clinicopathological features from 363 metastatic colorectal cancer patients, we identified 22 differently distributed variables, which were used for subsequent LASSO regression to construct a PM prediction model. The integrated model established by LASSO regression, which incorporated two clinicopathological variables and seven genomic variables, precisely discriminated PM cases (AUC 0.899; 95% CI 0.860-0.937) with good calibration (Hosmer-Lemeshow test p = .147). Model validation yielded AUCs of 0.898 (95% CI 0.896-0.899) and 0.704 (95% CI 0.622-0.787) internally and externally, respectively. Additionally, the peritoneal metastasis-related genomic signature (PGS), which was composed of the seven genes in the integrated model, has prognostic stratification capability for colorectal cancer. The divergent genomic landscape drives the driver genes of PM. Bioinformatic analysis concerning these driver genes indicated SERINC1 may be associated with PM. Subsequent experiments indicate that knocking down of SERINC1 functionally suppresses peritoneal dissemination, emphasizing its importance in CRCPM. In summary, the genomic landscape of primary cancer in colorectal cancer defines peritoneal metastatic pattern and reveals the potential target of SERINC1 for PM in colorectal cancer.

The history of cytoreduction and HIPEC: Heating up or just blowing smoke?

Peritoneal carcinomatosis carries a grim survival prognosis with complications ranging from the physical to the psychological. Cytoreductive surgery and infusion of heated intraperitoneal chemotherapy have evolved to become a commonly used treatment option in the multi-modal management of peritoneal carcinomatosis. Here, we examine the origins of surgery over a century ago as a potential cure for peritoneal carcinomatosis and how it has evolved with our knowledge of the disease to its present state. The origin of chemotherapy is similarly described as well as its progressive application in regional therapy, guided by the ongoing development of new agents, better understanding of peritoneal physiology, and improved systemic treatment. We show how these modalities began to be used in tandem, and standardized, leading to randomized trials and better understanding of the possibilities and limitations of treatment. Finally, we discuss the current status of patient selection for cytoreduction and future directions of intraperitoneal chemotherapy.

Is Hyperthermic Intraperitoneal Chemotherapy Appropriate for Colon Cancer?

Colorectal cancer (CRC) with peritoneal metastases is a complex disease and its management presents significant clinical challenges. In well-selected patients at experienced centers, CRS/hyperthermic intraperitoneal chemotherapy (HIPEC) can be performed with acceptable morbidity and is associated with prolonged survival. Based on the results of recent randomized controlled trials, HIPEC using oxaliplatin after CRS with shortened perfusion periods (30 minutes) is no longer recommended. There is a movement toward utilizing mitomycin C as a first-line intraperitoneal agent with extended perfusion times (90-120 minutes); however, there is currently little prospective evidence to support its widespread use.

Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Sarcomatosis

(1) Background: Cytoreductive surgery (CRS) with HIPEC is considered the standard of care for selected patients with peritoneal carcinomatosis, but evidence-based treatment recommendations for the therapy of peritoneal sarcomatosis are scarce. (2) Methods: We retrospectively analyzed all adult patients treated with CRS and HIPEC for peritoneal sarcomatosis between 2017 and 2024. (3) Results: Ten patients with a median age of 46.1 years (range: 23-77 years) with metachronous (40%) or synchronous (60%) peritoneal sarcomatosis from six different tumor entities were treated according to tumor board recommendation using CRS and HIPEC with cisplatin and doxorubicin over 60 min at 42.0 °C. The length of stay in the intensive care unit and hospital was 1.24 (0.6-1.9 days) and 11.1 days (6-17 days), respectively. Complete cytoreduction was achieved in 90% of the patients, with a median PSI of 11.5. Postoperative complications occurred in five cases, but no surgical revisions were necessary, and no acute kidney damage was recorded. (4) Conclusions: CRS with HIPEC in the presence of peritoneal sarcomatosis could be safely performed in our collective. Whether this resulted in an oncological treatment benefit cannot be concluded in view of the heterogeneous and small collective. Therefore, larger and prospective studies are warranted.

Unveiling the role of AGT in lipid metabolism and regulated cell death in colon cancer

BACKGROUND

Lipid metabolism and regulated cell death (RCD) play a role in the remodeling of tumor immune microenvironment and regulation of cancer progression. Since the underlying immune mechanisms of colon cancer remain elusive, this study aims to identify potential therapeutic target genes.

METHODS

Differential genes related to lipid metabolism and RCD in COAD patients were identified using R language and online tools. Based on the expression of genes, two groups were classified using consensus clustering. CIBERSORT and ssGSEA were used to detect immune infiltration in both groups. Prognostic signature genes for colon cancer were screened using machine learning algorithms. KEGG, GO and GSEA for gene pathway enrichment. In addition, interacting genes in the immune module were obtained using a weighted gene co-expression network (WGCNA). Finally, expression and mutation of key in colon cancer genes were detected using TIMER, HPR, cBioPortal website and qPCR.

RESULTS

The consensus clustering analysis revealed that 231 relevant differential genes were highly associated with immune infiltration. A series of machine learning and website analyses identified AGT as a hub gene linked to lipid metabolism and regulated cell death, which is overexpressed in colon cancer.

CONCLUSION

AGT, as a signature gene of lipid metabolism and regulated cell death, plays a critical role in the development of COAD and is associated with tumor immune infiltration.

Cytoreductive surgery without intra-peritoneal chemotherapy for metachronous colorectal peritoneal metastases

BACKGROUND

Cytoreductive surgery and chemotherapy reportedly improve the prognosis of patients with metachronous peritoneal metastases. However, the types of peritoneal metastases indicated for cytoreductive surgery remains unclear. Therefore, we aimed to clarify the category of cases for which cytoreductive surgery would be effective and report the prognosis associated with cytoreductive surgery for metachronous peritoneal metastases.

METHODS

This study included 52 consecutive patients who underwent cytoreductive surgery for metachronous peritoneal metastases caused by colorectal cancer between January 2005 and December 2018 and fulfilled the selection criteria. The median follow-up period was 54.9 months. Relapse-free survival was calculated as the time from cytoreductive surgery of metachronous peritoneal metastases to recurrence. Overall survival was defined as the time from cytoreductive surgery of metachronous peritoneal metastases to death or the end of the follow-up period.

RESULTS

The 5-year relapse-free survival rate was 30.0% and the 5-year overall survival rate was 72.3%. None of the patients underwent hyperthermic intraperitoneal chemotherapy. The analysis indicated no potential risk factors for 5-year relapse-free survival. However, for 5-year overall survival, the multivariate analysis revealed that time to diagnosis of metachronous peritoneal metastases of < 2 years after primary surgery (hazard ratio = 4.1, 95% confidence interval = 2.0-8.6, p = 0.0002) and number of metachronous peritoneal metastases ≥ 3 (hazard ratio = 9.8, 95% confidence interval = 2.3-42.3, p = 0.002) as independent factors associated with a poor prognosis.

CONCLUSIONS

Long intervals of more than 2 years after primary surgery and 2 or less metachronous peritoneal metastases were good selection criteria for cytoreductive surgery for metachronous peritoneal metastases from colorectal cancer.

Colorectal cancer

Despite decreased incidence rates in average-age onset patients in high-income economies, colorectal cancer is the third most diagnosed cancer in the world, with increasing rates in emerging economies. Furthermore, early onset colorectal cancer (age ≤50 years) is of increasing concern globally. Over the past decade, research advances have increased biological knowledge, treatment options, and overall survival rates. The increase in life expectancy is attributed to an increase in effective systemic therapy, improved treatment selection, and expanded locoregional surgical options. Ongoing developments are focused on the role of sphincter preservation, precision oncology for molecular alterations, use of circulating tumour DNA, analysis of the gut microbiome, as well as the role of locoregional strategies for colorectal cancer liver metastases. This overview is to provide a general multidisciplinary perspective of clinical advances in colorectal cancer.

Towards Equal Access to Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy and Survival in Patients with Isolated Colorectal Peritoneal Metastases: A Nationwide Population-Based Study

BACKGROUND

Before 2016, patients with isolated synchronous colorectal peritoneal metastases (PMCRC) diagnosed in expert centers had a higher odds of undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) and better overall survival (OS) than those diagnosed in referring centers. Nationwide efforts were initiated to increase awareness and improve referral networks.

METHODS

This nationwide study aimed to evaluate whether the between-center differences in odds of undergoing CRS-HIPEC and OS have reduced since these national efforts were initiated. All patients with isolated synchronous PMCRC diagnosed between 2009 and 2021 were identified from the Netherlands Cancer Registry. Associations between hospital of diagnosis and the odds of undergoing CRS-HIPEC, as well as OS, were assessed using multilevel multivariable regression analyses for two periods (2009-2015 and 2016-2021).

RESULTS

In total, 3948 patients were included. The percentage of patients undergoing CRS-HIPEC increased from 17.2% in 2009-2015 (25.4% in expert centers, 16.5% in referring centers), to 23.4% in 2016-2021 (30.2% in expert centers, 22.6% in referring centers). In 2009-2015, compared with diagnosis in a referring center, diagnosis in a HIPEC center showed a higher odds of undergoing CRS-HIPEC (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.02-2.67) and better survival (hazard ratio [HR] 0.80, 95% CI 0.66-0.96). In 2016-2021, there were no differences in the odds of undergoing CRS-HIPEC between patients diagnosed in HIPEC centers versus referring centers (OR 1.27, 95% CI 0.76-2.13) and survival (HR 1.00, 95% CI 0.76-1.32).

CONCLUSION

Previously observed differences in odds of undergoing CRS-HIPEC were no longer present. Increased awareness and the harmonization of treatment for PMCRC may have contributed to equal access to care and a similar chance of survival at a national level.

Neoplastic appendiceal mucinous lesions: a narrative review of the literature from an oncologist's perspective

Appendiceal mucinous lesions' classification and nomenclature has been modified several times along the last decades, reflecting their great heterogeneity and making difficult to compare results and draw conclusions. Despite its nearby origin, appendiceal mucinous lesions have a distinctive behaviour compared to colorectal cancer, including their molecular and genetic markers. Due to their low frequency, their management is not well standardised. However, surgery is considered the cornerstone of treatment. Their indolent behaviour has encouraged surgeons to apply more aggressive treatments, such as cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC), that may extend overall survival. Chemotherapy is reserved for unresectable and/or disseminated disease and could play a role in the adjuvant and neoadjuvant setting. Pressurised intraperitoneal aerosol chemotherapy (PIPAC) is recently emerging as a possible alternative for treatment in advanced disease although its results in long-term survival are lacking Hereby, we review the available evidence in the management of appendiceal mucinous lesions, including localised and disseminated disease, with a special emphasis on the oncological perspective, focusing on the lights and shadows of the systemic treatments.

Neoadjuvant treatment of colorectal cancer: comprehensive review

BACKGROUND

Neoadjuvant therapy has an established role in the treatment of patients with colorectal cancer. However, its role continues to evolve due to both advances in the available treatment modalities, and refinements in the indications for neoadjuvant treatment and subsequent surgery.

METHODS

A narrative review of the most recent relevant literature was conducted.

RESULTS

Short-course radiotherapy and long-course chemoradiotherapy have an established role in improving local but not systemic disease control in patients with rectal cancer. Total neoadjuvant therapy offers advantages over short-course radiotherapy and long-course chemoradiotherapy, not only in terms of increased local response but also in reducing the risk of systemic relapses. Non-operative management is increasingly preferred to surgery in patients with rectal cancer and clinical complete responses but is still associated with some negative impacts on functional outcomes. Neoadjuvant chemotherapy may be of some benefit in patients with locally advanced colon cancer with proficient mismatch repair, although patient selection is a major challenge. Neoadjuvant immunotherapy in patients with deficient mismatch repair cancers in the colon or rectum is altering the treatment paradigm for these patients.

CONCLUSION

Neoadjuvant treatments for patients with colon or rectal cancers continue to evolve, increasing the complexity of decision-making for patients and clinicians alike. This review describes the current guidance and most recent developments.

Data-Driven Surveillance Protocol for Patients at Risk for Peritoneal Recurrence of Primary Colon Cancer: Surveillance for Peritoneal Carcinomatosis

Peritoneal carcinomatosis (PC) is rarely discovered early due to low sensitivity of screening imaging and tumor markers, however, earlier identification may improve outcomes. This study assesses risk factors and time to recurrence of PC and implementation of a surveillance system. Patients with stage II-III colon adenocarcinoma undergoing curative colectomy between 2005-2022 were retrospectively reviewed at a single tertiary care institution. Patients were divided into three cohorts: no recurrence (NR), PC, and other types of recurrence (OTR). Baseline characteristics between cohorts were compared with univariate analysis. Overall survival and PC risk were assessed using multivariate analysis with Cox's proportional-hazard modelling. 412 patients were included; 78.4% had NR, 7.8% had PC, and 13.8% had OTR. Patient demographics, comorbidities, tumor side, and histologic features were similar between cohorts. Patients with PC were more likely to have microscopic tumor perforation (25% vs. 8.8% vs. 6.8%, p = 0.002), margin involvement (25% vs. 8.8% vs. 4.6%, p < 0.001), lymphovascular invasion (56.2% vs. 33.3%, vs. 24.5%, p < 0.001), perineural invasion (28.1% vs. 15.8% vs. 11.5%, p = 0.026) compared to OTR or NR. Median time to PC after colectomy was 11 months. Tumor characteristics of stage II-III colon cancer define a high-risk profile for PC. An early surveillance program sensitive for peritoneal disease should be adopted for these patients.

Repeat cytoreductive surgery with HIPEC for colorectal peritoneal metastases: a systematic review

BACKGROUND

Colorectal peritoneal metastases (CRPM) are present in 10-20% of patients at the time of their initial cancer diagnosis, and affects over 20% of those who develop colorectal cancer recurrence. Cytoreductive surgery (CRS) with HIPEC is firmly established as the optimal surgical treatment, but there is very little known about the benefit of repeat or iterative CRS. The aim of this review is to provide a systematic evaluation of the perioperative complications, survival outcomes and quality of life in patients undergoing repeat CRS with HIPEC for CRPM.

METHODS

A systematic review of PubMed, Ovid MEDLINE, EMBASE, Scopus and Cochrane databases was performed to identify all studies that reported outcomes for repeat CRS with or without HIPEC for CRPM.

RESULTS

Four hundred and ninety-three manuscripts were screened, and 15 retrospective studies were suitable for inclusion. Sample sizes ranged from 2 to 30 participants and comprised a total of 229 patients. HIPEC was used in all studies, but exact rates were not consistently stated. Perioperative morbidity was reported in four studies, between 16.7% and 37.5%. Nine studies reported mortality rate which was consistently 0%. The median overall survival after repeat CRS ranged from 20 to 62.6 months. No studies provided quality of life metrics.

CONCLUSION

Repeat CRS for CRPM has perioperative morbidity and mortality rates comparable to initial CRS, and offers a potential survival benefit in selected patients. There is however limited high-quality data in the literature.

International Expert Consensus on Defining Textbook Oncologic Outcomes in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Peritoneal Metastasis

BACKGROUND

Textbook oncologic outcome (TOO) is a composite metric shown to correlate with improved survival after curative intent oncologic procedures. Despite increasing use among disciplines in surgical oncology, no consensus exists for its definition in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

STUDY DESIGN

An international consensus-based study employed a Delphi methodology to achieve agreement. Fifty-four senior surgeons from the peritoneal surface malignancies field received a questionnaire comprising TOO parameters divided into 3 surgical domains: operative, short-term, and long-term postoperative outcomes. Two online meetings with participants defined the new criteria. Consensus was achieved when 75% of agreement rate was reached. Clinical data of patients who underwent CRS and HIPEC for colorectal peritoneal metastasis between 2010 and 2022 from 1 designated center (Sheba Medical Center) were collected, the consensus definition applied and outcomes analyzed.

RESULTS

Thirty-eight surgeons (70%) participated. Expert consensus TOO parameters for colorectal peritoneal metastasis CRS and HIPEC included the absence of unplanned reoperations during 30 days postoperation, absence of severe postoperative complications (Clavien-Dindo ≥III), absence of unplanned readmissions during 30 days postoperation, 90-day postoperative mortality, and absence of contraindications for chemotherapy within 12 weeks from operation, and included the achievement of complete cytoreduction (CC0). The study cohort consisted of 251 patients, and 151 (60%) met TOO criteria. Patients who achieved TOO had significantly better overall survival (median 67.5 months, 95% CI) vs patients who did not achieve TOO (median 44.6 months, 95% CI, p < 0.001) and significantly improved disease-free survival (median, 12 months, 95% CI, vs 9 months, 95% CI, p = 0.01).

CONCLUSIONS

Achievement of TOO as defined by consensus statement is associated with improved survival.

Efficacy of hyperthermic intraperitoneal chemotherapy in colorectal cancer: A phase I and III open label randomized controlled registry-based clinical trial protocol

Standard treatment for patient with peritoneal metastases from colorectal cancer is cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). In recent years, the efficacy of oxaliplatin-based HIPEC has been challenged. An intensified HIPEC (oxaliplatin+irinotecan) in combination with early postoperative intraperitoneal chemotherapy (EPIC) has shown increased recurrence-free survival in retrospective studies. The aim of this trial is to develop a new HIPEC/EPIC regimen and evaluate its effect on morbidity, oncological outcome, and quality-of-life (QoL). This study is designed as a combined phase I/III multicenter randomized trial (RCT) of patients with peritoneal metastases from colorectal cancer eligible for CRS-HIPEC. An initial phase I dose escalation study, designed as a 3+3 stepwise escalation, will determine the maximum tolerable dose of 5-Fluorouracil (5-FU) as 1-day EPIC, enrolling a total of 15-30 patients in 5 dose levels. In the phase III efficacy study, patients are randomly assigned intraoperatively to either the standard treatment with oxaliplatin HIPEC (control arm) or oxaliplatin/irinotecan-HIPEC in combination with single dose of 1-day 5-FU EPIC (experimental arm). 5-FU is administered intraoperatively after CRS-HIPEC and closure of the abdomen. The primary endpoint is 12-month recurrence-free survival. Secondary endpoints include 5-year overall survival, 5-year recurrence-free survival (registry based), postoperative complications, and QoL up to 3 years after study treatment. This phase I/III trial aims to identify a more effective treatment of colorectal peritoneal metastases by combination of HIPEC and EPIC.

Statement of the AGO Kommission Ovar, AGO Study Group, NOGGO, AGO Austria, Swiss AGO, BGOG, CEEGOG, GEICO, and SFOG regarding the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in epithelial ovarian cancer

An international joint statement about the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in ovarian cancer was published in 2016, warning about the uncritical use of HIPEC outside controlled studies. This statement has now been updated after the most recent literature was reviewed by the participating study groups and societies. HIPEC became a treatment option in patients with advanced colon cancer after positive results of a randomized trial comparing surgery and HIPEC versus palliative treatment alone. Although this trial did not compare the added value of HIPEC to surgery alone, HIPEC for the treatment of peritoneal metastases was in the subsequent years generalized to many other cancer types associated with peritoneal carcinomatosis including epithelial ovarian cancer (EOC). In the meantime, new evidence from prospective randomized trials specifically for EOC-patients emerged, with however contradicting results and several quality aspects that made the interpretation of their findings critical. Moreover, three additional trials in colorectal cancer failed to confirm the previously presumed survival benefit through the implementation of HIPEC in peritoneally disseminated colorectal cancers. Based on a still unclear and inconsistent landscape, the authors conclude that HIPEC should remain within the remit of clinical trials for EOC-patients. Available evidence is not yet sufficient to justify its broad endorsement into the routine clinical practice.

Current clinical practices of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)

Treatment of peritoneal surface malignancies makes physicians face demanding and new-fangled problems, as there are many uncertain aspects considering the outcomes of affected patients' prognoses. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are associated with favorable long-term outcomes in carefully selected patients with peritoneal metastases (PM). We aim to summarize the current results about the initial malignancies and their peritoneal spreads. The current literature has been scrutinized, and studies between 2016 and 2022 were included wherein long-term, progression-free (PFS), and overall survival (OS) data were considered relevant information. Medline, Embase, and Google Scholar have been the main sources. Hereby, we cover all the primer malignancies: gastric, ovarian, and colorectal cancers with peritoneal metastases (PM), malignant peritoneal mesothelioma, and pseudomyxoma peritonei. Examining the advances in the current peer-reviewed literature about the indications of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), target groups, risk factors, and other influencing elements, we intend to provide a complex state-of-the-art report, establishing the relevant aspects of that emerging treatment method.

[HIPEC morbidity and implications for post-surgical treatment. A medical oncologist advice]

The fear that the medical oncologist may have is that HIPEC integrated into a multidisciplinary care pathway will negatively impact the treatments that will follow. This fear is largely related to the side effects, which are themselves dependent on the medication used. Cisplatin, most frequently used for epithelial ovarian cancers, has essentially renal toxicity, which can be avoided by the use of sodium thiosulfate. Oxaliplatin induces more severe toxicities post surgery than mitomycin C in colorectal cancers. However, the data from randomized trials are reassuring for the medical oncologist concerning the course of postoperative treatment, as long as HIPEC is performed according to a standardized protocol, within trained teams, and after multidisciplinary discussion concerning its modalities.

Role of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in the Management of Colorectal Peritoneal Metastases

Peritoneal metastases from colon cancer are a particularly challenging disease process given the limited response to systemic chemotherapy. In patients with isolated peritoneal metastases, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy offers a potential treatment option to these patients with limited peritoneal metastases as long as a complete cytoreduction is achieved. Decision about a patient's candidacy for this treatment modality should be undertaken by a multidisciplinary group at expert centers.

[Contribution of intraperitoneal chemotherapy in the treatment of colorectal peritoneal carcinoma. HIPEC, PIPAC, state of the art and future directions]

After more than a decade of good results using the combination of cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal carcinosis of colorectal origin, the PRODIGE7 study, which specifically evaluated the role of HIPEC, failed to show any superiority in terms of overall and disease-free survival for the CRS+HIPEC combination compared with CRS alone. This study constituted a radical change in the knowledge and therapeutic attitudes observed to date. After reviewing the literature and the consensus of national and international experts, a synthesis is provided, together with an outlook on the questions raised and the therapeutic trials and innovations of the near future. An analysis of recent advances due to the advent of a new technique, PIPAC, is also proposed, as well as a review of current therapeutic trials in this field.

In vitro 3D microfluidic peritoneal metastatic colorectal cancer model for testing different oxaliplatin-based HIPEC regimens

Objectives

Treatment of colorectal peritoneal metastases with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is still evolving. Conducting a randomized trial is challenging due to the high heterogeneity in the presentation of peritoneal disease and various surgical approaches. Biological research may facilitate more rapid translation of information into clinical practice. There is an emerging need for a preclinical model to improve HIPEC treatment protocols in terms of drug doses and treatment durations. The aim of the study is to design a tool that serves as an in vitro three-dimensional (3D) microfluidic peritoneal metastatic colorectal cancer model to test the efficacy of different HIPEC treatments.

Methods

We determined the effects of current therapy options using a 3D static disease model on human colon carcinoma cell lines (HCT 116) and transforming growth factor-β1 induced epithelial-to-mesenchymal transition (EMT) HCT 116 lines at 37 °C and 42 °C for 30, 60, and 120 min. We determined oxaliplatin's half maximal inhibitory concentrations in a 3D static culture by using viability assay. Clinical practices of HIPEC were applied in the developed model.

Results

EMT-induced HCT 116 cells were less sensitive to oxaliplatin treatment compared to non-induced cells. We observed increased cytotoxicity when increasing the temperature from 37 °C to 42 °C and extending the treatment duration from 30 to 120 min. We found that 200 mg/m2 oxaliplatin administered for 120 min is the most effective HIPEC treatment option within the framework of clinic applications.

Conclusions

The tool map provide insights into creating more realistic pre-clinical tools that could be used for a patient-based drug screening.

Actual 5-Year Survival After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Patients with Peritoneal Carcinomatosis of Colorectal Origin

BACKGROUND

Cytoreductive surgery and heated intraperitoneal chemotherapy (CRS/HIPEC) improves survival compared with chemotherapy alone in patients with peritoneal carcinomatosis (PC) of colorectal (CRC) origin, however, long-term survival data are lacking. We report the actual survival of patients who underwent CRS/HIPEC for PC of CRC origin with a minimum potential 5-year follow-up period to identify factors that preclude long-term survival.

METHODS

We performed a retrospective analysis of a prospective database, analyzing patients undergoing CRS/HIPEC for PC of CRC origin from 2007 to 2017. Patients with aborted CRS/HIPEC, postoperative follow-up <90 days, or non-CRC histology were excluded. Overall survival (OS) and disease-free survival (DFS) were measured from date of surgery. Surviving patients with <60 months of follow-up were censored at date of last follow-up.

RESULTS

A total of 103 patients met inclusion criteria and were analyzed. CC score 0-1 was achieved in 89.3% of patients, and median peritoneal cancer index (PCI) was 9 (interquartile range [IQR] 5-17). Ninety-day mortality was 2.9%. The median follow-up of survivors was 88 months. Five-year OS was 36%, and median OS was 42.5 months. Factors independently associated with poor survival included high PCI (PCI = 14-20, hazard ratio [HR] 3.1, p = 0.007, and PCI > 20, HR 5.3, p ≤ 0.001) and incomplete CRS (CC score-2, HR 2.96, p = 0.02). Patients with low PCI (0-6) had 5-year OS 60.7%.

CONCLUSIONS

Actual 5-year OS was 36% and median OS was 42.5 months. Our study demonstrates that patients with PC from CRC origin with low PCI who undergo complete surgical resection can achieve favorable long-term survival.

Focus on RAS Codon 61 Mutations in Metastatic Colorectal Cancer: A Retrospective Analysis

RAS mutations involving codon 61 are rare in metastatic colorectal cancer (mCRC), accounting for only 1-4%, but they have recently been identified with high frequency in the circulating tumor DNA (ctDNA) of patients with secondary resistance to anti-EGFRs. This retrospective monocentric study aimed to investigate the clinical phenotype and prognostic performance of codon 61 RAS-mutated mCRC. Fifty patients with codon 61 RAS-mutated mCRC treated at our institution between January 2013 and December 2021 were enrolled. Additional datasets of codon 61 RAS wild-type mCRCs (648 patients) were used as comparators. The endpoint for prognostic assessment was overall survival (OS). Metastatic involvement of the peritoneum or ovary was significantly more frequent in codon 61 RAS-mutated mCRC compared to codon 61 RAS wild-type (54 vs. 28.5%), non-codon 61 RAS-mutated (35.6%), BRAF V600E-mutated (25%), and RAS/BRAF wild-type (20.5%) cohorts. At a median follow up of 96.2 months, the median OS for codon 61 RAS-mutated patients was significantly shorter compared to RAS/BRAF wild-type (26.9 vs. 36.0 months, HR 0.56) patients, while no significant difference was observed compared to non-codon 61 RAS-mutated and BRAF V600E-mutated patients. We showed a negative prognostic impact and a statistically significant correlation between codon 61 RAS mutations and metastatic involvement of the peritoneum and ovary.

Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for gastric cancer with intraoperative detection of limited peritoneal metastasis: a Phase II study of CLASS-05 trial

Background

Systemic chemotherapy for gastric cancer with peritoneal metastasis has limited clinical benefit; for those with intraoperative detection of occult peritoneal metastasis, cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is an alternative treatment. However, the feasibility and effects of this modality and criteria for selecting suitable groups remain unclear. This study aimed to explore the safety and efficacy of laparoscopic cytoreductive surgery (L-CRS) followed by HIPEC in gastric cancer with limited peritoneal metastasis, and this study also aimed to determine the optimized cut-off of the peritoneal cancer index.

Methods

Between March 2017 and November 2019, patients diagnosed with gastric cancer peritoneal metastases by using laparoscopy and the Sugarbaker peritoneal cancer index of ≤12 were eligible for inclusion. All patients received L-CRS (including gastrectomy with D2 lymph node dissection) and resection of visible peritoneal metastasis, followed by post-operative HIPEC, and systemic chemotherapy. The primary end points were median progression-free survival and median survival time, and the secondary outcomes were morbidity and mortality within 30 days after surgery.

Results

Thirty patients were eligible for analysis, of whom 19 (63.3%) were female, and the overall mean age was 53.0 years. The post-operative morbidity was 20% and the severe complication rate was 10%. The median survival time was 27.0 months with a 2-year overall survival rate of 52.3% and median progression-free survival was 14.0 months with a 2-year progression-free survival of 30.4%.

Conclusions

L-CRS followed by HIPEC can be safely performed for gastric cancer with limited peritoneal metastasis and potential survival benefits.