Efficacy of continuous hyperthermic peritoneal perfusion for the prophylaxis and treatment of peritoneal metastasis of advanced gastric cancer: evaluation by multivariate regression analysis

Current Evidence for the Use of HIPEC and Cytoreductive Surgery in Gastric Cancer Metastatic to the Peritoneum

Gastric cancer (GCa) is an aggressive malignancy, representing the third leading cause of cancer mortality worldwide. The poor prognosis of GCa can be associated with the prevalence of peritoneal metastasis (PM). Current international and national GCa treatment guidelines only recommend palliative treatment options for patients with PM. Since the 1980s there have been multiple single arm trials, randomized controlled trials, and metanalysis investigating the use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with advanced GCa, with or without PM. Results from these studies have been encouraging, with some large-volume centers even incorporating HIPEC into their treatment algorithms for patients with advanced GCa. Additionally, there are several ongoing trials that, when completed, will increase our understanding of the efficacy of CRS & HIPEC in patients with GCa metastatic to the peritoneum. Herein we review the current evidence, ongoing trials, consensus guidelines, and future considerations regarding the use of CRS & HIPEC in patients suffering from GCa with PM.

Hyperthermic intraperitoneal chemotherapy (HIPEC) plus systemic chemotherapy versus systemic chemotherapy alone in locally advanced gastric cancer after D2 radical resection: a randomized-controlled study

BACKGROUND

Currently, there is a lack of an effective strategy for the prevention of peritoneal metastasis (PM) from locally advanced gastric cancer (AGC). This randomized-controlled study aimed to evaluate the outcome of D2 radical resection with hyperthermic intraperitoneal chemotherapy (HIPEC) plus systemic chemotherapy versus systemic chemotherapy alone in locally AGC patients.

METHODS

All enrolled patients were randomly assigned to receive HIPEC plus systemic chemotherapy (HIPEC group) or systemic chemotherapy alone (non-HIPEC group) after radical gastrectomy. HIPEC was performed intraperitoneally with cisplatin (40 mg/m2) within 72 h after surgery, while systemic chemotherapy based on the SOX regimen (S-1 combined with oxaliplatin) was administered 4-6 weeks after radical surgery. Patterns of recurrence, adverse events, 3-year disease-free survival (DFS), and overall survival (OS) were analyzed.

RESULTS

A total of 134 patients were enrolled in the present study. The 3-year DFS rate was 73.8% in the HIPEC group, which was significantly higher than that in the non-HIPEC group (61.2%, P = 0.031). The 3-year OS rate was 73.9% in the HIPEC group and 77.6% in the non-HIPEC group, with no significant difference (P = 0.737). PM was the most common distant metastasis in both groups. The occurrence rate of PM in the HIPEC group was statistically lower than that in the non-HIPEC group (20.9% vs. 40.3%, P = 0.015). Grade 3 or 4 adverse events occurred in 19 (14.2%) patients, and there was no significant difference between the two groups.

CONCLUSION

Radical surgery followed by HIPEC combined with systemic chemotherapy is a safe and feasible strategy for locally AGC patients and could effectively improve DFS and reduce the occurrence of PM. However, more prospective randomized studies with a large sample size are warranted.

TRIAL REGISTRATION

This study was registered with www.medresman.org.cn as ChiCTR2200055966 on 10/12/2016.

Side-effects of hyperthermic intraperitoneal chemotherapy in patients with gastrointestinal cancers

Background

Hyperthermic intraperitoneal chemotherapy (HIPEC) produces unwanted side-effects that are mainly caused by chemotherapeutic drugs in the treatment of gastrointestinal (GI) cancers, and these effects have not been systematically summarized. The aim of this article was to provide a comprehensive overview of the side-effects of HIPEC for GI cancers and propose practical strategies for adverse event management.

Methodology

PubMed, Web of Science, and the Cochrane Library were systematically searched for side-effects of HIPEC in GI cancers prior to October 20, 2022. A total of 79 articles were included in this review.

Results

Adverse events, such as enterocutaneous digestive fistulas, GI tract perforation, neutropenia, postoperative bleeding, ventricular tachycardia, hyperglycemia, hypocalcemia, renal impairment, encapsulating peritoneal sclerosis, scrotal ulceration, and sarcopenia were described, and their clinical management was discussed. These side-effects involve the digestive, hematopoietic, circulatory, metabolic, and urinary systems. Effective methods for adverse event management included an expert multidisciplinary team, replacing chemotherapy drugs, using Chinese medicine, and careful preoperative assessments.

Conclusion

The side-effects of HIPEC are frequent and can be minimized by several effective methods. This study proposes practical strategies for adverse event management of HIPEC to assist physicians in choosing the optimal treatment method.

Impact of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy in the Treatment of Gastric Cancer with Peritoneal Carcinomatosis: A Systematic Review and Meta-analysis

BACKGROUND

Despite promising results, the effectiveness of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with gastric cancer with peritoneal carcinomatosis (GCPC) has not been systematically evaluated. The aim of this systematic review is to compare the survival, complications and risk of recurrence between CRS + HIPEC versus CRS alone in GCPC.

PATIENTS AND METHODS

A systematic review was performed in MEDLINE and Web of Science according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Primary studies with patients with GCPC older than 18 years were included. Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess the quality of the studies. We performed random-effects meta-analysis of risk ratios (RR). We assessed heterogeneity using the I² statistic.

RESULTS

Five studies were included in the qualitative and four in the quantitative analysis. The overall survival (OS) rate after 1 year was 3.65 times higher for CRS + HIPEC than CRS alone [RR = 3.65, 95% confidence interval (95% CI) = 1.01-13.26, I² = 73%]. The OS rate after 5 years was more than three times higher for CRS + HIPEC than for CRS alone (RR = 3.25, 95% CI = 1.28-8.26, I² = 8%). No significant differences between CRS + HIPEC and CRS alone related to complications were found (RR = 1.05, 95% CI = 0.83-1.33, I² = 0%). The risk of peritoneal recurrence was significantly lower for CRS + HIPEC than for CRS alone (RR = 0.23, 95% CI = 0.11-0.48, I² = 40%). The results may be associated with some information or indication bias.

CONCLUSIONS

Results should be analysed cautiously given the detected heterogeneity and limitations of included studies. However, treatment with CRS + HIPEC seems to increase the survival of patients with GCPC, more than treatment with CRS alone, decrease the risk of peritoneal recurrence and not be associated with more complications.

Role of prophylactic HIPEC in non-metastatic, serosa-invasive gastric cancer: a literature review

The role of prophylactic hyperthermic intraperitoneal chemotherapy (p-HIPEC) in serosa invasive gastric cancers without gross or microscopic peritoneal disease, to reduce the rate of peritoneal relapse is an area of ongoing research. Although p-HIPEC is effective in reducing the rate of peritoneal relapse and improving disease free and overall survival with or without adjuvant chemotherapy, when added to curative surgery in locally advanced, non-metastatic gastric cancers, the available literature is at best, heterogeneous, centre-specific and skewed. Apart from that, variations in the systemic therapy used, and the presence of the associated nodal disease further complicate this picture. To evaluate the role of p-HIPEC the PubMed, Cochrane central register of clinical trials, and the American Society of Clinical Oncology (ASCO) meeting library were searched with the search terms, “gastric”, “cancer”, “hyperthermic”, “intraperitoneal”, “chemotherapy”, prophylactic”, “HIPEC” in various combinations, and a critical review of the available evidence was done. Although p-HIPEC is a promising therapy in the management of locally advanced gastric cancers, the current evidence is insufficient to recommend its inclusion into routine clinical practice. Future research should be directed towards identification of the appropriate patient subset and towards redefining its role with current peri-operative systemic therapies.

Current role for cytoreduction and HIPEC for gastric cancer with peritoneal disease

Gastric cancer (GC) is an aggressive malignancy with a high burden of peritoneal disease. Evidence regarding the use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) to improve outcomes has been growing. However, given multiple limitations, there remains a lack of international consensus regarding the optimal treatment paradigm. This review article discusses the burden of peritoneal disease in GC patients and the role of CRS + HIPEC in all treatment intents—curative, prophylactic, and palliative.

Tumor Mutational Burden Associated With Response to Hyperthermic Intraperitoneal Chemotherapy

Background

Gastric cancer (GC) is one of the most common cancer types, especially in Asian countries. Hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to improve the progression-free survival among gastric cancer patients with peritoneal metastases; however, not all patients demonstrate response to HIPEC.

Methods

Biomarkers are needed to select patients for effective treatment of HIPEC. Here, we performed whole-exome sequencing on tumor samples from 18 gastric cancer patients who received HIPEC treatment and assessed the association between genomic mutation features and progression-free survival. Exome sequencing was further conducted on tumor samples from additional 15 gastric cancer patients as a replication study.

Results

The tumor mutational burden (TMB) was significantly higher in the group of patients with a better response to HIPEC treatment than that of the others. Kaplan–Meier survival curve showed that patients with high TMB had a significantly longer survival time than that in patients with low TMB. This discovery was validated in the replication cohort. Genes bearing mutations recurrently and selectively in patients with better response to HIPEC were found in the two cohorts.

Conclusion

We found that higher TMB is significantly associated with better response to HIPEC. Our results provide useful hints for prognostic stratification of HIPEC treatment.

Prophylactic hyperthermic intraperitoneal chemotherapy may benefit the long-term survival of patients after radical gastric cancer surgery

Hyperthermic intraperitoneal chemotherapy (HIPEC) has been proven to improve the survival rate of gastric cancer and reduce peritoneal recurrence. We aimed to evaluate the effectiveness and safety of prophylactic HIPEC after radical gastric cancer surgery in this study. Researchers searched for studies published in PubMed, Embase, Web of science, Scopus, Cochrane, Clinical key databases and Microsoft Academic databases to identify studies that examine the impact of prophylactic HIPEC on the survival, recurrence and adverse events of patients undergoing radical gastric cancer surgery. RevMan 5.3 was used to analyze the results and risk of bias. The PROSERO registration number is CRD42021262016. This meta-analysis included 22 studies with a total of 2097 patients, 12 of which are RCTs. The results showed that the 1-, 3- and 5-year overall survival rate was significantly favorable to HIPEC (OR 5.10, 2.07, 1.96 respectively). Compared with the control group, the overall recurrence rate and peritoneal recurrence rate of the HIPEC group were significantly lower (OR 0.41, 0.24 respectively). Significantly favorable to the control group in terms of renal dysfunction and pulmonary dysfunction complications (OR 2.44, 6.03 respectively). Regarding the causes of death due to postoperative recurrence: liver recurrence, lymph node and local recurrence and peritoneal recurrence, the overall effect is not significantly different (OR 0.81, 1.19, 0.37 respectively). 1-, 3- and 5-year overall survival follow-up may be incremented by the prophylactic HIPEC, and which reduce the overall recurrence rate and peritoneal recurrence rate. HIPEC may have high-risk of pulmonary dysfunction and renal dysfunction complications. No difference has been found in the deaths due to recurrence after surgery.

Effect of HIPEC on Peritoneal Recurrence in Peritoneal Metastasis Treated With Cytoreductive Surgery: A Systematic Review

BACKGROUND

Peritoneal metastasis (PM) is a late-stage manifestation of intra-abdominal malignancies. The current standard of care indicates that cure can only be achieved with cytoreductive surgery (CRS) which is often indicated with concurrent adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC). However, the utility of HIPEC within subsets of PM is not fully understood. We seek to compare the effectiveness of HIPEC in improving peritoneal recurrence rates in PM of different origins.

METHODS

We conducted a systematic review of trials on the PubMed, EMBASE, and Cochrane databases, last searched in August 2021. Biases were assessed using the Cochrane Collaboration's tool for assessing the risk of bias in randomized trials as well as the Methodological Index for Non-Randomized Studies (MINORS) framework.

RESULTS

7 gastric PM studies, 3 ovarian PM studies, and 3 colorectal PM studies were included. Recurrence-free survival was improved in the HIPEC + CRS cohort in 5 gastric trials but only 1 ovarian trial and none of colorectal origin.

DISCUSSION

Our findings indicate decent effectiveness of HIPEC in gastric PM, but limited utility in ovarian and colorectal PM. Limitations in the current literature are attributed to the paucity of data available, a lack of homogeneity and consideration of novel and personalised treatment regimens. We implore for further studies to be conducted with a focus on patient selection and stratification, and suggest a reframing of approach towards modern molecular and targeted therapeutic options in future studies of HIPEC.

SYSTEMATIC REVIEW REGISTRATION

https://www.researchregistry.com/browse-the-registry#registryofsystematicreviewsmeta-analyses/registryofsystematicreviewsmeta-analysesdetails/60c1ffff0c1b78001e8efbe3/, identifier reviewregistry1166.

Study Protocol: Phase I Dose Escalation Study of Oxaliplatin, Cisplatin and Doxorubicin Applied as PIPAC in Patients with Peritoneal Metastases

Pressurized Intra-Peritoneal Aerosol Chemotherapy (PIPAC) is a novel laparoscopic intraperitoneal chemotherapy approach offered in selected patients affected by non-resectable peritoneal carcinomatosis. Drugs doses currently established for nebulization are very low: oxaliplatin (OXA) 120 mg/sm, cisplatin (CDDP) 10.5 mg/sm and doxorubicin (DXR) 2.1 mg/sm. A model-based approach for dose-escalation design in a single PIPAC procedure and subsequent dose escalation steps is planned. The starting dose of oxaliplatin is 100 mg/sm with a maximum estimated dose of 300 mg/sm; an escalation with overdose and under-dose control (for probability of toxicity less than 16% in case of under-dosing and probability of toxicity greater than 33% in case of overdosing) will be further applied. Cisplatin is used in association with doxorubicin: A two-dimensional dose-finding design is applied on the basis of the estimated dose limiting toxicity (DLT) at all combinations. The starting doses are 15 mg/sm for cisplatin and 3 mg/sm for doxorubicin. Safety is assessed according to Common Terminology Criteria for Adverse Events (CTCAE version 4.03). Secondary endpoints include radiological response according to Response Evaluation Criteria in Solid Tumor (version 1.1) and pharmacokinetic analyses. This phase I study can provide the scientific basis to maximize the optimal dose of cisplatin, doxorubicin and oxaliplatin applied as PIPAC.

Intraperitoneal chemotherapy in the treatment of gastric cancer peritoneal metastases: an overview of common therapeutic regimens

Peritoneal metastasis (PM) have an incidence of 10-20% in patients with gastric cancer (GC), and even up to 40% in patients with UICC Stage III GC. Due to the aggressive characteristic of adenocarcinoma of the stomach, GC is the third leading cause of cancer deaths worldwide. For GC with PM, the treatment of choice is according to national and international guidelines systemic chemotherapy, combined with biologic therapy against specific receptor antigen in with overexpression, such as HER-2. Multimodal treatment regimens including intraperitoneal application of chemotherapy and cytoreductive surgery (CRS) have been investigated and established all over the world. Driven by pharmacological studies and thoughts considering the increased benefits of cytotoxic agents used in the abdominal cavity, several drugs and drug combinations are widely used. In order to standardize treatment protocols, it is crucial to differentiate between normothermic and hyperthermic intraperitoneal chemotherapy (NIPEC, HIPEC). The requirements of an ideal cytotoxic drug different obviously dependent on its application method. Because of their high molecular weight and lipophilic structure, taxanes, such as paclitaxel or docetaxel have a long intraperitoneal retention time and are commonly used in NIPEC, while platin derivates, such as carboplatin or oxaliplatin are known for their synergistic effect to heat and are chosen in HIPEC. This review aims to explore and summarize different intraperitoneal treatment regimens strictly evaluated by supporting evidence in an effort to consolidate many regimens to a few evidence-based treatment protocols that deserve further investigation and distribution. This analysis included all studies focusing on intraperitoneal chemotherapy: Phase II, Phase III trials and non-randomized retrospective trials of larger cohorts of patients with GC and established PM or risk of PM. Interestingly, the protocols for NIPEC are quite uniform, with less variation between the therapeutic components in contrast to the different HIPEC protocols. This difference might be explained by the divergent evolution of NIPEC and HIPEC, as the former exclusively originated in Japan, while HIPEC experienced a more multicentric evolution and distribution in the United States, Asia, Europe, and worldwide utilization today.

Intra-operative hyperthermic intraperitoneal chemotherapy for prevention and treatment of peritoneal metastases from gastric cancer: a narrative review

Peritoneal metastasis (PM) from gastric cancer (GC) has long been regarded as the terminal disease, lacking of effective treatments. In recent 40 years, cytoreductive surgery (CRS) plus perioperative intraperitoneal chemotherapy, including hyperthermic intraperitoneal chemotherapy (HIPEC), neoadjuvant intraperitoneal and systemic chemotherapy (NIPS), and early post-operative intraperitoneal chemotherapy (EPIC), has been recommended as a preferred treatment option for some selected patients with GCPM. Intraperitoneal free cancer cells were recognized as the pathological cause of PM and the primary target for intraperitoneal chemotherapy. There were a lot of evidence demonstrating that HIPEC could effectively eradiate intraperitoneal free cancer cells and prolong overall survival in GCPM. However, there are still no standard HIPEC protocols. This review summarized the current HIPEC regimens used in GCPM from a literature search, trying to conclude the optimal HIPEC in GCPM, and indicate the future direction of HIPEC study. Moreover, the new data on the exploration of HIPEC in GCPM at Shijitan Hospital, Capital Medical University was shared. In conclusion, there was not enough evidence from publications and our own experience to conclude a recommended HIPEC regimen for GCPM. There is urgent need for standardizing HIPEC protocols worldwide. Accordingly, more international collaborations focusing on pharmacology and HIPEC-related parameters to generate high level evidence are essential.

A Phase I Dose Escalation Study of Oxaliplatin, Cisplatin and Doxorubicin Applied as PIPAC in Patients with Peritoneal Carcinomatosis

Simple Summary

This study is one of the very few phase I trials on intraperitoneal chemotherapy applied as PIPAC. Cisplatin and doxorubicin may be safely used as PIPAC at a dose of 30 mg/m² and 6 mg/m², respectively; oxaliplatin can be used at an intraperitoneal dose of 135 mg/m². No serious adverse event was reported. The dosages achieved to date are the highest ever used in PIPAC. The results of these investigations should be the starting point for further clinical phase II trials regarding repeated PIPAC, possibly associated with systemic chemotherapy.

Abstract

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is an innovative laparoscopic intraperitoneal chemotherapy approach with the advantage of a deeper tissue penetration. Thus far, oxaliplatin has been administered at an arbitrary dose of 92 mg/m², cisplatin at 7.5 mg/m² and doxorubicin 1.5 mg/m². This is a model-based approach phase I dose escalation study with the aim of identifying the maximum tolerable dose of the three different drugs. The starting dose of oxaliplatin was 100 mg/m²; cisplatin was used in association with doxorubicin: 15 mg/m² and 3 mg/m² were the respective starting doses. Safety was assessed according to Common Terminology Criteria for Adverse Events (CTCAE version 4.03). Thirteen patients were submitted to one PIPAC procedure. Seven patients were treated with cisplatin and doxorubicin and 6 patients with oxaliplatin; no dose limiting toxicities and major side effects were found. Common adverse events included postoperative abdominal pain and nausea. The maximum tolerable dose was not reached. The highest dose treated cohort (oxaliplatin 135 mg/m²; cisplatin 30 mg/m² and doxorubicin 6 mg/m²) tolerated PIPAC well. Serological analyses revealed no trace of doxorubicin at any dose level. Serum levels of cis- and oxaliplatin reached a peak at 60–120 min after PIPAC and were still measurable in the circulation 24 h after the procedure. Cisplatin and doxorubicin may be safely used as PIPAC at a dose of 30 mg/m² and 6 mg/m², respectively; oxaliplatin can be used at an intraperitoneal dose of 135 mg/m². The dosages achieved to date are the highest ever used in PIPAC.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer

The management of peritoneal metastases from gastric cancer origin has evolved considerably over the last three decades with the establishment of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) as efficacious therapies in carefully selected patients. Other approaches such as the use of prophylactic/adjuvant HIPEC in patients who are considered high-risk and those with positive peritoneal cytology will benefit from additional data before being adopted into routine clinical practice. Lastly, there are new and emerging intraperitoneal chemotherapy techniques such as early post-operative intraperitoneal chemotherapy (EPIC) for residual microscopic disease, and pressurized intraperitoneal aerosolized chemotherapy (PIPAC) for patients with advanced unresectable peritoneal carcinomatosis, which are currently under evaluation in clinical trials. The following review outlines the natural history of gastric cancer, currently available neoadjuvant and adjuvant therapies for resectable disease, and existing evidence supporting various approaches to CRS and intraperitoneal chemotherapy.

Prophylactic Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Gastric Cancer-A Systematic Review

Survival after potentially curative treatment of gastric cancer remains low, mostly due to peritoneal recurrence. This descriptive review gives an overview of available comparative studies concerning prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with gastric cancer with neither clinically evident metastases nor positive peritoneal cytology who undergo potentially curative gastrectomy. After searching the PubMed, Embase, CDSR, CENTRAL and ASCO meeting library, a total of 11 studies were included comparing surgery plus prophylactic HIPEC versus surgery alone (SA): three randomised controlled trials and eight non-randomised comparative studies, involving 1145 patients. Risk of bias was high in most of the studies. Morbidity after prophylactic HIPEC was 17-60% compared to 25-43% after SA. Overall survival was 32-35 months after prophylactic HIPEC and 22-28 months after SA. The 5-year survival rates were 39-87% after prophylactic HIPEC and 17-61% after SA, which was statistically significant in three studies. Peritoneal recurrence occurred in 7-27% in the HIPEC group, compared to 14-45% after SA. This review tends to demonstrate that prophylactic HIPEC for gastric cancer can be performed safely, may prevent peritoneal recurrence and may prolong survival. However, studies were heterogeneous and outdated, which emphasizes the need for well-designed trials conducted according to current standards.

Management of Peritoneal Malignancies

Peritoneal malignancies may result in a widespread disease process, peritoneal carcinomatosis (PC), which has significant morbidity and mortality for patients afflicted by this disease. Dissemination into the peritoneum and throughout the abdomen can be due to a primary peritoneal cancer or other primary malignancies that have metastasized, including (but not limited to) colorectal cancer, gastric cancer, pancreatic cancer, appendiceal cancer, ovarian cancer, and mesothelioma. Patients with gastrointestinal (GI) or gynecologic malignancies with peritoneal carcinomatosis may have dismal survival due to a high disease burden within the abdominal cavity. Some studies suggest the average survival for patients with peritoneal carcinomatosis of colorectal origin is 18–48 months, for high-grade appendiceal adenocarcinoma 12–36 months, and for low-grade appendiceal neoplasms >60 months. As the understanding of peritoneal malignancies and peritoneal carcinomatosis evolved, it may now be acceptable to treat this as locoregional disease.

Implications of clinical research on adjuvant chemotherapy for gastric cancer: Where to go next?

Postoperative adjuvant chemotherapy (ACT) confers superior gastric cancer (GC) survival in the Eastern cohort. However, is the current standard of ACT already excessive, or is it still necessary to increase its intensity for specific subgroups? Tailored ACT strategies for GC depend on gradual exploration by clinical trials in selected patients. Thus, understanding the implications of previous and current research can help us respond wisely and design effective, rational trials, save medical resources and make better decisions in clinical practice. After reviewing and analyzing studies on ACT for GC patients undergoing curative resection, we found that research strategies for conducting “addition” ACT for specific stages of the disease have achieved great progress in making ACT more tailored and personalized in consideration of pathology stages. Furthermore, trials indicate that “addition” ACT strategies for GC patient subgroups based on histological characteristics might be helpful to move toward a more specific tailored and personalized management approach. Designing ACT research focused on different node statuses should also be conducted according to the biological specificity of lymph node (LN) metastasis. Therefore, future trials designed to determine tailored treatment based on histological and biological characteristics for specific subgroups are urgently needed and conducted as the theme of the 2019 American Society of Clinical Oncology (ASCO): Caring for Every Patient, Learning from Every Patient.

Current status and future prospects of clinical trials on CRS + HIPEC for gastric cancer peritoneal metastases

PURPOSE

There is no standard treatment for peritoneal metastases (PM) from gastric cancer (GC). The aim of this review is to evaluate the clinical trials on cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for GC PM.

MATERIALS AND METHODS

The published clinical trials on CRS + HIPEC for GC PM are critically evaluated, and survival and safety are the primary endpoints. In addition, the registered ongoing clinical trials are summarised.

RESULTS

The natural course of GC PM is <5 months. CRS + HIPEC could improve the overall survival (OS). In prospective studies, the median OS was 11.0 months in the CRS + HIPEC group vs. 5.4 months in the CRS alone group. In case-control studies, the median OS was 13.3 months in the CRS + HIPEC group vs. 7.9 months in the CRS alone group. In cohort studies, the median OS after CRS + HIPEC was 13.3. The median 1-, 2- and 5-year survival rates after CRS + HIPEC were 50.0%, 35.8% and 13.0%, respectively. There is no statistically significant increase in serious adverse events that are directly attributed to CRS + HIPEC.

CONCLUSIONS

The combination of CRS and HIPEC is a promising integrated treatment strategy for GC PM that has encouraging initial results, calling for urgent further evaluation of this strategy in randomised control trials (RCTs).

Applications of hyperthermic intraperitoneal chemotherapy for metastatic colorectal cancer

INTRODUCTION

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) plays a pivotal role in the current treatment of peritoneal carcinomatosis (PC) from colorectal cancer (CRC). Since the first demonstration, benefits for patients and especially an increase in survival have been described. In recent years, feasibility, efficacy and safety of HIPEC have been improved and progress has been made in understanding its oncological mechanism. Areas covered: In this article, leading publications have been reviewed including clinical trials to describe the clinical presentation of PC due to CRC and present recent evidence of the CRS/HIPEC procedure. The surgical approach including evaluation of the extent of PC is described and, in addition, the article reports about different HIPEC techniques as well as several protocols. Furthermore, the development and prognostic benefit of the combination of intraperitoneal and intravenous chemotherapy are outlined. Consideration has been given in particular to patient selection and the use of HIPEC if complete cytoreduction is not feasible. Expert commentary: The CRS/HIPEC procedure represents a curative approach to treat patients with PC from CRC. However, surgical skills and the HIPEC technique still require specialized oncological centers.

The 30-year experience-A meta-analysis of randomised and high-quality non-randomised studies of hyperthermic intraperitoneal chemotherapy in the treatment of gastric cancer

IMPORTANCE

Hyperthermic intraperitoneal chemotherapy (HIPEC) has been used within various multimodality strategies for the prevention and treatment of gastric cancer peritoneal carcinomatosis.

OBJECTIVE

To systematically evaluate the role of HIPEC in gastric cancer and clarify its effectiveness at different stages of peritoneal disease progression.

DATA SOURCES

Medline and Embase databases between January 1, 1985 and June 1, 2016.

STUDY SELECTION

Randomised control trials and high-quality non-randomised control trials selected on a validated tool (methodological index for non-randomised studies) comparing HIPEC and standard oncological management for the treatment of advanced stage gastric cancer with and without peritoneal carcinomatosis were considered.

DATA EXTRACTION AND SYNTHESIS

A random-effects network meta-analysis.

MAIN OUTCOMES AND MEASURES

The primary outcomes were overall survival and disease recurrence. Secondary outcomes were overall complications, type of complications, and sites of recurrence.

RESULTS

A total of 11 RCTs and 21 non-randomised control trials (2520 patients) were included. For patients without the presence of peritoneal carcinomatosis (PC), the overall survival rates between the HIPEC and control groups at 3 or 5 years resulted in favour of the HIPEC group (risk ratio [RR] = 0.82, P = 0.01). No difference in the 3-year overall survival (RR = 0.99, P = 0.85) in but a prolonged median survival of 4 months in favour of the HIPEC group (WMD = 4.04, P < 0.001) was seen in patients with PC. HIPEC was associated with significantly higher risk of complications for both patients with PC (RR = 2.15, P < 0.01) and without (RR = 2.17, P < 0.01). This increased risk in the HIPEC group was related to systemic drugs toxicity. Anastomotic leakage rates were found to be similar between groups.

CONCLUSIONS

Our study demonstrates a survival advantage of the use of HIPEC as a prophylactic strategy and suggests that patients whose disease burden is limited to positive cytology and limited nodal involvement may benefit the most from HIPEC. For patients with extensive carcinomatosis, the completeness of cytoreductive surgery is a critical prognostic factor for survival. Future RCTs should better define patient selection criteria.

Patterns of Initial Recurrence in Gastric Adenocarcinoma in the Era of Preoperative Therapy

BACKGROUND

We sought to determine the sites of recurrence and identify predicting factors for recurrence and survival in patients who underwent gastrectomy for adenocarcinoma at an institution where preoperative therapy is commonly used for advanced gastric cancer.

METHODS

We collected clinicopathologic data and sites of recurrence from a prospectively maintained database of patients who underwent potentially curative resection of gastric or gastroesophageal adenocarcinoma at our institution in 1995-2014, and we assessed associations between these characteristics and recurrence patterns and survival.

RESULTS

We identified 488 patients who underwent R0 resection of localized gastric cancer. The median age was 63 years (interquartile range 53-71 years), and 60% were male. The most common T and N categories, per endoscopic ultrasonography, were T3 (58%) and N0 (61%). Preoperative treatment was used in 61% of patients. A total of 125 (26%) patients experienced recurrence during follow-up. Recurrences were locoregional in 19 patients (15%), peritoneal in 61 (49%), and nonperitoneal distant in 67 (54%). The peritoneum also was the most common organ of recurrence (49%), followed by the liver (21%). The median time from primary resection to recurrence was 2.7 years for locoregional, 1.3 years for peritoneal, and 0.6 years for nonperitoneal distant recurrence (p = 0.01). Median overall survival was markedly shorter after peritoneal and nonperitoneal distant recurrences than after locoregional recurrences.

CONCLUSIONS

The peritoneum was a common site of recurrence after curative resection of gastric cancer and was associated with poor survival. Prophylactic treatment targeting the peritoneal cavity might improve survival of advanced gastric cancer.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in treatment of gastric cancer with peritoneal carcinomatosis

Although gastric cancer with peritoneal carcinomatosis is associated with poor prognosis and is generally treated with palliative systemic therapy, recent studies have shown that cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may prove to be an efficacious treatment option. In addition to reviewing the natural history of gastric cancer with peritoneal carcinomatosis, this mini-review examines literature on the efficacy of CRS and HIPEC as compared to chemotherapy and surgical options. Both randomized and non-randomized studies were summarized with the emphasis focused on overall survival. In summary, CRS and HIPEC are indeed a promising treatment option for gastric cancer with peritoneal carcinomatosis and large randomized clinical trials are warranted.

Adjuvant intraperitoneal chemotherapy for the treatment of gastric cancer at risk for peritoneal carcinomatosis: A systematic review

The peritoneal surface is a frequent site of recurrence following surgery for gastric cancer. A systematic review and random effect analysis was undertaken to analyze current literature regarding the role of adjuvant intraperitoneal chemotherapy in gastric cancer. While pooled analysis supports the use of adjuvant IP chemotherapy in resectable gastric cancer, maximal benefit occured with intra-operative delivery, and possibly the use of MMC. J. Surg. Oncol. 2017;115:192-201. © 2016 Wiley Periodicals, Inc.

Intraperitoneal free cancer cells in gastric cancer: pathology of peritoneal carcinomatosis and rationale for intraperitoneal chemotherapy/hyperthermic intraperitoneal chemotherapy in gastric cancer

Peritoneal carcinomatosis (PC) is one of the most common causes of death in gastric cancer patients. Intraperitoneal free cancer cells (IFCCs) play a very important role in forming PC, but the administration of intraperitoneal chemotherapy (IPC) and/or hyperthermic intraperitoneal chemotherapy (HIPEC) could be an effective treatment for IFCCs. This review focuses on the origin of IFCCs, the mechanism of PC formatting, the rationale of IPC/HIPEC, and the current clinical trials on IPC/HIPEC to treat advanced gastric cancer patients.

Survival outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis from gastric cancer: a systematic review

Background: The current treatment of choice for peritoneal carcinomatosis from gastric cancer is systemic chemotherapy. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a new aggressive form of loco-regional treatment that is currently being used in pseudomyxoma peritoneii, peritoneal mesothelioma and peritoneal carcinomatosis from colorectal cancer. It is still under investigation for its use in gastric cancer. Methods: The literature between 1970 and 2016 was surveyed systematically through a review of published studies on the treatment outcomes of CRS and HIPEC for peritoneal carcinomatosis from gastric cancer. Results: Seventeen studies were included in this review. The median survival for all patients ranged from 6.6 to 15.8 months. The 5-years overall survival ranged from 6 to 31%. For patients with complete cytoreduction, the median survival was 11.2 to 43.4 months and the 5-years overall survival was 13 % to 23%. Important prognostic factors were found to be a low peritoneal carcarcinomatosis index (PCI) score and the completeness of cytoreduction. Conclusion: The current evidence suggests that CRS and HIPEC has a role to play in the treatment of peritoneal carcinomatosis from gastric cancer. Long term survival has been shown for a select group of patients. However, further studies are needed to validate these results.

The Role of Hyperthermic Intraperitoneal Chemotherapy in Gastric Cancer

Peritoneal metastasis, either synchronous or metachronous, is commonly seen in gastric cancer. It is associated with a poor prognosis, with a median survival of less than one year. The outcomes are not significantly improved by the use of systemic chemotherapy. We review the relevant literature on the role of HIPEC in gastric cancer. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been used in three situations in gastric cancer. Besides its role as a definitive treatment in patients with established peritoneal metastasis (PM), it has been used as a prophylaxis against peritoneal recurrence after curative surgery and also as a palliative treatment in advanced peritoneal metastasis with intractable ascites. While prophylactic HIPEC has been shown to reduce peritoneal recurrence and improve survival in many randomised trials, palliative HIPEC can reduce the need for frequent paracentesis. Although CRS with HIPEC has shown promise in increasing the survival of selected patients with established PM from gastric cancer, larger studies are needed before this can be accepted as a standard of care.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in gastric cancer

Gastric cancer associated peritoneal carcinomatosis (GCPC) has a poor prognosis with a median survival of less than one year. Systemic chemotherapy including targeted agents has not been found to significantly increase the survival in GCPC. Since recurrent gastric cancer remains confined to the abdominal cavity in many patients, regional therapies like aggressive cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been investigated for GCPC. HIPEC has been used for three indications in GC- as an adjuvant therapy after a curative surgery, HIPEC has been shown to improve survival and reduce peritoneal recurrences in many randomised trials in Asian countries; as a definitive treatment in established PC, HIPEC along with CRS is the only therapeutic modality that has resulted in long-term survival in select groups of patients; as a palliative treatment in advanced PC with intractable ascites, HIPEC has been shown to control ascites and reduce the need for frequent paracentesis. While the results of randomised trials of adjuvant HIPEC from western centres are awaited, the role of HIPEC in the treatment of GCPC is still evolving and needs larger studies before it is accepted as a standard of care.

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) with Low-Dose Cisplatin and Doxorubicin in Gastric Peritoneal Metastasis

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel technique of intraperitoneal chemotherapy. First results obtained with PIPAC in patients with advanced peritoneal metastasis (PM) from gastric cancer (GC) are presented.

METHODS

Retrospective analysis: Sixty PIPAC were applied in 24 consecutive patients with PM from GC. 67 % patients had previous surgery, and 79 % previous platinum-based systemic chemotherapy. Mean Peritoneal Carcinomatosis Index (PCI) of 16 ± 10 and 18/24 patients had signet-ring GC. Cisplatin 7.5 mg/m(2) and doxorubicin 1.5 mg/m(2) were given for 30 min at 37 °C and 12 mmHg at 6 week intervals. Outcome criteria were survival, adverse events, and histological tumor response.

RESULTS

Median follow-up was 248 days (range 105-748), and median survival time was 15.4 months. Seventeen patients had repeated PIPAC, and objective tumor response was observed in 12 (12/24 = 50 %): no vital tumor cells = 6, major pathological response = 6, minor response = 3. Postoperative adverse events > CTCAE 2 were observed in 9 patients (9/24, 37.5 %). In 3/17 patients, a later PIPAC could not be performed due to non-access. Two patients (ECOG 3 and 4) died in the hospital due to disease progression.

CONCLUSION

PIPAC with low-dose cisplatin and doxorubicin was safe and induced objective tumor regression in selected patients with PM from recurrent, platinum-resistant GC. First survival data are encouraging and justify further clinical studies in this indication.

Selection of chemotherapy for hyperthermic intraperitoneal use in gastric cancer

PURPOSE

Several studies have shown the potential benefit of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in gastric cancer patients. At present the most effective chemotherapeutic regime in HIPEC for gastric cancer is unknown. The aim of this review was to provide a comprehensive overview of chemotherapeutic agents used for HIPEC in gastric cancer.

METHODS

A literature search was conducted using the PubMed database to identify studies on chemotherapy used for HIPEC in gastric cancer patients.

RESULTS AND CONCLUSION

The chemotherapeutic regime of choice in HIPEC for gastric cancer has yet to be determined. The wide variety in studies and study parameters, such as chemotherapeutic agents, dosage, patient characteristics, temperature of perfusate, duration of perfusion, carrier solutions, intraperitoneal pressure and open or closed perfusion techniques, warrant more experimental and clinical studies to determine the optimal treatment schedule. A combination of drugs probably results in a more effective treatment.

Peritoneal carcinomatosis in patients with gastric cancer, and the role for surgical resection, cytoreductive surgery, and hyperthermic intraperitoneal chemotherapy

BACKGROUND

The aims of this study were to create a model of peritoneal carcinomatosis in patients with gastric cancer and to evaluates outcomes in patients with gastric cancer treated using surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A single-institution cohort of patients with gastric cancer was analyzed according to the development of gastric cancer with peritoneal carcinomatosis (GCPC). Variables were evaluated using regression analysis. Kaplan-Meier analysis was used to evaluate outcomes after surgical resection, cytoreductive surgery, and HIPEC.

RESULTS

Age ≤60 years and local tumor stage (T3/T4) were significantly associated with GCPC (odds ratio, 3.95 and 3.94, respectively). Thirty-six-month survival was 57% for patients without peritoneal disease and 39% for patients with GCPC. There was no significant trend of improved survival after surgical management or HIPEC.

CONCLUSIONS

Age ≤60 years and T3/T4 tumor stage are risk factors for GCPC. Intermediate-term survival of patients with GCPC treated with surgical resection or cytoreductive surgery and HIPEC was not improved, though future research should address the possible benefits of aggressive approaches to the treatment of GCRC.

Benefits of hyperthermic intraperitoneal chemotherapy for patients with serosal invasion in gastric cancer: a meta-analysis of the randomized controlled trials

Background

In this meta-analysis we aimed to determine the effectiveness and safety of hyperthermic intraperitoneal chemotherapy (HIPC) for patients with advanced gastric cancer who underwent gastrectomy.

Methods

In accordance with standard meta-analysis procedures, our study included patients who underwent resection for advanced gastric cancer and were randomly allocated to receive either hyperthermic intraperitoneal chemotherapy or control. We searched PubMed (up to November 2011), EMBASE (up to November 2011), Cochrane Database of Systematic Reviews (CDSR), and Cochrane Central Register of Controlled Trials (CCTR) (up to November 2011). Both published and unpublished trials were included in the analysis, and no search restrictions were imposed. There was no language restriction. The results were analyzed using RevMan 5.1 software, which was provided by Cochrane Collaboration.

Results

There were ten randomized controlled trials included in the analysis. A total of 1062 patients with gastric cancer in these studies were divided into the HIPC group (n = 518) and control group (n = 544). A significant improvement in survival was observed in the HIPC groups compared to the control group in the mitomycin C (MMC) subgroup (RR = 0.75, 95%CI 0.65-0.86; P < 0.00001) and the 5-FU group (RR = 0.69, 95%CI 0.52-0.90; P < 0.00001); the total RR was 0.73 (95%CI 0.64-0.83; P < 0.00001). Our findings indicated that HIPC potentially exhibited a lower peritoneal recurrence rate in the HIPC group compared to the control group (RR = 0.45, 95%CI 0.28-0.72; P = 0.001).

Conclusions

Our meta-analysis demonstrated that HIPC may improve the overall survival rate for patients who receive resection for advance gastric cancer potentially, and help to prevent peritoneal local recurrence among patients with serosal invasion in gastric cancer.

[Morbidity and mortality in a series of patients suffering from intraperitoneal neoplasia treated with peritoneal cytoreduction and hyperthermic intraperitoneal chemotherapy at the Fundación Santa Fe de Bogotá Teaching Hospital (ONCOLGroup--ATIA study)]

BACKGROUND

The procedure of radical peritonectomy followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is considered the standard treatment for peritoneal cancers.

AIMS

To evaluate various outcomes in a cohort of patients with peritoneal tumors treated with HIPEC.

METHODS

Twenty-four patients consecutively treated with radical peritonectomy plus HIPEC within the time frame of November 2007 to July 2010 were enrolled; 15 (62%) had tumors of appendicular origin, 4 (16.7%) had primary peritoneal tumors, 2 had ovarian carcinomas and there was one case of colon cancer, one carcinosarcoma and one hemangioendothelioma. Mean age was 53 years (range: 26-68) and median follow-up was 14.2 months (range: 1-32). Demographic data, histology, peritoneal cancer index (PCI), surgical procedure characteristics, recurrence-free survival (RFS), and overall survival (OS) were all evaluated. Short-term morbidity and mortality were also determined.

RESULTS

Complete cytoreduction was achieved in 18 patients (75%). Mean PCI was 15 (<10: 41% and >10: 58%), and the median (range) for surgery duration, length of stay in the Intensive Care Unit, parenteral nutritional support, and hospital stay were 12,5 (7-20) hours, 11,4 (2-74) days, 13,8 (12-65) days, and 29,1 (10-90) days, respectively. One patient (4%) died 6 months after the procedure, due to multiple associated complications. Considerable morbidity was seen in 52% of cases, including thromboembolic events (41%), catheter-related bacteremia (29%), fistulas (29%), and nephrotoxicity (25%). Six patients (25%) recurred after a median of 21 months of RFS.

CONCLUSIONS

Cytoreductive surgery plus HIPEC in well-selected patients presenting with tumors that affect the peritoneum is a procedure that can be carried out in Colombia with an adequate safety and effectiveness profile. Mortality was similar to that reported in the international literature.

Surgical treatment for peritoneal carcinomatosis from gastric cancer

This review describes the latest surgical treatments for peritoneal carcinomatosis (PC) arising from gastric cancer. Systemic chemotherapy is less effective against PC because of the existence of the blood-peritoneal barrier. Accordingly, perioperative intraperitoneal chemotherapy plus cytoreductive surgery (CRS) is a new trend of multidisciplinary therapy for PC. Intraperitoneally administered drugs penetrate directly into the peritoneal dissemination, resulting in the high loco-regional intensity of drugs. A new bidirectional chemotherapy called neoadjuvant intraperitoneal/systemic chemotherapy (NIPS) has been developed. After NIPS, the disappearance of PFCCs has been reported, and the incidence of complete cytoreduction has increased accordingly. Complete cytoreduction, a low peritoneal carcinomatosis index, and negative PFCCs are significant favorable prognostic factors. Hyperthermic intraperitoneal chemotherapy (HIPEC) after CRS is associated with improved survival with an acceptable postoperative mortality and morbidity. Early postoperative intraperitoneal chemotherapy (EPIC) has also contributed to improving survival after CRS.

[Peritoneal carcinomatosis: diagnosis and therapeutics in 2009]

Peritoneal carcinomatosis is often correlated with end-stage disease. Its diagnosis is guided by history, physical examination and imaging, as well as pathological examination which defines this carcinomatosis. Its management should be multidisciplinary and must insist on support treatment and guidance. Prognosis was changed by the advent of intraperitoneal chemotherapy combined with surgery.

The GYMSSA trial: a prospective randomized trial comparing gastrectomy, metastasectomy plus systemic therapy versus systemic therapy alone

BACKGROUND

The standard of care for metastatic gastric cancer (MGC) is systemic chemotherapy which leads to a median survival of 6-15 months. Survival beyond 3 years is rare. For selected groups of patients with limited MGC, retrospective studies have shown improved overall survival following gastrectomy and metastasectomies including peritoneal stripping with continuous hyperthermic peritoneal perfusion (CHPP), liver resection, and pulmonary resection. Median survival after liver resection for MGC is up to 34 months, with a five year survival rate of 24.5%. Similarly, reported median survival after pulmonary resection of MGC is 21 months with long term survival of greater than 5 years a possibility. Several case reports and small studies have documented evidence of long-term survival in select individuals who undergo CHPP for MGC.

DESIGN

The GYMSSA trial is a prospective randomized trial for patients with MGC. It is designed to compare two therapeutic approaches: gastrectomy with metastasectomy plus systemic chemotherapy (GYMS) versus systemic chemotherapy alone (SA). Systemic therapy will be composed of the FOLFOXIRI regimen. The aim of the study is to evaluate overall survival and potential selection criteria to determine those patients who may benefit from surgery plus systemic therapy. The study will be conducted by the Surgery Branch at the National Cancer Institute (NCI), National Institutes of Health (NIH) in Bethesda, Maryland. Surgeries and followup will be done at the NCI, and chemotherapy will be given by either the local oncologist or the medical oncology branch at NCI.

TRIAL REGISTRATION

ClinicalTrials.gov ID. NCT00941655.

Anterior intratumoural chemotherapy: a newer modality of treatment in advanced solid tumours in children

OBJECTIVE

Advanced and inoperable solid tumours in children have high mortality despite aggressive multimodal treatment. Intravenous chemotherapy is abandoned at times because of systemic toxicity. This study investigated intratumoural chemotherapy and compared it with intravenous chemotherapy.

METHODS

Forty children with advanced inoperable solid tumours (Wilms' tumour and neuroblastoma) were randomly allocated into two groups of 20. Group A was given intratumoural chemotherapy and group B was given intravenous chemotherapy. Both groups were compared for reduction in tumour size and volume, tumour resectability, histopathological changes and drug side effects.

RESULTS

Intratumoural chemotherapy was superior to intravenous chemotherapy in terms of reducing tumour size and volume (63% in group A vs. 22% in group B). The resectability was 70% in the intratumoural group compared with 40% in the intravenous group. The overall good histopathological response was 71% in group A as opposed to 0% in group B. Moreover, the incidence and severity of drug side effects and morbidity were less with intratumoural chemotherapy. Mortality was also low in group A (5%) compared to group B (20%).

CONCLUSION

Intratumoural chemotherapy can be offered as an effective and safe alternative treatment modality for advanced and inoperable Wilms' tumour and neuroblastoma.

Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Background

Peritoneal tumor dissemination arising from colorectal cancer, appendiceal cancer, gastric cancer, gynecologic malignancies or peritoneal mesothelioma is a common sign of advanced tumor stage or disease recurrence and mostly associated with poor prognosis.

Methods and results

In the present review article preoperative workup, surgical technique, postoperative morbidity and mortality rates, oncological outcome and quality of life after CRS and HIPEC are reported regarding the different tumor entities.

Conclusion

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provide a promising combined treatment strategy for selected patients with peritoneal carcinomatosis that can improve patient survival and quality of life. The extent of intraperitoneal tumor dissemination and the completeness of cytoreduction are the leading predictors of postoperative patient outcome. Thus, consistent preoperative diagnostics and patient selection are crucial to obtain a complete macroscopic cytoreduction (CCR-0/1).

Hyperthermic intraperitoneal chemotherapy: nomenclature and modalities of perfusion

Following international consensus, HIPEC should be the acronym used in the scientific literature to refer to the hyperthermic intraperitoneal chemotherapy. Several modalities of perfusion are used to deliver HIPEC: open abdominal technique (Coliseum), closed abdominal technique, peritoneal cavity expander, semi-opened abdominal technique. There is no sufficient evidence in literature confirming the superiority of one technique over the others in terms of outcome, morbidity and safety to the personnel of the operating theatre. Each option has its own operational advantages and disadvantages and future prospective studies must be conducted to establish which one is the best alternative. Today, the best technique is the one which is routinely used and improved into each specialized institution involved in the management of peritoneal surface malignancy.

[Hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal carcinomatosis arising from gastric cancer]

Since 20 years, treatment of peritoneal carcinomatosis has been developed in expert centers. Cytoreductive surgery and perioperative intraperitoneal chemotherapy, especially hyperthermic intraperitoneal chemotherapy, was assessed by many nonrandomised studies for the treatment of peritoneal carcinomatosis arising from gastric cancer. Results described increased survival, especially for the most favourable cases: limited carcinomatosis and complete cytoreductive surgery. A strict selection of the patients is necessary because of the important morbidity of those treatments. Only patients with good general health, able to tolerate a threatening treatment, with possible complete cytoreduction, may benefit from those treatments. Many japanese studies had demonstrated the efficacy of hyperthermic intraperitoneal chemotherapy for the prophylactic treatment of carcinomatosis in advanced-gastric cancers. These results have to be confirmed by european randomised studies.

Staged laparoscopic adjuvant intraperitoneal chemohyperthermia after complete resection for locally advanced colorectal or gastric cancer: a preliminary experience

BACKGROUND

Cytoreductive surgery followed by intraperitoneal chemohyperthermia (IPCH) is a promising treatment for patients with peritoneal carcinomatosis, a disease with dismal prognosis.

METHODS

We describe our preliminary experience with staged adjuvant laparoscopic IPCH after complete resection in patients with locally or regionally advanced colorectal or gastric cancer.

RESULTS

Twenty-one patients underwent resection for colorectal (N = 16) or gastric cancer (N = 5) followed by staged laparoscopic IPCH. No conversion to laparotomy was required. No major operative incident occurred. Mean duration of hospital stay was 12 days (range 9-23 days). No mortality occurred in the 30-day postoperative period. Four patients developed major complications (19%). One patient (5%) was reoperated. Mean follow-up period was 15.5 months (range 9-29 months). Three patients died, including two of cancer-related causes. No patient developed peritoneal carcinomatosis during the follow-up period.

CONCLUSION

Staged laparoscopic adjuvant IPCH after open or laparoscopic resection in selected patients with colorectal or gastric cancer is feasible and reasonably safe. However, additional data are required to determine the effect on long-term survival.

A comparative study of intratumoral chemotherapy in advanced childhood common solid tumors

BACKGROUND

Advanced and inoperable solid tumors in children are great killer despite aggressive multimodality treatment. Intravenous chemotherapy, due to high dose of drug given systemically, at times leads to abandonment of therapy due to systemic toxicities. To overcome this problem lots of studies are going on to explore alternative modes of giving anticancer drugs so as to decrease the systemic toxicities of the drugs and increase their therapeutic index at the same time.

AIM

The study was conducted to know the results of anterior intratumoral chemotherapy and its comparison to anterior intravenous chemotherapy.

MATERIALS AND METHODS

Forty patients of advanced inoperable solid tumors in children (Wilms' tumor and neuroblastoma) between 2000-2004 were randomly allocated to two groups. Group A (20 patients) was given intratumoral chemotherapy while Group B (20 patients) was given intravenous chemotherapy. Both the groups were compared in terms of reduction in size and volume, resectability of tumor, histopathological changes and side-effects of chemotherapeutic drugs. The Institute's ethics committee approved this study.

RESULTS

Males were predominant in both type of cases (Wilms' tumor and neuroblastoma) in both the groups (Group A and Group B). Mean age in the study was 3.27 years. All cases in Group A had Stage III disease except three cases which had Stage IV disease (one case of Wilms' tumor and two cases of neuroblastoma) while in Group B only two cases had Stage IV disease (one case of Wilms' tumor and one case of neuroblastoma). Intratumoral chemotherapy was found to be superior over intravenous chemotherapy in terms of reduction of size and volume (63% in Group A vs. 22% in Group B). The resectability was 70% in the intratumoral group in comparison to 40% in the intravenous group. The overall good histopathological response was 71% in Group A as opposed to 0% in Group B. Moreover, the incidence and severity of side-effects of chemotherapy and morbidity was less in intratumoral chemotherapy. Mortality was also low in Group A (5%) in comparison to Group B (20%).

CONCLUSION

In this study intratumoral chemotherapy was found to be superior over intravenous chemotherapy in terms of better and early tumor regression, minimal side-effects, better tumor resectability and well response on histopathological criteria. This study is still going on at our center where different drug combinations, different drug doses, their toxicities, their mechanisms of action, their serum levels and long-term results of intratumoral mode of chemotherapy are to be evaluated thoroughly in future.

Technology for the delivery of hyperthermic intraoperative intraperitoneal chemotherapy: a survey of techniques

Peritoneal metastases are common sequelae of gastrointestinal malignancy. The treatment of peritoneal metastases through use of aggressive surgical cytoreduction including peritonectomy coupled with HIPEC has now been reported in several large single-institution series. The available literature suggests that in experienced hands and with appropriate patient selection cytoreduction and HIPEC can be an effective therapy, particularly when all macroscopic tumor deposits are removed. Different techniques involving the administration of intraperitoneal chemotherapy have been reported, including the closed intraoperative technique, the open or coliseum technique, and the open technique using a PCE device. All techniques have been associated with mortality and morbidity that is significant, but generally consistent with other major surgical procedures. In theory, the coliseum and PCE techniques may have less associated morbidity because of improved heat distribution; however, this remains to be definitively proven in a controlled clinical trial. Such controlled studies are critical to defining the best techniques for HIPEC administration and the appropriate role for this treatment regimen in patients with peritoneal metastases. The development of a program in cytoreductive surgery and HIPEC requires a comprehensive patient care team led by appropriately trained surgeons. Such teams are best suited to provide the highest-quality care to patients with peritoneal surface malignancy.

Surgical Management of Metastatic Peritoneal or Pleural Disease

The surgeon's role in the treatment of malignant peritoneal disease has expanded over time, stemming from a better understanding of tumor biology. For the majority of patients, carcinomatosis is a terminal process with surgical intervention being reserved for palliation of bowel obstruction or symptomatic ascites. However, for select patients with favorable tumor biologies, aggressive surgical approaches may result in long-term survival. This review describes the patterns of peritoneal tumor dissemination, surgical palliation of malignant bowel obstruction or ascites, and the principles, indications, toxicities, and overall results of cytoreductive surgery with intraperitoneal hyperthermic chemotherapy. On the other hand, long-term survival is rarely expected for malignant pleural disease unless the causal tumor is highly responsive to systemic chemotherapy. There are controversies and considerable geographic variations in the management of malignant pleural effusions. However, less invasive ambulatory palliative treatments for patients so afflicted are gaining popularity.

Nouveautés thérapeutiques dans la prise en charge des carcinoses péritonéales d'origine digestive : chirurgie de cytoréduction et chimiothérapie intrapéritonéale

PURPOSE

Peritoneal carcinomatosis and particularly those from digestive origin has long been considered as an automatically terminal disease in abdominal cancer patients.

CURRENT KNOWLEDGE AND KEY POINTS

Over the past decade, new locoregional treatments combining cytoreductive surgery, peritonectomy procedures with perioperative intraperitoneal chemotherapy (with or without hyperthermia) have been developed by specialized teams. Because of its high but acceptable mortality and morbidity, this aggressive but comprehensive therapeutic strategy requires accurate and strict patient's selection into multidisciplinary and specialized teams. It may allow prolonged survival and cure for patients with pseudomyxoma peritonei, peritoneal mesothelioma, carcinomatosis from colorectal or gastric cancer. Qualitative and quantitative prognostic indicators are needed to assess a patient's eligibility, including tumor histopathology, assessment of carcinomatosis extent or completeness of cytoreduction which appears to be the most important.

PERSPECTIVES

Combination of cytoreductive surgery with perioperative intraperitoneal chemotherapy appears to be an adapted therapeutic approach for patients strictly selected, with peritoneal carcinomatosis. Phase III studies are now needed for the validation and the evaluation of the type of intraperitoneal chemotherapy.

Neoadjuvant treatment of gastric cancer with peritoneal dissemination

AIMS

To report our experience of neoadjuvant intraperitoneal and systemic chemotherapy (NIPS) for patients having a complete resection of the primary gastric cancer and peritoneal carcinomatosis (PC).

PATIENTS AND METHODS

Patients with advanced peritoneal dissemination of primary gastric cancer had the placement of a peritoneal port system. For intraperitoneal chemotherapy, 40 mg of docetaxel and 150 mg of carboplatin were introduced in 1000 ml of saline on a weekly basis. Simultaneously, 100 mg/m2 of methotrexate and 600 mg/m2 of 5-fluorouracil were infused via a peripheral vein. A minimum of two cycles and up to six cycles of NIPS were used prior to cancer resection. At surgery a complete removal of the primary gastric cancer and the peritoneal implants by peritonectomy was attempted.

RESULTS

Sixty-one patients were enrolled in the study. Thirty-nine had positive intraperitoneal cytology which reverted to negative cytology after treatment in 22. Thirty-eight showed a partial response. Thirty patients came to resection and 14 patients could be made disease-free. Median survival time of all patients was 14.4 months. Patients who received a complete resection had a median survival time of 20.4 months. Grade III/IV toxicities were not found after two courses of NIPS, but did develop in seven patients after more than three courses of NIPS.

CONCLUSION

NIPS can downstage large volume peritoneal dissemination of gastric cancer. When combined with gastrectomy including peritonectomy a complete surgical resection was possible in one-quarter of the patients and resulted in a prolonged survival. This combined intraperitoneal and systemic chemotherapy for PC from gastric cancer is worthy of consideration for phase III clinical investigations.

Peritoneal Cytology Does Not Increase the Prognostic Information Provided by TNM in Gastric Cancer

BACKGROUND

This study aimed at verifying whether peritoneal cytology could improve the prognostic information provided by TNM staging in gastric cancer patients.

METHOD

The presence of free peritoneal tumor cells was investigated in 168 patients who underwent curative resection for gastric cancer from January 1992 to July 2002 in Verona, Italy. The influence of peritoneal cytology on survival was evaluated by a Cox regression model, controlling for potential confounders.

RESULTS

Twenty-three patients (14%) had positive peritoneal cytology. Patients with positive lavage were more likely to present serosal infiltration (100 vs. 46%) and nodal metastases (91 vs. 67%; P < 0.001). Positive lavage was associated with a very poor prognosis: 3-year survival was only 9% (95% CI 2-27%) when peritoneal cancer cells had been detected, whereas survival reached 50% (95% CI 42-59%) in patients with a negative cytology. In multivariate survival analysis, peritoneal cytology was an independent predictor of mortality when controlling for sex, age, site, histology, and nodal metastases, but not when adjusting also for depth of tumor invasion (RR of positive versus negative = 1.2, 95% CI 0.7-2.0). Similarly, the influence of peritoneal cytology on survival was no longer significant when univariate analysis was restricted to T3/T4 patients (RR = 1.5, 0.9-2.5).

CONCLUSIONS

Positive peritoneal cytology was a marker of poor prognosis in gastric cancer patients. Nevertheless, peritoneal lavage did not increase the prognostic information already provided by the TNM staging system in this Italian series.