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Álvarez-Aguilera M, González De Pedro C, Aparicio-Sánchez D, Espada Fuentes FJ, Padillo-Ruiz J, Díaz Gómez D. Standardized laparoscopic staging protocol for incidental and elective carcinomatosis surgery. Am J Surg 2024; 232:146-148. [PMID: 38218682 DOI: 10.1016/j.amjsurg.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 01/15/2024]
Affiliation(s)
- M Álvarez-Aguilera
- Department of Surgery, Virgen del Rocio University Hospital, Seville, Spain
| | - C González De Pedro
- Surgical Oncology and Peritoneal Malignancies Unit, Department of Surgery, Virgen del Rocio University Hospital, Seville, Spain
| | - D Aparicio-Sánchez
- Surgical Oncology and Peritoneal Malignancies Unit, Department of Surgery, Virgen del Rocio University Hospital, Seville, Spain.
| | - F J Espada Fuentes
- Department of Surgery, Virgen del Rocio University Hospital, Seville, Spain
| | - J Padillo-Ruiz
- Chief of department. Department of Surgery, Virgen del Rocio University Hospital, Seville, Spain
| | - D Díaz Gómez
- Surgical Oncology and Peritoneal Malignancies Unit Chief, Department of Surgery, Virgen del Rocio University Hospital, Seville, Spain
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Seibæk L, Thaysen HV, Lomborg KE. Non-curative surgical oncology: postoperative needs and preferences. BMJ Support Palliat Care 2024; 14:208-214. [PMID: 33941572 DOI: 10.1136/bmjspcare-2020-002789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/18/2021] [Accepted: 04/01/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE When intended curative cancer surgery is not completed, the postoperative transition to palliative care represents a prognostic landmark to patients and their families. In patients referred for highly specialised surgery for peritoneal metastases from the intestinal tract and ovaries, surgery is not performed in approximately 25%. Still, little is known of their postoperative needs and preferences. METHODS We performed 14 qualitative research interviews with 12 patients (four men and eight women, aged 41-85 years) undergoing surgery for peritoneal metastases; five of these were together with a relative. Five of the participants had ovarian, and seven had colorectal cancer (four men and seven women). The interviews followed a semistructured interview guide, were audio recorded, transcribed verbatim and analysed using meaning condensation. RESULTS Patients accepted the surgeon's decision of refraining from the intended surgery. During the postoperative period, when realising the prognostic consequences, their needs changed rapidly, in some cases from day to day, and gradually they developed a reoriented focus on their lives. The findings were framed by two themes dealing with 'Change in treatment strategy' and 'Physical and psychosocial aspects of not undergoing curative surgery'. CONCLUSION When curative cancer surgery is not completed as intended, patient-centred communication is essential for patients' psychosocial reorientation and quality of life. Further, to support their well-being and action competences, patients have a need for basic supportive care and physical restitution. Finally, high-quality postoperative palliative care needs to be coordinated, which requires staff training and reorganisation of pathways.
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Affiliation(s)
- Lene Seibæk
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
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3
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Shah R, Gangi A. Role of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in the Management of Colorectal Peritoneal Metastases. Clin Colon Rectal Surg 2024; 37:90-95. [PMID: 38322605 PMCID: PMC10843886 DOI: 10.1055/s-0042-1758759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
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.
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Affiliation(s)
- Rupen Shah
- Division of Surgical Oncology, Henry Ford Cancer Institute/Henry Ford Health, Detroit, Michigan
| | - Alexandra Gangi
- Division of Surgical Oncology, Cedars Sinai Medical Center, Los Angeles, California
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Boldrin V, Khaled C, El Asmar A, Kamden L, Sclafani F, Gomez MG, Moreau M, Vouche M, Liberale G. Predictive factors of non-completion of cytoreductive surgery in colorectal peritoneal metastasis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107251. [PMID: 38096699 DOI: 10.1016/j.ejso.2023.107251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/15/2023] [Accepted: 10/27/2023] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) is the only potentially curative treatment that can improve the survival prognosis for patients with peritoneal metastasis (PM) of colorectal origin. The main independent prognostic factors are extent of disease, as measured by the Peritoneal Cancer Index (PCI), and completion of CRS (CC-0 or R1). Despite thorough preoperative work-up for selection of surgical candidates, 20%-25 % of CRS procedures are stopped after exploration during laparotomy. These patients undergo "open-and-close" procedures associated with a risk of complications and without any benefit. The aim of this study was to identify preoperative predictors of non-resectability and/or non-completion of CRS in patients with colorectal PMs who were candidates for surgery. MATERIALS AND METHODS Retrospective, monocentric study including patients admitted for CRS ± HIPEC at the Jules Bordet Institute between January 01, 2010 and December 31, 2021. The preoperative epidemiological, pathological, clinical, radiological, and biological features of patients with unresectable disease were compared with those of patients treated with CRS. RESULTS One hundred nineteen patients were included, 60 men and 59 women (median age 61 years). Twenty-one CRS procedures (17.65 %) were stopped during exploratory laparotomy. Statistically significant factors associated with non-completion were age (p = 0.0183), PCI (p = 0.0001), presence of sub/occlusive episode(s) prior to CRS (p = 0.0012), and multifocal-diffuse uptakes on PET-scan (p = 0.0017). CONCLUSION Almost 18 % of patients had an "open-and-close" procedure. PCI was the major determinant of non-completion of CRS. Other predictive factors of unresectability of colorectal PM were age, the presence of sub/occlusive episodes, and PET/CT with multiple peritoneal uptakes.
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Affiliation(s)
- Veronica Boldrin
- Department of Surgery, Jules Bordet Institute (The Brussels University Hospital - H.U.B.), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Charif Khaled
- Department of Surgery, Jules Bordet Institute (The Brussels University Hospital - H.U.B.), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Antoine El Asmar
- Department of Surgery, Jules Bordet Institute (The Brussels University Hospital - H.U.B.), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Leonel Kamden
- Department of Surgery, Jules Bordet Institute (The Brussels University Hospital - H.U.B.), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Francesco Sclafani
- Department of Oncology, Jules Bordet Institute (The Brussels University Hospital - H.U.B.), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Maria Galdon Gomez
- Department of Pathology, Jules Bordet Institute (The Brussels University Hospital - H.U.B.), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Michel Moreau
- Statistics Department, Jules Bordet Institute (The Brussels University Hospital - H.U.B.), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Michael Vouche
- Department of Radiology, Jules Bordet Institute (The Brussels University Hospital - H.U.B.), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Gabriel Liberale
- Department of Surgery, Jules Bordet Institute (The Brussels University Hospital - H.U.B.), Université Libre de Bruxelles (ULB), Brussels, Belgium.
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Grávalos C, Pereira F, Vera R, Arjona-Sánchez A, Losa F, Ramos I, García-Alfonso P, Gonzalez-Bayón L, Cascales-Campos PA, Aranda E. Recommendations for the optimal management of peritoneal metastases in patients with colorectal cancer: a TTD and GECOP-SEOQ expert consensus statement. Clin Transl Oncol 2023; 25:3378-3394. [PMID: 37140736 DOI: 10.1007/s12094-023-03204-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/13/2023] [Indexed: 05/05/2023]
Abstract
Peritoneal metastases (PM) occur when cancer cells spread inside the abdominal cavity and entail an advanced stage of colorectal cancer (CRC). Prognosis, which is poor, correlates highly with tumour burden, as measured by the peritoneal cancer index (PCI). Cytoreductive surgery (CRS) in specialized centres should be offered especially to patients with a low to moderate PCI when complete resection is expected. The presence of resectable metastatic disease in other organs is not a contraindication in well-selected patients. Although several retrospective and small prospective studies have suggested a survival benefit of adding hyperthermic intraperitoneal chemotherapy (HIPEC) to CRS, the recently published phase III studies PRODIGE-7 in CRC patients with PM, and COLOPEC and PROPHYLOCHIP in resected CRC with high-risk of PM, failed to show any survival advantage of this strategy using oxaliplatin in a 30-min perfusion. Final results from ongoing randomized phase III trials testing CRS plus HIPEC based on mitomycin C (MMC) are awaited with interest. In this article, a group of experts selected by the Spanish Group for the Treatment of Digestive Tumours (TTD) and the Spanish Group of Peritoneal Oncologic Surgery (GECOP), which is part of the Spanish Society of Surgical Oncology (SEOQ), reviewed the role of HIPEC plus CRS in CRC patients with PM. As a result, a series of recommendations to optimize the management of these patients is proposed.
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Affiliation(s)
- Cristina Grávalos
- Medical Oncology Department, 12 de Octubre University Hospital, Madrid, Spain
| | - Fernando Pereira
- Departamento de Cirugía, Hospital Universitario de Fuenlabrada, Camino del Molino, 2, 28942, Fuenlabrada, Madrid, Spain.
| | - Ruth Vera
- Medical Oncology Department, Navarra University Hospital, Navarra's Health Research Institute (IdiSNA), Pamplona, Spain
| | - Alvaro Arjona-Sánchez
- Unit of Surgical Oncology and GE09 Research in Peritoneal and Retroperitoneal Oncology Surgery, Reina Sofía University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
| | - Ferran Losa
- Medical Oncology Department, Sant Joan Despí - Moisés Broggi Hospital/ICO-Hospitalet, Barcelona, Spain
| | - Isabel Ramos
- Surgery Department, Sant Joan Despí - Moisés Broggi Hospital, Hospitalet de Llobregat, Spain
| | - Pilar García-Alfonso
- Medical Oncology Department, Gregorio Marañón General University Hospital, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense, Madrid, Spain
| | - Luis Gonzalez-Bayón
- Surgery Department, Gregorio Marañón General University Hospital, Madrid, Spain
| | | | - Enrique Aranda
- Medical Oncology Department, Reina Sofía University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba University, Center for Biomedical Research in Cancer Network (CIBERONC), Carlos III Health Institute, Córdoba, Spain
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6
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Wang J, Hu Y, Xiong H, Song T, Wang S, Xu H, Xiong B. CT-based deep learning model: a novel approach to the preoperative staging in patients with peritoneal metastasis. Clin Exp Metastasis 2023; 40:493-504. [PMID: 37798391 PMCID: PMC10618318 DOI: 10.1007/s10585-023-10235-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/21/2023] [Indexed: 10/07/2023]
Abstract
Peritoneal metastasis (PM) is a frequent manifestation of advanced abdominal malignancies. Accurately assessing the extent of PM before surgery is essential for patients to receive optimal treatment. Therefore, we propose to construct a deep learning (DL) model based on enhanced computed tomography (CT) images to stage PM preoperatively in patients. All 168 patients with PM underwent contrast-enhanced abdominal CT before either open surgery or laparoscopic exploration, and peritoneal cancer index (PCI) was used to evaluate patients during the surgical procedure. DL features were extracted from portal venous-phase abdominal CT scans and subjected to feature selection using the Spearman correlation coefficient and LASSO. The performance of models for preoperative staging was assessed in the validation cohort and compared against models based on clinical and radiomics (Rad) signature. The DenseNet121-SVM model demonstrated strong patient discrimination in both the training and validation cohorts, achieving AUC was 0.996 in training and 0.951 validation cohort, which were both higher than those of the Clinic model and Rad model. Decision curve analysis (DCA) showed that patients could potentially benefit more from treatment using the DL-SVM model, and calibration curves demonstrated good agreement with actual outcomes. The DL model based on portal venous-phase abdominal CT accurately predicts the extent of PM in patients before surgery, which can help maximize the benefits of treatment and optimize the patient's treatment plan.
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Affiliation(s)
- Jipeng Wang
- Department of Gastrointestinal Surgery, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430071, Hubei, China
- Hubei Key Laboratory of Tumor Biological Behaviors, No.169 Donghu Road, Wuchang District, Wuhan, 430071, China
| | - Yuannan Hu
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Hao Xiong
- Department of information Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Tiantian Song
- Department of Gastrointestinal Surgery, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430071, Hubei, China
- Hubei Key Laboratory of Tumor Biological Behaviors, No.169 Donghu Road, Wuchang District, Wuhan, 430071, China
| | - Shuyi Wang
- Department of Gastrointestinal Surgery, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430071, Hubei, China.
- Hubei Key Laboratory of Tumor Biological Behaviors, No.169 Donghu Road, Wuchang District, Wuhan, 430071, China.
| | - Haibo Xu
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
| | - Bin Xiong
- Department of Gastrointestinal Surgery, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuhan, 430071, Hubei, China.
- Hubei Key Laboratory of Tumor Biological Behaviors, No.169 Donghu Road, Wuchang District, Wuhan, 430071, China.
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Strating E, van de Loo A, Elias S, Lam M, Kranenburg O. Fibroblast Activation Protein Inhibitor-PET Imaging in Colorectal Cancer. PET Clin 2023:S1556-8598(23)00016-0. [PMID: 37030984 DOI: 10.1016/j.cpet.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
Fibroblast activation protein inhibitor (FAPI)-PET imaging holds great promise for improving the clinical management of colorectal cancer. High fibroblast activation protein expression is particularly observed in lymph node metastases, in the aggressive Consensus Molecular Subtype 4, in peritoneal metastases, and in tumors that respond poorly to immunotherapy. We have defined six clinical dilemmas in the diagnosis and treatment of colorectal cancer, which FAPI-PET may help solve. Future clinical trials should include patients undergoing tumor resection, allowing correlation of FAPI-PET signals with in-depth histopathological, cellular, and molecular tissue analyses.
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Affiliation(s)
- Esther Strating
- Division of Imaging and Cancer, Laboratory Translational Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, G.04.2.28, Utrecht, the Netherlands
| | - Anne van de Loo
- Division of Imaging and Cancer, Laboratory Translational Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, G.04.2.28, Utrecht, the Netherlands
| | - Sjoerd Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, STR.6.131, Utrecht, the Netherlands
| | - Marnix Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, E.01.1.32, Utrecht, the Netherlands.
| | - Onno Kranenburg
- Division of Imaging and Cancer, Laboratory Translational Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, G.04.2.28, Utrecht, the Netherlands.
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Dietz MV, Ziekman MJ, van Kooten JP, Brandt-Kerkhof ARM, van Meerten E, Verhoef C, Madsen EVE. Treatment and Survival Outcomes for Patients with Colorectal Peritoneal Metastases Deemed Ineligible for Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC): Results of a Retrospective Study. Ann Surg Oncol 2023; 30:2048-2056. [PMID: 36566258 DOI: 10.1245/s10434-022-12969-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/08/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment option for selected patients with colorectal peritoneal metastases (PM). This report provides an overview of treatment and survival outcomes for patients deemed ineligible for CRS-HIPEC. METHODS Colorectal PM patients referred to a tertiary center from 2014 to 2020 that were ineligible for CRS-HIPEC were included. Patient, tumor, and treatment characteristics were provided. Survival analyses were performed using the Kaplan-Meier method. RESULTS Of 476 patients referred for CRS-HIPEC, 227 (48%) were deemed ineligible. Median follow-up was 15 months [IQR 10-22]. Data on follow-up treatment was available for 198 patients, of which 73% received systemic therapy. These patients had a median overall survival (OS) of 17 months [IQR 9-25]. For patients receiving best supportive care (BSC) median OS was 4 months [IQR 2-9]. The main reason for ineligibility was extensive PM (42%), with a median OS of 11 months [IQR 5-18]. Patients deemed ineligible due to (extensive) liver (9%) or lung metastases (8%) showed longer OS (median 22 months, IQR 8-27, and 24 months, IQR 12-29, respectively) than patients with extensive PM (median 11 months, IQR 5-18) or distant lymph node metastases (median 14 months, IQR 4-25). CONCLUSION The main reason for CRS-HIPEC ineligibility was extensive PM. The majority of patients received systemic therapy. Patients deemed ineligible due to extra-peritoneal metastases had better survival outcomes than patients deemed ineligible due to extensive PM.
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Affiliation(s)
- Michelle V Dietz
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Merijn J Ziekman
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Job P van Kooten
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Esther van Meerten
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Eva V E Madsen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Mangieri CW, Valenzuela CD, Solsky IB, Erali RA, Votanopoulos KI, Shen P, Levine EA. Impact of myometrium invasion on survival outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). J Surg Oncol 2023; 127:450-456. [PMID: 36285743 PMCID: PMC10065224 DOI: 10.1002/jso.27122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/01/2022] [Accepted: 09/18/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective surgical intervention for peritoneal surface malignancy. The effect of myometrium invasion on outcomes is unknown. METHODS Retrospective review of our institutional registry with analysis of CRS-HIPEC cases involving a hysterectomy. Compared cases with myometrium invasion versus those without invasion. Primary outcome was survival as measured by overall survival (OS) and disease-free survival (DFS). Secondary outcome was the evaluation of risk factors for myometrium invasion based on multivariate analysis. RESULTS A total of 126 cases of CRS-HIPEC involving a hysterectomy were identified. Ninety-seven cases (76.9%) had no myometrium invasion and the remaining 29 cases (23.1%) had malignant invasion. The presence of myometrial invasion was a significant negative survival prognostic factor. The OS was halved with mean survival times of 2.8 (±2.3) versus 5.8 (±4.7) years for cases with and without invasion, respectively (p = 0.002). Five-year OS rates were also inferior with myometrium invasion at 17.4% versus 53.8% (odds ratio [OR] = 0.181, 95% confidence interval [CI]: 0.057-0.580, p = 0.002). A similar trend was present with DFS with mean survival times of 1.4 (±0.9) versus 3.7 (±3.9) years for noninvasion and invasion cases (p = 0.009). The 5-year DFS rates were 0% versus 34.8% (OR = 0.652, 95% CI: 0.549-0.775, p = 0.004). Secondary analysis significantly associated several risk factors with myometrium invasion to include lymph node positivity (OR = 2.539, 95% CI: 1.074-6.003, p = 0.012), colorectal primary tumors (OR = 2.248, 95% CI: 1.094-5.161, p = 0.035), and high-grade tumors (OR = 2.160, 95% CI: 1.080-4.820, p = 0.038). CONCLUSION Myometrium invasion is a significant negative prognostic factor for survival following CRS-HIPEC. Several risk factors are potentially predictive of identifying those at high-risk for myometrium invasion.
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Affiliation(s)
| | | | - Ian B. Solsky
- Wake Forest Baptist Health Medical Center, Section of Surgical Oncology
| | - Richard A. Erali
- Wake Forest Baptist Health Medical Center, Section of Surgical Oncology
| | | | - Perry Shen
- Wake Forest Baptist Health Medical Center, Section of Surgical Oncology
| | - Edward A. Levine
- Wake Forest Baptist Health Medical Center, Section of Surgical Oncology
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Sökmen S, Bişgin T, Manoğlu B, Altay C, Ellidokuz H. Extreme cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in treatment of peritoneal metastasis. Turk J Surg 2023; 39:43-51. [PMID: 37275926 PMCID: PMC10234707 DOI: 10.47717/turkjsurg.2023.5881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/26/2022] [Indexed: 06/07/2023]
Abstract
Objectives It was aimed to define the oncologic concept of "extremeness" in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) to determine morbidity-mortality results and final oncologic outcomes. Material and Methods Prospectively recorded data of 666 patients with peritoneal metastases who had undergone CRS/HIPEC between 2007 and 2020 were analyzed. Patients were divided into two groups as extreme (n= 371) and non-extreme (n= 295). Extreme CRS was defined as resection of ≥5 major organs or creation of ≥2 bowel anastomoses or peritoneal carcinomatosis index (PCI)≥ 15 or re-cytoreductive surgery. Results More CC-1 or CC-2 cytoreduction (p <.001), increased mortality and morbidity (p <.001), prolonged operative time (p <.001), increased intraoperative erythrocyte suspension (p <.001), albumin (p <.001), fresh frozen plasma (FFP) (p <.001), and post-operative erythrocyte suspension (p <.001) usage were found in the extreme CRS/HIPEC group. Operative time, CC-1 or CC-2 cytoreduction, presence of ostomy, development of infection, and use of intra-operative albumin and FFP were found to be independent prognostic factors in Cox regression analysis. Three and five-year survival rates were significantly lower in the extreme CRS/HIPEC group (p <.001). Conclusion High-volume peritoneal metastatic disease can be completely resected with extreme cytoreduction in carefully selected patients responsive to chemotherapy. Since the significant morbi-mortality related to the treatment of peritoneal metastasis is a real concern, it should be considered in experienced complex cancer centers that provides relatively better oncological outcomes compared to conventional treatments.
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Affiliation(s)
- Selman Sökmen
- Department of General Surgery, Dokuz Eylül University Faculty of Medicine, İzmir, Türkiye
| | - Tayfun Bişgin
- Department of General Surgery, Dokuz Eylül University Faculty of Medicine, İzmir, Türkiye
| | - Berke Manoğlu
- Department of General Surgery, Dokuz Eylül University Faculty of Medicine, İzmir, Türkiye
| | - Canan Altay
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, İzmir, Türkiye
| | - Hülya Ellidokuz
- Department of Biostatistics, Dokuz Eylül University Faculty of Medicine, İzmir, Türkiye
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van de Vlasakker VCJ, van den Heuvel TBM, Rijken A, Nienhuijs SW, Ketelaers SHJ, Verrijssen ASE, Rutten HJ, Nieuwenhuijzen GAP, Burger JWA, de Hingh IHJT. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy with Intra-Operative Radiotherapy for Patients with Locally Advanced or Locally Recurrent Rectal Cancer and Peritoneal Metastases. Cancers (Basel) 2023; 15:cancers15030858. [PMID: 36765814 PMCID: PMC9913342 DOI: 10.3390/cancers15030858] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/25/2023] [Accepted: 01/28/2023] [Indexed: 01/31/2023] Open
Abstract
Purpose: To assess the safety and long-term outcome of a multimodality treatment consisting of radical surgery, intra-operative radiotherapy (IORT), and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for patients with locally advanced rectal cancer (LARC) or locally recurrent rectal carcinoma (LRRC) and peritoneal metastases (PM). Methods: The present study was a single-center cohort study, including all consecutive patients undergoing this treatment in a tertiary referral center for LARC, LRRC, and PM. Postoperative complications, intensive care stay (ICU stay), and re-admission rates were assessed as well as disease-free survival (DFS) and overall survival (OS). Results: A total of 14 LARC and 16 LRRC patients with PM were included in the study. The median ICU stay was 1 day, and 57% of patients developed a severe postoperative complication. No 90-day mortality was observed. Median DFS was 10.0 months (Interquartile Range 7.1-38.7), and median OS was 31.0 months (Interquartile Range 15.9-144.3). Conclusions: As postoperative complications and survival were in line with treatments that are accepted for LARC or LRRC and PM as separate procedures, we conclude that combined treatment with IORT and CRS-HIPEC should be considered as a treatment option for selected patients with LARC or LRRC and peritoneal metastases in tertiary referral centers.
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Affiliation(s)
| | | | - Anouk Rijken
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Simon W. Nienhuijs
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | | | | | - Harm J. Rutten
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
- GROW–School for Oncology and Reproduction, Maastricht University, 6211 LK Maastricht, The Netherlands
| | | | | | - Ignace H. J. T. de Hingh
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
- GROW–School for Oncology and Reproduction, Maastricht University, 6211 LK Maastricht, The Netherlands
- Department of Research, Netherlands Comprehensive Cancer Organization, P.O. Box 19079, 3501 DB Utrecht, The Netherlands
- Correspondence: ; Tel.: +31-40-239-7150
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12
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Sugarbaker PH, Chang D. Incomplete cytoreduction with peritoneal metastases from appendiceal mucinous neoplasms. J Surg Oncol 2022; 126:1462-1470. [DOI: 10.1002/jso.27087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/28/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Paul H. Sugarbaker
- Program in Peritoneal Surface Malignancy Washington Cancer Institute Washington District of Columbia USA
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13
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Baron E, Sardi A, King MC, Nikiforchin A, Lopez-Ramirez F, Nieroda C, Gushchin V, Ledakis P. Systemic Chemotherapy for High-Grade Mucinous Appendiceal Cancer with Peritoneal Spread After Unsuccessful CRS/HIPEC. Ann Surg Oncol 2022; 29:6581-6589. [PMID: 35641710 DOI: 10.1245/s10434-022-11894-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/28/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The best management of patients who have unresectable mucinous appendiceal cancer (MAC) with peritoneal spread after a failed attempt at cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is unclear. This study aimed to assess outcomes after systemic chemotherapy (SCT) for patients with unresectable peritoneal metastases from high-grade MAC. METHODS A single-center retrospective cohort study was conducted using a prospective CRS/HIPEC database. The study included high-grade MAC patients with peritoneal carcinomatosis who were deemed surgical candidates, but had an aborted CRS/HIPEC or only palliative HIPEC due to unresectable disease. Overall survival (OS) was compared. RESULTS Of 72 identified patients, 20 received SCT and 52 did not (NoCT). The groups were balanced by age (p = 0.299), sex (p = 0.930), histopathologic subtype (p = 0.096), preoperative chemotherapy (p = 0.981), and postoperative major complication rates (p = 0.338). Both groups had extensive disease (median peritoneal cancer index at exploration, 39 vs 39). The median number of cycles was 12 (interquartile range [IQR], 6-15), and the median time between the procedure and SCT was 7 weeks (IQR, 5-10 weeks). The median follow-up period was 65 months. The median OS was significantly higher for the SCT group (26 months; 95 % confidence interval [CI], 10.8-41.5 months) than for the NoCT group (12 months; 95 % CI, 9.6-14.4 months) (p < 0.001), with hazard ratio (HR) of 0.22 (95 % CI, 0.08-0.66; p = 0.007) after adjustment for other factors. CONCLUSION Systemic chemotherapy is associated with improved OS for high-grade MAC patients with unresectable peritoneal metastases who are deemed surgical candidates but underwent an unsuccessful CRS/HIPEC attempt. Further prospective studies with a larger sample are required to identify patient subgroups who benefit the most from SCT.
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Affiliation(s)
- Ekaterina Baron
- Department of Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Armando Sardi
- Department of Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA.
| | - Mary Caitlin King
- Department of Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Andrei Nikiforchin
- Department of Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Felipe Lopez-Ramirez
- Department of Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Carol Nieroda
- Department of Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Vadim Gushchin
- Department of Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Panayotis Ledakis
- Department of Medical Oncology and Hematology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
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14
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Multimodal CEA-targeted fluorescence and radioguided cytoreductive surgery for peritoneal metastases of colorectal origin. Nat Commun 2022; 13:2621. [PMID: 35551444 PMCID: PMC9098887 DOI: 10.1038/s41467-022-29630-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 03/16/2022] [Indexed: 11/09/2022] Open
Abstract
In patients with colorectal peritoneal metastases scheduled for cytoreductive surgery, accurate preoperative estimation of tumor burden and subsequent intraoperative detection of all tumor deposits remains challenging. In this study (ClinicalTrials.gov NCT03699332) we describe the results of a phase I clinical trial evaluating [111In]In-DOTA-labetuzumab-IRDye800CW, a dual-labeled anti-carcinoembryonic antigen (anti-CEA) antibody conjugate that enables both preoperative imaging and intraoperative radioguidance and fluorescence imaging. Primary study outcomes are safety and feasibility of this multimodal imaging approach. Secondary outcomes are determination of the optimal dose, correlation between tracer uptake and histopathology and effects on clinical strategy. Administration of [111In]In-DOTA-labetuzumab-IRDye800CW is well-tolerated and enables sensitive pre- and intraoperative imaging in patients who receive 10 or 50 mg of the tracer. Preoperative imaging revealed previously undetected lymph node metastases in one patient, and intraoperative fluorescence imaging revealed four previously undetected metastases in two patients. Alteration of clinical strategy based on multimodal imaging occurred in three patients. Thus, multimodal image-guided surgery after administration of this dual-labeled tracer is a promising approach that may aid in decision making before and during cytoreductive surgical procedures.
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15
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Strating E, Wassenaar E, Verhagen M, Rauwerdink P, van Schelven S, de Hingh I, Rinkes IB, Boerma D, Witkamp A, Lacle M, Fodde R, Volckmann R, Koster J, Stedingk K, Giesel F, de Roos R, Poot A, Bol G, Lam M, Elias S, Kranenburg O. Fibroblast activation protein identifies Consensus Molecular Subtype 4 in colorectal cancer and allows its detection by 68Ga-FAPI-PET imaging. Br J Cancer 2022; 127:145-155. [PMID: 35296803 PMCID: PMC9276750 DOI: 10.1038/s41416-022-01748-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/13/2022] [Accepted: 02/08/2022] [Indexed: 12/14/2022] Open
Abstract
Background In colorectal cancer (CRC), the consensus molecular subtype 4 (CMS4) is associated with therapy resistance and poor prognosis. Clinical diagnosis of CMS4 is hampered by locoregional and temporal variables influencing CMS classification. Diagnostic tools that comprehensively detect CMS4 are therefore urgently needed. Methods To identify targets for molecular CMS4 imaging, RNA sequencing data of 3232 primary CRC patients were explored. Heterogeneity of marker expression in relation to CMS4 status was assessed by analysing 3–5 tumour regions and 91.103 single-tumour cells (7 and 29 tumours, respectively). Candidate marker expression was validated in CMS4 peritoneal metastases (PM; n = 59). Molecular imaging was performed using the 68Ga-DOTA-FAPI-46 PET tracer. Results Fibroblast activation protein (FAP) mRNA identified CMS4 with very high sensitivity and specificity (AUROC > 0.91), and was associated with significantly shorter relapse-free survival (P = 0.0038). Heterogeneous expression of FAP among and within tumour lesions correlated with CMS4 heterogeneity (AUROC = 1.00). FAP expression was homogeneously high in PM, a near-homogeneous CMS4 entity. FAPI-PET identified focal and diffuse PM that were missed using conventional imaging. Extra-peritoneal metastases displayed extensive heterogeneity of tracer uptake. Conclusion FAP expression identifies CMS4 CRC. FAPI-PET may have value in the comprehensive detection of CMS4 tumours in CRC. This is especially relevant in patients with PM, for whom effective imaging tools are currently lacking. ![]()
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Affiliation(s)
- Esther Strating
- Department of Surgical Oncology, Lab Translational Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Emma Wassenaar
- Department of Surgical Oncology, Lab Translational Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Paulien Rauwerdink
- Department of Surgical Oncology, Lab Translational Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Susanne van Schelven
- Department of Surgical Oncology, Lab Translational Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ignace de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Inne Borel Rinkes
- Department of Surgical Oncology, Lab Translational Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Djamila Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Arjen Witkamp
- Department of Surgical Oncology, Lab Translational Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Miangela Lacle
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Riccardo Fodde
- Department of Pathology, Erasmus MC, Rotterdam, Netherlands
| | - Richard Volckmann
- Department of Oncogenomics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jan Koster
- Department of Oncogenomics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Kris Stedingk
- Department of Oncogenomics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Frederik Giesel
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany.,Department of Nuclear Medicine, Medical Faculty, Heinrich-Heine-University, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Remmert de Roos
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Alex Poot
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Guus Bol
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marnix Lam
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Sjoerd Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Onno Kranenburg
- Department of Surgical Oncology, Lab Translational Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands. .,Utrecht Platform for Organoid Technology, Utrecht University, Utrecht, The Netherlands.
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16
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Rijsemus CJV, Kok NFM, Aalbers AGJ, Buffart TE, Fijneman RJA, Snaebjornsson P, Engbersen M, Lambregts DMJ, Beets-Tan RGH, Lahaye MJ. Diagnostic performance of MRI for staging peritoneal metastases in patients with colorectal cancer after neoadjuvant chemotherapy. Eur J Radiol 2022; 149:110225. [DOI: 10.1016/j.ejrad.2022.110225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/31/2022] [Accepted: 02/16/2022] [Indexed: 11/03/2022]
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17
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Abstract
Peritoneal surface malignancies comprise a heterogeneous group of primary tumours, including peritoneal mesothelioma, and peritoneal metastases of other tumours, including ovarian, gastric, colorectal, appendicular or pancreatic cancers. The pathophysiology of peritoneal malignancy is complex and not fully understood. The two main hypotheses are the transformation of mesothelial cells (peritoneal primary tumour) and shedding of cells from a primary tumour with implantation of cells in the peritoneal cavity (peritoneal metastasis). Diagnosis is challenging and often requires modern imaging and interventional techniques, including surgical exploration. In the past decade, new treatments and multimodal strategies helped to improve patient survival and quality of life and the premise that peritoneal malignancies are fatal diseases has been dismissed as management strategies, including complete cytoreductive surgery embedded in perioperative systemic chemotherapy, can provide cure in selected patients. Furthermore, intraperitoneal chemotherapy has become an important part of combination treatments. Improving locoregional treatment delivery to enhance penetration to tumour nodules and reduce systemic uptake is one of the most active research areas. The current main challenges involve not only offering the best treatment option and developing intraperitoneal therapies that are equivalent to current systemic therapies but also defining the optimal treatment sequence according to primary tumour, disease extent and patient preferences. New imaging modalities, less invasive surgery, nanomedicines and targeted therapies are the basis for a new era of intraperitoneal therapy and are beginning to show encouraging outcomes.
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18
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Tonello M, Baratti D, Sammartino P, Di Giorgio A, Robella M, Sassaroli C, Framarini M, Valle M, Macrì A, Graziosi L, Coccolini F, Lippolis PV, Roberta G, Deraco M, Biacchi D, Santullo F, Vaira M, Di Lauro K, D'Acapito F, Carboni F, Giuffrè G, Donini A, Fugazzola P, Faviana P, Lorena S, Scapinello A, Del Bianco P, Sommariva A. Microsatellite and RAS/RAF Mutational Status as Prognostic Factors in Colorectal Peritoneal Metastases Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Ann Surg Oncol 2021; 29:3405-3417. [PMID: 34783946 DOI: 10.1245/s10434-021-11045-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/20/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) leads to prolonged survival for selected patients with colorectal (CRC) peritoneal metastases (PM). This study aimed to analyze the prognostic role of micro-satellite (MS) status and RAS/RAF mutations for patients treated with CRS. METHODS Data were collected from 13 Italian centers with PM expertise within a collaborative group of the Italian Society of Surgical Oncology. Clinical and pathologic variables and KRAS/NRAS/BRAF mutational and MS status were correlated with overall survival (OS) and disease-free survival (DFS). RESULTS The study enrolled 437 patients treated with CRS-HIPEC. The median OS was 42.3 months [95% confidence interval (CI), 33.4-51.2 months], and the median DFS was 13.6 months (95% CI, 12.3-14.9 months). The local (peritoneal) DFS was 20.5 months (95% CI, 16.4-24.6 months). In addition to the known clinical factors, KRAS mutations (p = 0.005), BRAF mutations (p = 0.01), and MS status (p = 0.04) were related to survival. The KRAS- and BRAF-mutated patients had a shorter survival than the wild-type (WT) patients (5-year OS, 29.4% and 26.8% vs 51.5%, respectively). The patients with micro-satellite instability (MSI) had a longer survival than the patients with micro-satellite stability (MSS) (5-year OS, 58.3% vs 36.7%). The MSI/WT patients had the best prognosis. The MSS/WT and MSI/mutated patients had similar survivals, whereas the MSS/mutated patients showed the worst prognosis (5-year OS, 70.6%, 48.1%, 23.4%; p = 0.0001). In the multivariable analysis, OS was related to the Peritoneal Cancer Index [hazard ratio (HR), 1.05 per point], completeness of cytoreduction (CC) score (HR, 2.8), N status (HR, 1.6), signet-ring (HR, 2.4), MSI/WT (HR, 0.5), and MSS/WT-MSI/mutation (HR, 0.4). Similar results were obtained for DFS. CONCLUSION For patients affected by CRC-PM who are eligible for CRS, clinical and pathologic criteria need to be integrated with molecular features (KRAS/BRAF mutation). Micro-satellite status should be strongly considered because MSI confers a survival advantage over MSS, even for mutated patients.
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Affiliation(s)
- Marco Tonello
- Unit of Surgical Oncology of the Esophagus and Digestive Tract, Surgical Oncology Department, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Dario Baratti
- Peritoneal Surface Malignancy Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Paolo Sammartino
- Cytoreductive Surgery and HIPEC Unit, Department of Surgery "Pietro Valdoni", Sapienza University of Rome, Rome, Italy
| | - Andrea Di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Manuela Robella
- Surgical Oncology Unit, Candiolo Cancer Institute, Candiolo, Turin, Italy
| | - Cinzia Sassaroli
- Colorectal Surgical Oncology, Abdominal Oncology Department, Fondazione Giovanni Pascale" IRCCS, Naples, Italy
| | - Massimo Framarini
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Mario Valle
- Peritoneal Malignancies Unit, INT "Regina Elena", Rome, Italy
| | - Antonio Macrì
- Peritoneal Surface Malignancy and Soft Tissue Sarcoma Program, University of Messina, Messina, Italy
| | - Luigina Graziosi
- General and Emergency Surgery Department, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Federico Coccolini
- General Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy.,General Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Piero Vincenzo Lippolis
- General and Peritoneal Surgery, Department of Surgery, Hospital University Pisa (AOUP), Pisa, Italy
| | - Gelmini Roberta
- General and Oncological Surgery Unit, AOU of Modena University of Modena and Reggio Emilia, Modena, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancy Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Daniele Biacchi
- Cytoreductive Surgery and HIPEC Unit, Department of Surgery "Pietro Valdoni", Sapienza University of Rome, Rome, Italy
| | - Francesco Santullo
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Vaira
- Surgical Oncology Unit, Candiolo Cancer Institute, Candiolo, Turin, Italy
| | - Katia Di Lauro
- Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
| | - Fabrizio D'Acapito
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Fabio Carboni
- Peritoneal Malignancies Unit, INT "Regina Elena", Rome, Italy
| | - Giuseppe Giuffrè
- Department of Human Pathology in Adult and Developmental Age 'Gaetano Barresi', Section of Pathology, University of Messina, Messina, Italy
| | - Annibale Donini
- General and Emergency Surgery Department, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Paola Fugazzola
- General Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Pinuccia Faviana
- Pathological Anatomy III, Laboratory Medicine Department, Hospital University Pisa (AOUP), Pisa, Italy
| | - Sorrentino Lorena
- General and Oncological Surgery Unit, AOU of Modena University of Modena and Reggio Emilia, Modena, Italy
| | | | - Paola Del Bianco
- Clinical Research Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Antonio Sommariva
- Unit of Surgical Oncology of the Esophagus and Digestive Tract, Surgical Oncology Department, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy.
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19
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Hanna DN, Ghani MO, Hermina A, Mina A, Bailey CE, Idrees K, Magge D. Diagnostic Laparoscopy in Patients With Peritoneal Carcinomatosis Is Safe and Does Not Delay Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy. Am Surg 2021; 88:698-703. [PMID: 34732056 DOI: 10.1177/00031348211048819] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) among patients with peritoneal carcinomatosis (PC) depend largely on the extent of peritoneal disease. Since PC is not reliably evaluated with cross-sectional imaging, tumor burden is often evaluated with diagnostic laparoscopy (DLS). The aims of this study are to evaluate the safety of DLS in patients with peritoneal disease and determine if DLS delays time to CRS-HIPEC. METHODS We performed an institutional retrospective review of 145 patients who underwent CRS-HIPEC between 2013 and 2020. Patients were divided into 2 groups: those who underwent an electively scheduled DLS prior to CRS-HIPEC and those who did not. Intraoperative and postoperative complications associated with DLS were determined from the surgeon's operative report. Time from diagnosis of PC to CRS-HIPEC was compared between the 2 groups. RESULTS Of the 145 patients available for analysis, 47% (68) underwent DLS and 44% (64) did not. Of all the diagnostic laparoscopies performed, there was 1 (1.5%) intraoperative complication. The duration between diagnosis of peritoneal carcinomatosis and surgery was 4.9 months among patients who underwent DLS prior to CRS-HIPEC and 4.3 months among patients who did not (P = .79). CONCLUSION In this retrospective analysis, diagnostic laparoscopy prior to CRS-HIPEC demonstrated a comparable rate of DLS-associated complications compared to other gastrointestinal malignancies and does not prolong time from diagnosis to CRS-HIPEC. Thus, in patients undergoing evaluation for CRS-HIPEC, diagnostic laparoscopy provides significant value in patient selection without incurring perioperative risk or delay in CRS-HIPEC.
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Affiliation(s)
- David N Hanna
- Section of Surgical Sciences, Division of Surgical Oncology and Endocrine Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Muhammad O Ghani
- Section of Surgical Sciences, Division of Surgical Oncology and Endocrine Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Alexander Mina
- 12327Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Christina E Bailey
- Section of Surgical Sciences, Division of Surgical Oncology and Endocrine Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kamran Idrees
- Section of Surgical Sciences, Division of Surgical Oncology and Endocrine Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Deepa Magge
- Section of Surgical Sciences, Division of Surgical Oncology and Endocrine Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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20
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Pletcher E, Gleeson E, Shaltiel T, Leigh N, Sullivan B, Labow D, Magge D, Golas B, Cohen N, Sarpel U. Lymphocyte-to-monocyte ratio predicts survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Biomark Med 2021; 15:965-975. [PMID: 34289740 DOI: 10.2217/bmm-2020-0720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Lymphocyte-to-monocyte ratio (LMR) predicts overall survival (OS) in patients with colorectal cancer. We explored LMR in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). Materials & methods: We identified all patients undergoing CRS/HIPEC for colorectal or appendiceal adenocarcinoma at our institution. We analyzed LMR's relationship with clinicopathologic variables with Kaplan-Meier log-rank survival analyses and multivariable Cox regression models with 5-year OS. Results: Two hundred and sixteen patients underwent CRS/HIPEC. Five-year OS for low LMR (≤3.71) was 35.2 versus 60.4% for elevated LMR (hazard ratio [HR]: 2.0; 95% CI: 1.1-3.5; p = 0.02). On multivariable Cox-regression, elevated LMR was significantly associated with OS (p ≤ 0.05). Conclusion: LMR is an independent predictor of OS in patients undergoing CRS/HIPEC for colorectal and appendiceal adenocarcinoma.
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Affiliation(s)
- Eric Pletcher
- Division of Surgical Oncology, Department of Surgery, Mount Sinai West, NY 10019, USA
| | - Elizabeth Gleeson
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Tali Shaltiel
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Natasha Leigh
- Division of Surgical Oncology, Department of Surgery, Mount Sinai West, NY 10019, USA
| | - Brianne Sullivan
- Division of Surgical Oncology, Department of Surgery, Mount Sinai West, NY 10019, USA
| | - Daniel Labow
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Deepa Magge
- Division of Surgical Oncology, Department of Surgery, Mount Sinai West, NY 10019, USA
| | - Benjamin Golas
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Noah Cohen
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Umut Sarpel
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
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21
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Simkens GA, Wintjens AGWE, Rovers KP, Nienhuijs SW, de Hingh IH. Effective Strategies to Predict Survival of Colorectal Peritoneal Metastases Patients Eligible for Cytoreductive Surgery and HIPEC. Cancer Manag Res 2021; 13:5239-5249. [PMID: 34234566 PMCID: PMC8257566 DOI: 10.2147/cmar.s277912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/16/2021] [Indexed: 12/11/2022] Open
Abstract
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), often combined with systemic therapy, can be offered to selected colorectal peritoneal metastases (PM) patients. However, clinical heterogeneity and the lack of high-level evidence challenges determination of the correct treatment strategy. This review aims to provide an overview of current strategies to predict survival of colorectal PM patients treated with CRS and HIPEC, guiding clinicians to select a suitable treatment-strategy and to inform patients about their prognosis. First, the prognostic relevance of several clinicopathological prognostic factors, such as extent of PM, location of primary tumor, histology type, and the presence of lymph node or liver metastases will be discussed. Subsequently, special attention will be given to recent developments in several aspects of tumor biology such as RAF/RAS mutations, circulating tumor DNA, immunoprofiling, and consensus molecular subtypes. Finally, currently available prognostic models to predict survival will be evaluated, concluding these models perform moderate to good, but most of them partly rely on intra-operative data. New insights in tumor biology, as well as the reliable assessment of extent of peritoneal disease by diffusion weighted MRI pose promising opportunities to establish an adequate and clinically meaningful preoperative prognostic model in the near future.
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Affiliation(s)
- Geert A Simkens
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Anne G W E Wintjens
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Koen P Rovers
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - Simon W Nienhuijs
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands.,GROW - School for Oncology and Development Biology, Maastricht University, Maastricht, The Netherlands
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22
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Rovers KP, Bakkers C, Nienhuijs SW, Burger JWA, Creemers GJM, Thijs AMJ, Brandt-Kerkhof ARM, Madsen EVE, van Meerten E, Tuynman JB, Kusters M, Versteeg KS, Aalbers AGJ, Kok NFM, Buffart TE, Wiezer MJ, Boerma D, Los M, de Reuver PR, Bremers AJA, Verheul HMW, Kruijff S, de Groot DJA, Witkamp AJ, van Grevenstein WMU, Koopman M, Nederend J, Lahaye MJ, Kranenburg O, Fijneman RJA, van 't Erve I, Snaebjornsson P, Hemmer PHJ, Dijkgraaf MGW, Punt CJA, Tanis PJ, de Hingh IHJT. Perioperative Systemic Therapy vs Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Alone for Resectable Colorectal Peritoneal Metastases: A Phase 2 Randomized Clinical Trial. JAMA Surg 2021; 156:710-720. [PMID: 34009291 DOI: 10.1001/jamasurg.2021.1642] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance To date, no randomized clinical trials have investigated perioperative systemic therapy relative to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) alone for resectable colorectal peritoneal metastases (CPM). Objective To assess the feasibility and safety of perioperative systemic therapy in patients with resectable CPM and the response of CPM to neoadjuvant treatment. Design, Setting, and Participants An open-label, parallel-group phase 2 randomized clinical trial in all 9 Dutch tertiary centers for the surgical treatment of CPM enrolled participants between June 15, 2017, and January 9, 2019. Participants were patients with pathologically proven isolated resectable CPM who did not receive systemic therapy within 6 months before enrollment. Interventions Randomization to perioperative systemic therapy or CRS-HIPEC alone. Perioperative systemic therapy comprised either four 3-week neoadjuvant and adjuvant cycles of CAPOX (capecitabine and oxaliplatin), six 2-week neoadjuvant and adjuvant cycles of FOLFOX (fluorouracil, leucovorin, and oxaliplatin), or six 2-week neoadjuvant cycles of FOLFIRI (fluorouracil, leucovorin, and irinotecan) and either four 3-week adjuvant cycles of capecitabine or six 2-week adjuvant cycles of fluorouracil with leucovorin. Bevacizumab was added to the first 3 (CAPOX) or 4 (FOLFOX/FOLFIRI) neoadjuvant cycles. Main Outcomes and Measures Proportions of macroscopic complete CRS-HIPEC and Clavien-Dindo grade 3 or higher postoperative morbidity. Key secondary outcomes were centrally assessed rates of objective radiologic and major pathologic response of CPM to neoadjuvant treatment. Analyses were done modified intention-to-treat in patients starting neoadjuvant treatment (experimental arm) or undergoing upfront surgery (control arm). Results In 79 patients included in the analysis (43 [54%] men; mean [SD] age, 62 [10] years), experimental (n = 37) and control (n = 42) arms did not differ significantly regarding the proportions of macroscopic complete CRS-HIPEC (33 of 37 [89%] vs 36 of 42 [86%] patients; risk ratio, 1.04; 95% CI, 0.88-1.23; P = .74) and Clavien-Dindo grade 3 or higher postoperative morbidity (8 of 37 [22%] vs 14 of 42 [33%] patients; risk ratio, 0.65; 95% CI, 0.31-1.37; P = .25). No treatment-related deaths occurred. Objective radiologic and major pathologic response rates of CPM to neoadjuvant treatment were 28% (9 of 32 evaluable patients) and 38% (13 of 34 evaluable patients), respectively. Conclusions and Relevance In this randomized phase 2 trial in patients diagnosed with resectable CPM, perioperative systemic therapy seemed feasible, safe, and able to induce response of CPM, justifying a phase 3 trial. Trial Registration ClinicalTrials.gov Identifier: NCT02758951.
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Affiliation(s)
- Koen P Rovers
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Checca Bakkers
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Simon W Nienhuijs
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Geert-Jan M Creemers
- Department of Medical Oncology, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Anna M J Thijs
- Department of Medical Oncology, Catharina Cancer Institute, Eindhoven, the Netherlands
| | | | - Eva V E Madsen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Esther van Meerten
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Miranda Kusters
- Department of Surgery, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Kathelijn S Versteeg
- Department of Medical Oncology, Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
| | - Arend G J Aalbers
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Niels F M Kok
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Tineke E Buffart
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marinus J Wiezer
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Djamila Boerma
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Maartje Los
- Department of Medical Oncology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andreas J A Bremers
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Derk Jan A de Groot
- Department of Medical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Arjen J Witkamp
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Max J Lahaye
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Onno Kranenburg
- Cancer Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Remond J A Fijneman
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Iris van 't Erve
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Patrick H J Hemmer
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Cornelis J A Punt
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
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23
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Engbersen MP, Rijsemus CJV, Nederend J, Aalbers AGJ, de Hingh IHJT, Retel V, Lambregts DMJ, Van der Hoeven EJRJ, Boerma D, Wiezer MJ, De Vries M, Madsen EVE, Brandt-Kerkhof ARM, Van Koeverden S, De Reuver PR, Beets-Tan RGH, Kok NFM, Lahaye MJ. Dedicated MRI staging versus surgical staging of peritoneal metastases in colorectal cancer patients considered for CRS-HIPEC; the DISCO randomized multicenter trial. BMC Cancer 2021; 21:464. [PMID: 33902498 PMCID: PMC8077799 DOI: 10.1186/s12885-021-08168-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 04/11/2021] [Indexed: 12/18/2022] Open
Abstract
Background Selecting patients with peritoneal metastases from colorectal cancer (CRCPM) who might benefit from cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is challenging. Computed tomography generally underestimates the peritoneal tumor load. Diagnostic laparoscopy is often used to determine whether patients are amenable for surgery. Magnetic resonance imaging (MRI) has shown to be accurate in predicting completeness of CRS. The aim of this study is to determine whether MRI can effectively reduce the need for surgical staging. Methods The study is designed as a multicenter randomized controlled trial (RCT) of colorectal cancer patients who are deemed eligible for CRS-HIPEC after conventional CT staging. Patients are randomly assigned to either MRI based staging (arm A) or to standard surgical staging with or without laparoscopy (arm B). In arm A, MRI assessment will determine whether patients are eligible for CRS-HIPEC. In borderline cases, an additional diagnostic laparoscopy is advised. The primary outcome is the number of unnecessary surgical procedures in both arms defined as: all surgeries in patients with definitely inoperable disease (PCI > 24) or explorative surgeries in patients with limited disease (PCI < 15). Secondary outcomes include correlations between surgical findings and MRI findings, cost-effectiveness, and quality of life (QOL) analysis. Conclusion This randomized trial determines whether MRI can effectively replace surgical staging in patients with CRCPM considered for CRS-HIPEC. Trial registration Registered in the clinical trials registry of U.S. National Library of Medicine under NCT04231175.
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Affiliation(s)
- M P Engbersen
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands. .,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - C J V Rijsemus
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - A G J Aalbers
- Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - V Retel
- Department of Psychosocial research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,Department Health Technology and Services Research (HTSR), University of Twente, Drienerlolaan 5, Enschede, The Netherlands
| | - D M J Lambregts
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - E J R J Van der Hoeven
- Department of Radiology, St. Antonius Hospital, Soestwetering 1, 3543 AZ, Utrecht, The Netherlands
| | - D Boerma
- Department of Surgery, St. Antonius Hospital, Soestwetering 1, 3543 AZ, Utrecht, The Netherlands
| | - M J Wiezer
- Department of Surgery, St. Antonius Hospital, Soestwetering 1, 3543 AZ, Utrecht, The Netherlands
| | - M De Vries
- Department of Radiology, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - E V E Madsen
- Department of Surgery, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - A R M Brandt-Kerkhof
- Department of Surgery, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - S Van Koeverden
- Department of Radiology, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - P R De Reuver
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - R G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - N F M Kok
- Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - M J Lahaye
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
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24
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Kranenburg O, van der Speeten K, de Hingh I. Peritoneal Metastases From Colorectal Cancer: Defining and Addressing the Challenges. Front Oncol 2021; 11:650098. [PMID: 33816304 PMCID: PMC8010649 DOI: 10.3389/fonc.2021.650098] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/15/2021] [Indexed: 12/19/2022] Open
Abstract
The presence of peritoneal metastases (PM) in patients with colorectal cancer (CRC) is associated with an extremely poor prognosis. The diagnosis of PM is challenging, resulting in an underestimation of their true incidence. While surgery can be curative in a small percentage of patients, effective treatment for non-operable PM is lacking, and clinical and pre-clinical studies are relatively sparse. Here we have defined the major clinical challenges in the areas of risk assessment, detection, and treatment. Recent developments in the field include the application of organoid technology, which has generated highly relevant pre-clinical PM models, the application of diffusion-weighted MRI, which has greatly improved PM detection, and the design of small clinical proof-of-concept studies, which allows the efficient testing of new treatment strategies. Together, these developments set the stage for starting to address the clinical challenges. To help structure these efforts, a translational research framework is presented, in which clinical trial design is based on the insight gained from direct tissue analyses and pre-clinical (organoid) models derived from CRC patients with PM. This feed-forward approach, in which a thorough understanding of the disease drives innovation in its clinical management, has the potential to improve outcome in the years to come.
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Affiliation(s)
- Onno Kranenburg
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, Netherlands
- Utrecht platform for Organoid Technology, Utrecht University, Utrecht, Netherlands
- *Correspondence: Onno Kranenburg
| | - Kurt van der Speeten
- Department of Surgical Oncology, Faculty of Medicine, Biomedical Research Institute (BIOMED) Research Institute, Hospital Oost-Limburg, Belgium and University Hasselt, Diepenbeek, Belgium
| | - Ignace de Hingh
- Department of Surgery, Research School for Oncology and Developmental Biology, Catharina Hospital Eindhoven, The Netherlands and Maastricht University, Maastricht, Netherlands
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25
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Zager Y, Hoffman A, Dreznik Y, Jacoby H, Cordoba M, Horesh N, Nevler A, Gutman M, Berger Y. Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis from colorectal cancer: The prognostic impact of baseline neutrophil-lymphocyte, platelet-lymphocyte and lymphocyte-monocyte ratios. Surg Oncol 2020; 35:321-327. [PMID: 32977104 DOI: 10.1016/j.suronc.2020.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/14/2020] [Accepted: 09/06/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE In this retrospective analysis we sought to determine if the preoperative neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lymphocyte-monocyte ratio (LMR) were predictive of both operability and survival in those patients presenting with peritoneal carcinomatosis (PC) from colorectal cancer (CRC) who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS Analysis included all patients admitted between 2009 and 2017 with PC from CRC who were treated with curative intent by CRS-Mitomycin C-HIPEC. Patients were assessed pre- and intra-operatively by the PC index (PCI) and by a completeness of cytoreduction (CC) score with calculation of Kaplan-Meier survival curves and multivariate analysis of prognostic factors. Discrimination was made for NLR >3.5, PLR >168.8 and LMR >4.4. RESULTS We identified 98 CRC patients undergoing 105 CRS-HIPEC procedures. There were no associations detected between NLR/PLR/LMR and the rates of incomplete or abandoned CRS cases. Overall survival (OS) after CRS-HIPEC was worse with high versus low NLR (19.9 mths vs. 45.7 mths, respectively; P = 0.009) and also with low versus high LMR (27.1 mths vs. 53.2 mths, respectively; P = 0.01). On multivariate analysis, a low LMR (P = 0.008), the preoperative CT PCI value (P = 0.004), poor tumor differentiation (P = 0.023) and the preoperative CEA level (P < 0.001) were all independent variables associated with a worse OS after surgery. CONCLUSIONS The baseline LMR value may have potential value as a selection tool for CRS-HIPEC in patients with CRC-related PC.
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Affiliation(s)
- Yaniv Zager
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Aviad Hoffman
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Yael Dreznik
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Harel Jacoby
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Mordehay Cordoba
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Nir Horesh
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Avinoam Nevler
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel; Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mordechai Gutman
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Yaniv Berger
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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26
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de Gooyer JM, Elekonawo FMK, Bos DL, van der Post RS, Pèlegrin A, Framery B, Cailler F, Vahrmeijer AL, de Wilt JHW, Rijpkema M. Multimodal CEA-Targeted Image-Guided Colorectal Cancer Surgery using 111In-Labeled SGM-101. Clin Cancer Res 2020; 26:5934-5942. [PMID: 32900795 DOI: 10.1158/1078-0432.ccr-20-2255] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/22/2020] [Accepted: 09/02/2020] [Indexed: 12/09/2022]
Abstract
PURPOSE Intraoperative image guidance may aid in clinical decision-making during surgical treatment of colorectal cancer. We developed the dual-labeled carcinoembryonic antigen-targeting tracer, [111In]In-DTPA-SGM-101, for pre- and intraoperative imaging of colorectal cancer. Subsequently, we investigated the tracer in preclinical biodistribution and multimodal image-guided surgery studies, and assessed the clinical feasibility on patient-derived colorectal cancer samples, paving the way for rapid clinical translation. EXPERIMENTAL DESIGN SGM-101 was conjugated with p-isothiocyanatobenzyl-diethylenetriaminepentaacetic acid (DTPA) and labeled with Indium-111 (111In). The biodistribution of 3, 10, 30, and 100 μg [111In]In-DTPA-SGM-101 was assessed in a dose escalation study in BALB/c nude mice with subcutaneous LS174T human colonic tumors, followed by a study to determine the optimal timepoint for imaging. Mice with intraperitoneal LS174T tumors underwent micro-SPECT/CT imaging and fluorescence image-guided resection. In a final translational experiment, we incubated freshly resected human tumor specimens with the tracer and assessed the tumor-to-adjacent tissue ratio of both signals. RESULTS The optimal protein dose of [111In]In-DTPA-SGM-101 was 30 μg (tumor-to-blood ratio, 5.8 ± 1.1) and the optimal timepoint for imaging was 72 hours after injection (tumor-to-blood ratio, 5.1 ± 1.0). In mice with intraperitoneal tumors, [111In]In-DTPA-SGM-101 enabled preoperative SPECT/CT imaging and fluorescence image-guided resection. After incubation of human tumor samples, overall fluorescence and radiosignal intensities were higher in tumor areas compared with adjacent nontumor tissue (P < 0.001). CONCLUSIONS [111In]In-DTPA-SGM-101 showed specific accumulation in colorectal tumors, and enabled micro-SPECT/CT imaging and fluorescence image-guided tumor resection. Thus, [111In]In-DTPA-SGM-101 could be a valuable tool for preoperative SPECT/CT imaging and intraoperative radio-guided localization and fluorescence image-guided resection of colorectal cancer.
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Affiliation(s)
- Jan Marie de Gooyer
- Department of Radiology, Nuclear Medicine & Anatomy, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands. .,Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Fortuné M K Elekonawo
- Department of Radiology, Nuclear Medicine & Anatomy, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands.,Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Desirée L Bos
- Department of Radiology, Nuclear Medicine & Anatomy, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Rachel S van der Post
- Department of Pathology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - André Pèlegrin
- IRCM, Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Institut régional du Cancer de Montpellier, Montpellier, France
| | | | | | | | - Johannes H W de Wilt
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Mark Rijpkema
- Department of Radiology, Nuclear Medicine & Anatomy, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
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27
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Carboni F, Federici O, Giofrè M, Valle M. An 18-Year Experience in Diagnostic Laparoscopy of Peritoneal Carcinomatosis: Results from 744 Patients. J Gastrointest Surg 2020; 24:2096-2103. [PMID: 31432327 DOI: 10.1007/s11605-019-04368-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/12/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite accurate preoperative imaging assessment, optimal cytoreductive surgery with hyperthermic intraperitoneal chemotherapy remains unfeasible in many patients with peritoneal carcinomatosis at the time of surgery. The aim of this study was to evaluate the role of diagnostic laparoscopy in the selection of candidates. METHODS Prospectively collected data of all patients undergoing diagnostic laparoscopy in our Department were retrospectively analyzed. Demographics and perioperative features as well as operative details and outcome were evaluated. RESULTS The study included 744 consecutive patients. Primary ovarian tumors were the most common indications, followed by gastric tumors and recurrent colorectal cancers. The procedure was successfully completed in 99.73% of cases. Approximately two thirds of them (68%) had undergone previous surgical procedures. The presence of ascites was recorded in 482 patients (64.78%). A total of 374 (50.3%) patients were excluded from surgical exploration. Among those who eventually underwent surgery, CC0 resection was obtained in 64.6% (239) of cases. Understaging of peritoneal carcinomatosis was observed in 11 patients (1.48%). Postoperative mortality was null and 5 (0.8%) complications were observed. Three (0.4%) port-site metastases were recorded at the beginning of the experience. CONCLUSION Diagnostic laparosocopy is a safe and feasible tool able to improve the selection of patients eligible for cytoreduction with hyperthermic intraperitoneal chemotherapy, at the same time allowing avoiding a significant number of unnecessary laparotomies.
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Affiliation(s)
- Fabio Carboni
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, via Elio Chianesi 53, 00144, Rome, Italy.
| | - Orietta Federici
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, via Elio Chianesi 53, 00144, Rome, Italy
| | - Manuel Giofrè
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, via Elio Chianesi 53, 00144, Rome, Italy
| | - Mario Valle
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, via Elio Chianesi 53, 00144, Rome, Italy
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28
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Spectral photon-counting CT imaging of colorectal peritoneal metastases: initial experience in rats. Sci Rep 2020; 10:13394. [PMID: 32770125 PMCID: PMC7414131 DOI: 10.1038/s41598-020-70282-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 07/23/2020] [Indexed: 12/16/2022] Open
Abstract
Computed tomography imaging plays a major role in the preoperative assessment of tumor burden by providing an accurate mapping of the distribution of peritoneal metastases (PM). Spectral Photon Counting Computed Tomography (SPCCT) is an innovative imaging modality that could overcome the current limitations of conventional CT, offering not only better spatial resolution but also better contrast resolution by allowing the discrimination of multiple contrast agents. Based on this capability, we tested the feasibility of SPCCT in the detection of PM at different time of tumor growth in 16 rats inoculated with CC531 cells using dual-contrast injection protocols in two compartments (i.e. intravenous iodine and intraperitoneal gadolinium or the reverse protocol), compared to surgery. For all peritoneal regions and for both protocols, sensitivity was 69%, specificity was 100% and accuracy was 80%, and the correlation with surgical exploration was strong (p = 0.97; p = 0.0001). No significant difference was found in terms of diagnostic performance, quality of peritoneal opacification or diagnostic quality between the 2 injection protocols. We also showed poor vascularization of peritoneal metastases by measuring low concentrations of contrast agent in the largest lesions using SPCCT, which was confirmed by immunohistochemical analyses. In conclusion, SPCCT using dual-contrast agent injection protocols in 2 compartments is a promising imaging modality to assess the extent of PM in a rat model.
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29
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Birgisson H, Enblad M, Artursson S, Ghanipour L, Cashin P, Graf W. Patients with colorectal peritoneal metastases and high peritoneal cancer index may benefit from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Eur J Surg Oncol 2020; 46:2283-2291. [PMID: 32873455 DOI: 10.1016/j.ejso.2020.07.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/07/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Peritoneal cancer index (PCI) >20 is often seen as a contraindication for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with peritoneal metastases (PM) from colorectal cancer. The aim of this study was to compare the overall survival in colorectal PM patients with PCI >20 and PCI ≤20 treated with CRS and HIPEC to those having open-close/debulking procedure only. METHODS All patients with colorectal PM and intention to treat with CRS and HIPEC in Uppsala Sweden 2004-2017 were included. Patients scheduled for CRS and HIPEC were divided into three groups, PCI >20, PCI ≤20, and those not operated with CRS and HIPEC stated as open-close including those treated with palliative debulking. RESULTS Of 201 operations, 112 (56%) resulted in CRS and HIPEC with PCI ≤20, 45 (22%) in CRS and HIPEC with PCI >20 and 44 (22%) resulted in open-close/debulking. Median survival for CRS and HIPEC and PCI >20 was 20 months (95%CI 14-27 months) with 7% surviving longer than 5 years (n = 3). For CRS and HIPEC and PCI ≤20 the median survival was 33 months (95%CI 30-39 months) with 23% (n = 26) surviving >5years. The median survival for open-close was 9 months (95%CI 4-10 months), no one survived >5years. CONCLUSION Patients with PM from colorectal cancer and PCI >20 that were treated with CRS and HIPEC experience a one year longer and doubled overall survival compared with open-close/debulking patients. In addition to PCI, more factors should be taken into account when a decision about proceeding with CRS or not is taken.
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Affiliation(s)
- Helgi Birgisson
- Department of Surgical Sciences, Uppsala University, Sweden.
| | - Malin Enblad
- Department of Surgical Sciences, Uppsala University, Sweden
| | - Sara Artursson
- Department of Surgical Sciences, Uppsala University, Sweden
| | - Lana Ghanipour
- Department of Surgical Sciences, Uppsala University, Sweden
| | - Peter Cashin
- Department of Surgical Sciences, Uppsala University, Sweden
| | - Wilhelm Graf
- Department of Surgical Sciences, Uppsala University, Sweden
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Ellebæk SB, Graversen M, Detlefsen S, Lundell L, Fristrup CW, Pfeiffer P, Mortensen MB. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC)-directed treatment of peritoneal metastasis in end-stage colo-rectal cancer patients. Pleura Peritoneum 2020; 5:20200109. [PMID: 32566727 PMCID: PMC7292236 DOI: 10.1515/pp-2020-0109] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/19/2020] [Indexed: 02/06/2023] Open
Abstract
Background Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) represents a novel approach to intraperitoneal chemotherapy. Hereby results, obtained with PIPAC in patients with advanced peritoneal metastasis (PM) from colorectal cancer (CRC), are presented. Methods Data from CRC patients (n = 24) included in the prospective PIPAC-OPC1 and PIPAC-OPC2 trials are reported. Oxaliplatin 92 mg/m2 was administered at 4-6-week intervals. A CE certified nebulizer was used to aerosolize the chemotherapeutics. Outcome criteria were objective tumor response, survival and adverse events. Results Retrospective analysis of 74 PIPAC procedures carried out in 24 consecutive patients with PM from CRC included from October 2015 to February 2019. Five patients had still the primary tumor in situ, and 22 patients had received palliative systemic chemotherapy. Nineteen patients completed more than two PIPAC procedures, and objective tumor response according to the histological Peritoneal Regression Grading Score (PRGS) was observed in 67% of the patients, while 21% had stable disease. Four patients (21%) had complete response (mean PRGS = 1 and negative cytology). We recorded a median survival of 37.6 (range 7.3–48.9) months from the time of PM diagnosis, whereas it was 20.5 (range 0.13–34.7) months following the first PIPAC session. Minor postoperative complications were noted, and few were considered causally related to the PIPAC treatment. However, two cases of severe postoperative complications were recorded (urosepsis and iatrogenic bowel perforation). Conclusions PIPAC with low-dose oxaliplatin can induce objective tumor regression in selected patients with advanced PM from colorectal cancer.
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Affiliation(s)
| | - Martin Graversen
- Surgical department, Odense Universitetshospital, Odense Denmark
| | - Sönke Detlefsen
- Department of Pathology, Odense Universitetshospital, Odense, Denmark
| | - Lars Lundell
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Claus W Fristrup
- Surgical department, Odense Universitetshospital, Odense Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense Universitetshospital, Odense, Denmark
| | - Michael B Mortensen
- Upper GI and HPB Section, Department of Surgery, Odense Universitetshospital, Odense, Denmark
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31
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Engbersen MP, Aalbers AGJ, Van't Sant-Jansen I, Velsing JDR, Lambregts DMJ, Beets-Tan RGH, Kok NFM, Lahaye MJ. Extent of Peritoneal Metastases on Preoperative DW-MRI is Predictive of Disease-Free and Overall Survival for CRS/HIPEC Candidates with Colorectal Cancer. Ann Surg Oncol 2020; 27:3516-3524. [PMID: 32239338 DOI: 10.1245/s10434-020-08416-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether the extent of peritoneal metastases (PMs) on preoperative diffusion-weighted magnetic resonance imaging (DW-MRI) can be used as a biomarker of disease-free and overall survival in patients with colorectal cancer who are considered for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). METHODS For this retrospective cohort study, patients with PMs considered for CRS/HIPEC who underwent DW-MRI for preoperative staging in 2016-2017 were included. The DW-MRI protocol consisted of diffusion-weighted, T2-weighted, and pre- and post-gadolinium T1-weighted imaging of the chest, abdomen, and pelvis. DW-MRI images were evaluated by two independent readers to determine the extent of PMs represented by the Peritoneal Cancer Index (MRI-PCI), as well as extraperitoneal metastases. Cox regression and Kaplan-Meier analysis was performed to determine the prognostic value of DW-MRI for overall and disease-free survival. RESULTS Seventy-eight patients were included. CRS/HIPEC was planned for 53 patients and completed in 50 patients (60.5%). Median follow-up after DW-MRI was 23 months (interquartile range 13-24). The MRI-PCI of both readers showed prognostic value for overall survival, independently of whether R1 resection was achieved (hazard ratio [HR] 1.06-1.08; p < 0.05). For the patients who received successful CRS/HIPEC, the MRI-PCI also showed independent prognostic value for disease-free survival for both readers (HR 1.09-1.10; p < 0.05). CONCLUSION The extent of PMs on preoperative DW-MRI is an independent predictor of overall and disease-free survival and should therefore be considered as a non-invasive prognostic biomarker.
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Affiliation(s)
- Maurits P Engbersen
- Department of Radiology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Arend G J Aalbers
- Department of Surgery, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Iris Van't Sant-Jansen
- Department of Radiology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jeroen D R Velsing
- Department of Radiology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Doenja M J Lambregts
- Department of Radiology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Niels F M Kok
- Department of Surgery, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Max J Lahaye
- Department of Radiology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, The Netherlands.
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32
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Baron E, Gushchin V, Sittig M, Sardi A. ASO Author Reflections: When Laboratories Could Help Avoid Unnecessary Surgery. Ann Surg Oncol 2020; 27:2557-2558. [PMID: 32189168 DOI: 10.1245/s10434-020-08313-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Ekaterina Baron
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care at Mercy, Baltimore, MD, USA
| | - Vadim Gushchin
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care at Mercy, Baltimore, MD, USA
| | - Michelle Sittig
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care at Mercy, Baltimore, MD, USA
| | - Armando Sardi
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care at Mercy, Baltimore, MD, USA.
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33
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Low RN, Barone RM, Duggan B, Bahador A, Daniels C, Veerapong J. Detection of Mesenteric Tumor Using Dynamic Contrast Enhanced MRI. Ann Surg Oncol 2020; 27:2525-2536. [PMID: 32157527 DOI: 10.1245/s10434-020-08308-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE This study was designed to evaluate the use of a novel imaging technique, dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI), for detecting mesenteric peritoneal metastases. METHODS Thirty-four patients underwent preoperative conventional MRI, including T1, T2, diffusion-weighted (DWI), and delayed gadolinium MRI, as well as DCE MRI. DCE MRI involved imaging the peritoneal cavity every 9 s for 6 min. DCE images were processed to generate parametric maps of tumor vascularity. Two oncologic surgeons and a radiologist reviewed conventional MRI for all tumor and then later reviewed the conventional MRI plus the DCE parametric maps. Images were reviewed for tumor of the parietal peritoneum, porta hepatis, bowel serosa, upper small bowel mesentery, lower small bowel mesentery, and pelvis. Conventional MRI and DCE + MRI findings were compared to operative and histopathologic reports for tumor detection. PCI scores were calculated for surgery, MRI, and DCE. RESULTS Upper mesenteric tumor was present in 21 patients. DCE images showed a sensitivity of 100%, specificity of 92%, and accuracy of 97% compared with conventional MRI sensitivity of 24%, specificity of 93%, and accuracy of 50% (p = 0.006). Lower mesenteric tumor was present in 22 patients. DCE images showed a sensitivity of 100%, specificity of 92%, and accuracy of 97% compared with conventional MRI sensitivity of 45%, specificity of 92%, and accuracy of 62% (p = 0.008). The mean surgical PCI for all 34 patients was 23.4 compared with MRI 20.0 (p = 0.003) and DCE MRI 24.1 (p = 0.26). The addition of the DCE images improved the accuracy of total PCI by > 10% in 16 (0.46) patients. For PCI regions 9-12, the mean surgical PCI was 6.0 compared with MRI 4.8 (p = 0.08) and DCE 6.6 (p = 0.02). The addition of DCE images improved the accuracy of the regional PCI > 10% in 15 (0.43) patients. CONCLUSIONS DCE MRI provides a novel contrast tool that improves detection of mesenteric tumor. Depicting small-volume mesenteric tumor is better on DCE MRI compared with conventional MRI.
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Affiliation(s)
- Russell N Low
- Department of Radiology, Sharp Memorial Hospital, San Diego, CA, USA.
| | - Robert M Barone
- Department of Surgical Oncology, Sharp Memorial Hospital, San Diego, CA, USA
| | - Bridgette Duggan
- Department of Gynecologic Oncology, Sharp Memorial Hospital, San Diego, CA, USA
| | - Afshin Bahador
- Department of Gynecologic Oncology, Sharp Memorial Hospital, San Diego, CA, USA
| | | | - Jula Veerapong
- Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
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Leimkühler M, de Haas RJ, Pol VEH, Hemmer PHJ, Been LB, van Ginkel RJ, Kruijff S, de Bock GH, van Leeuwen BL. Adding diagnostic laparoscopy to computed tomography for the evaluation of peritoneal metastases in patients with colorectal cancer: A retrospective cohort study. Surg Oncol 2020; 33:135-140. [PMID: 32561078 DOI: 10.1016/j.suronc.2020.02.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/13/2020] [Accepted: 02/13/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Despite its widespread use, computed tomography (CT) is not perfect for evaluating peritoneal metastases of colorectal origin before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). We therefore evaluated the value of adding diagnostic laparoscopy to CT when assessing patient eligibility for CRS + HIPEC. METHODS This was a retrospective study of a consecutive series of 112 patients evaluated systematically by diagnostic laparoscopy and CT between January 2012 and January 2018. Patient eligibility for CRS + HIPEC was assessed by the peritoneal cancer index (PCI) both at the time of initial diagnostic laparoscopy and during the retrospective review of CT images. Two experienced radiologists who were blinded to the PCI result at laparoscopy then independently estimated the PCI based on CT imaging. The primary outcome was the number of patients eligible for CRS + HIPEC by each method. RESULTS We identified 112 patients, of whom 95 (85%) were eligible for CRS + HIPEC based on diagnostic laparoscopy and 84 underwent CRS + HIPEC. Overall, 14 patients (17%) experienced an "open-and-close" procedure. In contrast to diagnostic laparoscopy, 100 patients (89%) were identified as being eligible for CRS + HIPEC by CT (p = 0.13), which would have resulted in an additional five open-and-close procedures. CONCLUSIONS Adding diagnostic laparoscopy to CT produced a clinically relevant, but statistically non-significant, reduction in the number of patients eligible for CRS + HIPEC. We conclude that diagnostic laparoscopy may be of use in preoperative assessments when systematic analysis by CT scores the PCI as greater than ten. Future research should focus on the cost-effectiveness of this approach.
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Affiliation(s)
- Maleen Leimkühler
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Robbert J de Haas
- Department of Radiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Vincent E H Pol
- Department of Radiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Patrick H J Hemmer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Lukas B Been
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Robert J van Ginkel
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Schelto Kruijff
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Geertruida H de Bock
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
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Hentzen JEKR, van der Plas WY, Been LB, Hoogwater FJH, van Ginkel RJ, van Dam GM, Hemmer PHJ, Kruijff S. Surgeons' Ability to Predict the Extent of Surgery Prior to Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2020; 27:2997-3008. [PMID: 32052304 PMCID: PMC7334271 DOI: 10.1245/s10434-020-08237-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Indexed: 12/28/2022]
Abstract
Background The extent of surgery (ES) during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is a well-known risk factor for major postoperative morbidity. Interestingly, the reliability of surgeons to predict the ES prior to CRS + HIPEC is unknown. Methods In this prospective, observational cohort study, five surgeons predicted the ES prior to surgery in all consecutive patients with peritoneal metastases (PM) who were scheduled for CRS + HIPEC between March 2018 and May 2019. After the preoperative work-up for CRS + HIPEC was completed, all surgeons independently predicted, for each individual patient, the resection or preservation of 22 different anatomical structures and the presence of a stoma post-HIPEC according to a standardized ES form. The actual ES during CRS + HIPEC was extracted from the surgical procedure report and compared with the predicted ES. Overall and individual positive (PPV) and negative predictive values (NPV) for each anatomical structure were calculated. Results One hundred and thirty-one ES forms were collected from 32 patients who successfully underwent CRS + HIPEC. The number of resections was predicted correctly 24 times (18.3%), overestimated 57 times (43.5%), and underestimated 50 times (38.2%). Overall PPVs for the different anatomical structures ranged between 33.3 and 87.8%. Overall, NPVs ranged between 54.9 and 100%, and an NPV > 90% was observed for 12 anatomical structures. Conclusions Experienced surgeons seem to be able to better predict the anatomical structures that remain in situ after CRS + HIPEC, rather than predict the resections that were necessary to achieve a complete cytoreduction. Electronic supplementary material The online version of this article (10.1245/s10434-020-08237-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Judith E K R Hentzen
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Willemijn Y van der Plas
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lukas B Been
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frederik J H Hoogwater
- Department of Surgery, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert J van Ginkel
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gooitzen M van Dam
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick H J Hemmer
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Schelto Kruijff
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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36
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Baron E, Milovanov V, Gushchin V, Sittig M, Neiroda C, Sardi A. Predicting Aborted Hyperthermic Intraperitoneal Chemotherapy (AHIPEC) with Preoperative Tumor and Inflammatory Markers in Potentially Resectable Appendiceal Cancer Patients with Peritoneal Carcinomatosis. Ann Surg Oncol 2020; 27:2548-2556. [DOI: 10.1245/s10434-019-08117-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Indexed: 11/18/2022]
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37
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Hentzen JEKR, Constansia RDN, Been LB, Hoogwater FJH, van Ginkel RJ, van Dam GM, Hemmer PHJ, Kruijff S. Diagnostic Laparoscopy as a Selection Tool for Patients with Colorectal Peritoneal Metastases to Prevent a Non-therapeutic Laparotomy During Cytoreductive Surgery. Ann Surg Oncol 2019; 27:1084-1093. [PMID: 31641950 PMCID: PMC7060164 DOI: 10.1245/s10434-019-07957-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the introduction of diagnostic laparoscopy (DLS) in patients with colorectal peritoneal metastases (PM) to prevent non-therapeutic laparotomies during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). METHODS Patients with histologically proven colorectal PM who underwent a laparotomy for potential CRS + HIPEC from January 2006 to January 2019 were retrospectively identified from a prospectively maintained database. In 2012, DLS was introduced in the preoperative work-up for CRS + HIPEC in our academic center. The rates of non-therapeutic laparotomies, major postoperative complications (Clavien-Dindo grade III or higher), and survival outcomes were investigated for patients who underwent a laparotomy before (cohort A) and after (cohort B) the introduction of DLS. In cohort B, the reasons to refrain from DLS were retrospectively explored from medical records. RESULTS Overall, 172 patients were included [cohort A: 48 patients (27.9%); cohort B: 124 patients (72.1%)]. A significant drop in the rate of non-therapeutic laparotomies occurred in cohort B compared with cohort A (21.0 vs. 35.4%: p = 0.044), despite only 85 patients (68.5%) from cohort B undergoing DLS in our academic center. The most important reason to refrain from DLS was a recently performed DLS or laparotomy in the referring hospital (48.7%). Major postoperative complications, in-hospital mortality, and survival outcomes were similar for both cohorts. CONCLUSIONS Performing DLS during the preoperative work-up for CRS + HIPEC prevents non-therapeutic laparotomies in patients with colorectal PM. We recommend performing this laparoscopic screening in an experienced HIPEC center.
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Affiliation(s)
- Judith E K R Hentzen
- Division of Surgical Oncology, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Reickly D N Constansia
- Division of Surgical Oncology, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lukas B Been
- Division of Surgical Oncology, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frederik J H Hoogwater
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert J van Ginkel
- Division of Surgical Oncology, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gooitzen M van Dam
- Division of Surgical Oncology, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Nuclear Medicine, Molecular Imaging and Intensive Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick H J Hemmer
- Division of Surgical Oncology, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Schelto Kruijff
- Division of Surgical Oncology, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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The role of single-incision laparoscopic peritoneal exploration in the management of patients with peritoneal metastases. Surg Endosc 2019; 34:2040-2049. [PMID: 31321535 DOI: 10.1007/s00464-019-06984-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 07/15/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The outcome of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) depends on the extent of peritoneal metastases (PM) and the completeness of cytoreduction (CCR). The role of preoperative assessment of PM is to identify potential candidates for CRS/HIPEC and to prevent unwarranted laparotomy for those who are not. Laparoscopy has been utilized for that purpose but with concerns related to technical difficulties and risk of trocar site metastases. Single-incision laparoscopic peritoneal exploration (SILPE) has not yet been evaluated in this setting. METHODS This single-center retrospective study examined patients from January 2011 to December 2015 who underwent SILPE for diagnosis and staging of PM. Preoperative, intraoperative, and postoperative data were collected. For the patients who underwent subsequent laparotomy, a comparison between SILPE and laparotomy findings was made. RESULTS A total of 183 SILPE were performed. Primary sites were mostly colorectal in 72 cases (39.3%) and gastric in 47 (25.7%). Overall, 157 patients (85.8%) had at least one prior abdominal surgery and 48 (26.2%) had 3 or more. SILPE was successfully achieved in 90.2% of the cases. Two (1.2%) intraoperative complications and five (3%) postoperative complications were observed. Eighty-one patients had laparotomy, with a median of 27 days between SILPE and laparotomy (4-162 days). The peritoneal carcinomatosis index PCI was 9.7 ± 7.5 at SILPE, and 13.5 ± 9.6 at laparotomy. The positive predictive value of SILPE to predict CCR was 79.5%. SILPE sensitivity was 75% and specificity 97%. The lowest sensitivity was in regions 9-12 ranging from 44 to 53%. CONCLUSION SILPE can be safely incorporated in the management of patients with PM. It is a safe and feasible staging tool, allowing for preventing unwarranted laparotomy for patients not deemed candidate for CRS/HIPEC. Even though it may underestimate PCI, SILPE accurately predicts the possibility of CCR.
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Maubert A, Birtwisle L, Bernard JL, Benizri E, Bereder JM. Can machine learning predict resecability of a peritoneal carcinomatosis? Surg Oncol 2019; 29:120-125. [PMID: 31196475 DOI: 10.1016/j.suronc.2019.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 04/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Approximately 20% of initially eligible patients in a HIPEC procedure eventually underwent a simple surgical exploration. These procedures are called 'open & close' (O & C) representing up to 48% of surgery. The objective of this study was to predict the resecability of peritoneal carcinomatosis using a machine-learning model for decision-making support, for eligible patients of HIPEC. METHODS The study was conducted as an intention to treat based on three databases including a prospective, between January 2000 and December 2015. A propensity score allowed us to obtain two groups of comparable and matched patients. Subsequently, several algorithm models of classification were studied (simple classification, conditional tree, support vector machine, random forest) to determine the model having the best performance and accuracy. RESULTS Two groups of 155 patients were obtained: one group without resection and one group with resection. Nine criteria of non-resecability reflecting the organ involvement have been retained. They were coded according to their importance. Five classification algorithms were tested. The training data included 218 patients and 92 test data. The random forest model exhibited the best performance with an accuracy of close to 98%. Only two errors of predictions were observed. DISCUSSION The largest number of patients will allow us to improve the precision prediction. Gathering more data such as biologic, radiologic, and even laparoscopic features, should improve the knowledge of the disease and decrease the number of 'O & C' procedures.
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Affiliation(s)
- A Maubert
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France.
| | - L Birtwisle
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - J L Bernard
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - E Benizri
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - J M Bereder
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
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Berger Y, Jacoby H, Kaufmann MI, Ben-Yaacov A, Westreich G, Sharon I, Barda L, Sharif N, Nadler R, Horesh N, Nissan A, Gutman M, Hoffman A. Correlation Between Intraoperative and Pathological Findings for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2019; 26:1103-1109. [PMID: 30746598 DOI: 10.1245/s10434-019-07219-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study aimed to examine the correlation between intraoperative and pathological findings for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) and to determine their prognostic significance. METHODS Pathological reports of all colorectal cancer (CRC) patients undergoing CRS/HIPEC between 2009 and 2016 were retrospectively reviewed. Pathological specimens lacking tumor cells were defined as negative pathological specimens (NPS). The intraoperative peritoneal cancer index (PCI) and pathological PCI (excluding NPS) were calculated separately. Receiver operating characteristic (ROC) curves were applied to compare the prognostic value of intraoperative and pathological scoring systems. RESULTS For 108 CRC patients, 113 CRS/HIPEC procedures were performed. Of 959 pathological specimens examined, 178 (18.6%) were NPS. Overall, 78 procedures (69%) showed NPS. In 52 procedures (46%), the pathological PCI differed from the intraoperative PCI (∆PCI > 0). The ROC areas for intraoperative PCI and pathological PCI were similar in predicting 1-year overall survival (OS), 2-year OS, and 1-year disease-free survival (all p values not significant). However, for the patients with NPS, the number of positive specimens (containing tumor tissue) was superior to intraoperative PCI in predicting 2-year OS (ROC under the curve areas, 0.69 vs. 0.58, respectively; p = 0.012). In addition, a subgroup of 15 patients with a high ∆PCI (≥ 3) had a more favorable median OS than a matched group of 30 patients with similar intraoperative PCI and a ∆PCI of 0 (median survival not reached vs. 21.6 months, respectively; p = 0.05). CONCLUSIONS In the majority of CRC CRS/HIPEC procedures, NPS may be found. Among patients with NPS, pathological correlation may have a prognostic significance.
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Affiliation(s)
- Y Berger
- Department of General Surgery and Transplantation-Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel.
| | - H Jacoby
- Department of General Surgery and Transplantation-Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - M I Kaufmann
- Department of Pathology, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - A Ben-Yaacov
- Department of General and Oncological Surgery-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - G Westreich
- Department of General and Oncological Surgery-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - I Sharon
- Department of General and Oncological Surgery-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - L Barda
- Department of General Surgery and Transplantation-Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - N Sharif
- Department of General Surgery and Transplantation-Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - R Nadler
- Department of General Surgery and Transplantation-Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - N Horesh
- Department of General Surgery and Transplantation-Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - A Nissan
- Department of General and Oncological Surgery-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - M Gutman
- Department of General Surgery and Transplantation-Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
| | - A Hoffman
- Department of General Surgery and Transplantation-Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel
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Dresen RC, De Vuysere S, De Keyzer F, Van Cutsem E, Prenen H, Vanslembrouck R, De Hertogh G, Wolthuis A, D'Hoore A, Vandecaveye V. Whole-body diffusion-weighted MRI for operability assessment in patients with colorectal cancer and peritoneal metastases. Cancer Imaging 2019; 19:1. [PMID: 30616608 PMCID: PMC6322317 DOI: 10.1186/s40644-018-0187-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 12/26/2018] [Indexed: 02/06/2023] Open
Abstract
Background Correct staging of patients with colorectal cancer is of utmost importance for the prediction of operability. Although computed tomography (CT) has a good overall performance, estimation of peritoneal cancer spread is a known weakness, a problem that cannot always be overcome by Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT); especially in infiltrative and miliary disease spread. Due to its high spatial and contrast resolution magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) might have a better performance. Our aim was to evaluate the added value of whole-body diffusion-weighted MRI (WB-DWI/MRI) to CT for prediction of peritoneal cancer spread and operability assessment in colorectal cancer patients with clinically suspected peritoneal carcinomatosis (PC). Methods This institutional review board approved retrospective study included sixty colorectal cancer patients who underwent WB-DWI/MRI in addition to CT for clinically suspected peritoneal metastases. WB-DWI/MRI and CT were assessed for detecting PC following the peritoneal cancer index (PCI), determination of PCI-score categorized as PC < 12, PCI = 12–15 and PCI > 15, detection of nodal and distant metastases and estimation of overall operability. Histopathology after surgery and biopsy and/or 6 months follow-up were used as reference standard. Results For detection of PC, CT had 43.2% sensitivity, 95.6% specificity, 84.5% positive predictive value (PPV) and 75.2% negative predictive value (NPV). WB-DWI/MRI had 97.8% sensitivity, 93.2% specificity, 88.9% PPV and 98.7% NPV. WB-DWI/MRI enabled better detection of inoperable distant metastases (all 12 patients) than CT (2/12 patients) and significantly improved prediction of PCI category [WB-DWI/MRI PCI < 12: 37/39 patients (94.9%); PCI = 12–15: 4/4 patients (100%); PCI > 15: 16/17 patients (94.1%) versus CT PCI < 12: 38/39 patients (97.4%); PCI = 12–15: 0/4 patients (0%); PCI > 15: 2/17 patients (11.8%); p < 0.0001)]. WB-DWI/MRI improved prediction of inoperability over CT with 90.6% sensitivity compared to 25% (p < 0.0001). Conclusions WB-DWI/MRI significantly outperformed CT for estimation of spread of PC, overall staging and prediction of operability. Pending validation in larger prospective trials, WB-DWI/MRI could be used to guide surgical planning and minimize unnecessary exploratory laparotomies.
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Affiliation(s)
- Raphaëla Carmen Dresen
- Department of Radiology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Sofie De Vuysere
- Department of Radiology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Frederik De Keyzer
- Department of Radiology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Eric Van Cutsem
- Department of Digestive Oncology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Hans Prenen
- Department of Digestive Oncology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Ragna Vanslembrouck
- Department of Radiology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Gert De Hertogh
- Department of Pathology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, from the University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, from the University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Vincent Vandecaveye
- Department of Radiology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
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Abstract
MRI provides considerable advantages for imaging of patients with peritoneal tumor. Its inherently superior contrast resolution compared with computed tomography allows MRI to more accurately depict small peritoneal tumors that are often missed on other imaging tests. Combining different contrast mechanisms, including diffusion-weighted MRI and gadolinium-enhanced MRI, provides a powerful tool for preoperative and surveillance imaging in patients being considered for cytoreductive surgery and heated intraperitoneal chemotherapy.
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Affiliation(s)
- Russell N Low
- Department of Radiology, Sharp Memorial Hospital, 7901 Frost Street, San Diego, CA 92123, USA.
| | - Robert M Barone
- Department of Surgical Oncology, Sharp Memorial Hospital, 7901 Frost Street, San Diego, CA 92123, USA
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Sluiter NR, Vlek SL, Wijsmuller AR, Brandsma HT, de Vet HCW, van Grieken NCT, Kazemier G, Tuynman JB. Narrow-Band Imaging Improves Detection of Colorectal Peritoneal Metastases: A Clinical Study Comparing Advanced Imaging Techniques. Ann Surg Oncol 2018; 26:156-164. [PMID: 30421052 PMCID: PMC6338718 DOI: 10.1245/s10434-018-7005-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Indexed: 12/20/2022]
Abstract
Background Colorectal peritoneal metastases (PM) are often diagnosed in an advanced disease stage. Cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) improve survival of patients with colorectal PM, although most benefit is seen in patients with limited peritoneal disease. Advanced imaging techniques might improve the detection of PM, potentially leading to earlier diagnosis and improved cytoreduction. This prospective clinical trial compared three advanced techniques with conventional white-light imaging for the detection of colorectal PM: narrow-band imaging (NBI), near-infrared indocyanine green fluorescent imaging (NIR-ICG), and spray-dye chromoendoscopy (SDCE).
Methods Patients with colorectal PM were prospectively included. Prior to cytoreduction and HIPEC, all abdominal regions were inspected with white-light imaging, NBI, NIR-ICG, and SDCE during exploratory laparoscopy. Primary endpoints were sensitivity and specificity for the detection of PM, using pathological examination of biopsied lesions as the reference standard. The safety of all techniques was assessed. Results Between May 2016 and March 2018, four different techniques were analyzed in 28 patients, resulting in 169 biopsies. Sensitivity for the detection of PM significantly increased from 80.0% with white light to 96.0% with NBI (p = 0.008), without loss of specificity (74.8% vs. 73.1%, respectively, p = 0.804). The use of NIR-ICG and SDCE was discontinued after 10 patients had undergone treatment because the lesions were not fluorescent using NIR-ICG, and because SDCE did not visualize the whole peritoneum. No adverse events relating to the imaging techniques occurred. Conclusion NBI substantially increased the detection of PM. This method is safe and could improve the detection of metastatic lesions and help optimize cytoreduction in patients with colorectal PM. Electronic supplementary material The online version of this article (10.1245/s10434-018-7005-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nina Roelie Sluiter
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Stijn Lucas Vlek
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Arthur Randolph Wijsmuller
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Henk Thijs Brandsma
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | | | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jurriaan Benjamin Tuynman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Guerrero W, Munene G, Dickson PV, Stiles ZE, Mays J, Davidoff AM, Glazer ES, Shibata D, Deneve JL. Outcome and factors associated with aborted cytoreduction for peritoneal carcinomatosis. J Gastrointest Oncol 2018; 9:664-673. [PMID: 30151262 DOI: 10.21037/jgo.2018.04.05] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) offers a potential cure for peritoneal carcinomatosis (PC), whereas aborted cytoreduction is associated with a poor outcome. We evaluate factors associated with aborted CRS procedures. Methods An IRB approved retrospective review was performed from 12/2011 to 2/2016. Clinicopathologic variables and outcomes are described. Results Seventy-four patients underwent attempted CRS/HIPEC which was completed in 51 (69%) and aborted in 23 (31%). There was no difference in age, race, gender or prior treatment between groups. Patients who underwent aborted procedures had a higher peritoneal cancer index (PCI, 26.1±9.9 vs. 16.2±10.5, P=0.001). Overall survival (OS) was significantly improved for patients who underwent completed CRS/HIPEC (41.0±10.4 vs. 6.0±2.3 months, P<0.0001). Patients with an appendiceal and colorectal primary who underwent CRS/HIPEC had a significantly better outcome (median not reached vs. 6±5.4 months, P<0.0001, and 28.0±7.5 vs. 8.0±4.0 months, P<0.0001, respectively). Colorectal pathology (P=0.014) and PCI score (<0.0001) were independent predictors of aborted CRS procedures. Conclusions One-third of patients with PC had significant disease which prevented successful completion of CRS/HIPEC. PCI and colorectal primary tumor pathology were associated with a greater likelihood of aborted CRS procedures.
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Affiliation(s)
- Whitney Guerrero
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Gitonga Munene
- Western Michigan University, Homer Stryker School of Medicine, West Michigan Cancer Center, Kalamazoo, MI, USA
| | - Paxton V Dickson
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Zachary E Stiles
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Johnathan Mays
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew M Davidoff
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Evan S Glazer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David Shibata
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Preoperative CT-based predictive factors for resectability and medium-term overall survival in patients with peritoneal carcinomatosis from colorectal cancer. Clin Radiol 2018; 73:756.e11-756.e16. [DOI: 10.1016/j.crad.2018.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/22/2018] [Indexed: 12/12/2022]
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Glockzin G, Zeman F, Croner RS, Königsrainer A, Pelz J, Ströhlein MA, Rau B, Arnold D, Koller M, Schlitt HJ, Piso P. Perioperative Systemic Chemotherapy, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy in Patients With Colorectal Peritoneal Metastasis: Results of the Prospective Multicenter Phase 2 COMBATAC Trial. Clin Colorectal Cancer 2018; 17:285-296. [PMID: 30131226 DOI: 10.1016/j.clcc.2018.07.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/21/2018] [Accepted: 07/24/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) as parts of an interdisciplinary treatment concept including systemic chemotherapy can improve survival of selected patients with peritoneal metastatic colorectal cancer (pmCRC). Nevertheless, the sequence of the therapeutic options is still a matter of debate. Thus, the COMBATAC (COMBined Anticancer Treatment of Advanced Colorectal cancer) trial was conducted to evaluate a combined treatment regimen consisting of preoperative systemic polychemotherapy + cetuximab followed by CRS + HIPEC and postoperative systemic polychemotherapy + cetuximab. PATIENTS AND METHODS The COMBATAC trial is a prospective, multicenter, open-label, single-arm, single-stage phase 2 trial. Twenty-six patients with synchronous or metachronous colorectal or appendiceal peritoneal carcinomatosis were included. Enrollment was terminated prematurely by the sponsor because of slow recruitment. Progression-free survival as primary end point and overall survival were estimated by the Kaplan-Meier method. Also evaluated were morbidity according to Common Terminology Criteria for Adverse Events v4.0 and feasibility of the combined treatment concept. RESULTS Median progression-free survival for the intention-to-treat population (n = 25) was 14.9 months. Median overall survival was not reached during the study duration. Ninety-two adverse events were documented in 16 patients, including 14 serious adverse events in 9 patients. The overall morbidity rate was 64%, and the grade 3/4 morbidity rate was 44%. Of all grade 3/4 morbidity events, 36.4% were related to systemic chemotherapy and 22.7% to surgery, whereas 40.9% were not directly related. There was no treatment-related mortality. CONCLUSION The results of the COMBATAC trial show that the multimodal treatment concept consisting of perioperative systemic chemotherapy and CRS + HIPEC is safe and feasible. Progression-free survival in selected patients with colorectal or appendiceal peritoneal metastasis might be improved.
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Affiliation(s)
- Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany; Department of Surgery, Klinikum Bogenhausen, Munich, Germany.
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Roland S Croner
- Department of Surgery, University of Erlangen-Nuremberg, Erlangen, Germany; Department of Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Alfred Königsrainer
- Department of Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen, Germany
| | - Jörg Pelz
- Department of Surgery, University Hospital Würzburg, Würzburg, Germany; Department of Surgery, St Bernward Hospital, Hildesheim, Germany
| | - Michael A Ströhlein
- Department of Abdominal, Vascular and Transplant Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Beate Rau
- Department of Surgery, Campus Virchow and Mitte, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk Arnold
- Asklepios Tumor Center Hamburg, AK Altona, Department of Oncology, Hamburg, Germany
| | - Michael Koller
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Hans J Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Pompiliu Piso
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany; Department of Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
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Wang W, Tan GHC, Skanthakumar T, Chia CS, Soo KC, Teo MCC. Exploring the trend in referrals for consideration of CRS and HIPEC to understand the attitudes of clinicians in the development of a national cancer centre programme in peritoneal disease. Int J Hyperthermia 2017; 34:551-558. [DOI: 10.1080/02656736.2017.1387939] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Weining Wang
- Division of Surgical Oncology, National Cancer Centre Singapore, Singapore
| | | | | | | | - Khee Chee Soo
- Division of Surgical Oncology, National Cancer Centre Singapore, Singapore
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48
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Wang W, Tan GHC, Chia CS, Skanthakumar T, Soo KC, Teo MCC. Are positron emission tomography-computed tomography (PET-CT) scans useful in preoperative assessment of patients with peritoneal disease before cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)? Int J Hyperthermia 2017; 34:524-531. [DOI: 10.1080/02656736.2017.1366554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Weining Wang
- National Cancer Centre Singapore, Singapore, Singapore
| | | | | | | | - Khee Chee Soo
- National Cancer Centre Singapore, Singapore, Singapore
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49
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Maciver AH, Lee N, Skitzki JJ, Boland PM, Francescutti V. Cytoreduction and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) in colorectal cancer: Evidence-based review of patient selection and treatment algorithms. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2017; 43:1028-1039. [PMID: 28029523 DOI: 10.1016/j.ejso.2016.09.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/29/2016] [Accepted: 09/13/2016] [Indexed: 02/06/2023]
Abstract
Cytoreduction and heated intraperitoneal chemotherapy (CS/HIPEC) is increasingly utilized as a treatment strategy for patients with peritoneal metastases from various primary tumor sites. For this heterogenous procedure, related to patient characteristics, patient selection, and the extent of surgical completeness of cytoreduction, high level evidence (ex: multiple randomized controlled trials) is not available to support efficacy. This review of the available literature supporting application of the procedure, focusing on colorectal cancer, provides a summary of current evidence for patient selection and treatment algorithms based on patient presentation.
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Affiliation(s)
- A H Maciver
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - N Lee
- Department of Internal Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - J J Skitzki
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - P M Boland
- Department of Medical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - V Francescutti
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA.
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50
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Lee L, Alie-Cusson F, Dubé P, Sideris L. Postoperative complications affect long-term outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis. J Surg Oncol 2017; 116:236-243. [PMID: 28409831 DOI: 10.1002/jso.24632] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 03/09/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Morbidity after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) for colorectal peritoneal carcinomatosis (PC) may negatively affect survival. The objective was to determine the impact of postoperative complications (CX) on survival in patients undergoing CRS + HIPEC for colorectal PC. METHODS All patients undergoing laparotomy for planned CRS + HIPEC for colorectal PC at a single institution from 1999 to 2014 were included. Patients were divided into three groups: CRS + HIPEC without CX (+HIPEC-CX); CRS + HIPEC with postoperative complication (+HIPEC + CX); and aborted CRS and HIPEC due to unresectable disease (-HIPEC). Postoperative morbidity were defined as Clavien II+ complications. Kaplan-Meier survival analyses and multivariable Cox proportional hazard modeling were used to describe the disease-free (DFS) and overall survival (OS). RESULTS One hundred and twenty-two patients were included in the analysis (50 +HIPEC - CX, 40 +HIPEC + CX, 32-HIPEC). Overall complication rate was 42%. OS at 1-, 3-, and 5-years in patients undergoing successful CRS + HIPEC were 97%, 67%, and 45%. CX after successful CRS + HIPEC was independently associated with worsened OS (HR1.58, 95%CI, 1.19-1.97) but not DFS (HR1.11, 95%CI, 0.56-2.20). PCI also independently predicted worsened DFS (HR1.12, 95%CI, 1.06-1.18) and OS (HR1.08, 95%CI, 1.04-1.12). Patients with unresectable disease had significantly worse OS (HR6.50, 95%CI, 1.37-7.01). CONCLUSIONS CX after CRS + HIPEC significantly affect OS. Patient selection and perioperative care are of paramount importance in the management of CRS + HIPEC for colorectal PC.
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Affiliation(s)
- Lawrence Lee
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Quebec, Canada
| | - Fanny Alie-Cusson
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Quebec, Canada
| | - Pierre Dubé
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Quebec, Canada
| | - Lucas Sideris
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Quebec, Canada
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