Peritoneal carcinomatosis: cytoreductive surgery and HIPEC--overview and basics

A Case of Primary Peritoneal Adenocarcinoma: Diagnostic and Therapeutic Challenges

Primary peritoneal adenocarcinoma (PPA) is a rare and aggressive malignancy that closely resembles high-grade serous ovarian carcinoma but originates from the peritoneal lining with minimal ovarian involvement. We present the case of a 72-year-old female patient with a history of endometrial cancer who developed progressive ascites, recurrent hospitalizations, and a hypercoagulable state. Imaging revealed peritoneal carcinomatosis, and paracentesis confirmed high-grade serous carcinoma through immunohistochemical staining. Despite initial plans for chemotherapy, treatment was deferred for outpatient initiation. Due to disease progression, she underwent cytoreductive surgery with tumor debulking, but pathology confirmed metastatic spread. Postoperative complications included hypotension and ileus, which extended hospitalization. This case highlights the diagnostic and therapeutic challenges of PPA, emphasizing the need for a multidisciplinary approach to optimize patient outcomes.

Long-term intraperitoneal access with description of a new access catheter

BACKGROUND AND OBJECTIVES

Intraperitoneal chemotherapy can be administered as a single dose associated with hyperthermia (HIPEC) or in successive doses under normothermic conditions, such as early postoperative intraperitoneal chemotherapy (EPIC) or normothermic intraperitoneal chemotherapy (NIPEC or NIPEC-LT). Repetitive administration of intraperitoneal chemotherapy over a prolonged period may be associated with catheter-related complications, which are the primary cause of treatment interruption. This study aims to introduce and evaluate an innovative catheter system designed to mitigate these issues.

METHODS

Using a porcine experimental model, we tested a new catheter for long-term intraperitoneal access. Sixteen animals underwent catheter implantation followed by normothermic recirculation of peritoneal dialysis solution. Catheter functionality and any complications were monitored throughout successive treatment cycles.

RESULTS

The new catheter system demonstrated optimal recirculation and maintained its functionality throughout successive treatments, without complications. Catheter replacement with a guidewire was successful, ensuring continued efficacy.

CONCLUSIONS

The innovative catheter system shows promise in reducing complications and improving compliance in successive intraperitoneal chemotherapy doses, justifying further clinical trials to confirm its efficacy in patients.

The Importance of Preoperative NLR, PLR, and MPV Values in Predicting the Risk of Complications in Colorectal Peritoneal Carcinomatosis

BACKGROUND

Colorectal cancer peritoneal carcinomatosis (CRC PC) necessitates preoperative assessment of inflammatory markers to predict postoperative outcomes and guide treatment. This study aims to evaluate the prognostic value of preoperative Neutrophil-Lymphocyte Ratio (NLR), Platelet-Lymphocyte Ratio (PLR), and Mean Platelet Volume (MPV) in predicting complications for CRC PC patients undergoing surgery.

METHODS

Calculating NLR, PLR, and MPV from patient data: NLR = absolute neutrophil count/total lymphocyte count, PLR = total lymphocyte count/total platelet count × 100, and MPV = platelet crit (PCT)/total platelet count.

RESULT

The study included 196 CRC PC patients and found significant relationships between these markers and overall survival (OS). Patients with an NLR of 3.77 had a median OS of 22.1 months, compared to 58.3 months for those with lower NLR (HR 2.7, 95% CI 1.1-5.3, p < 0.001).

CONCLUSIONS

For CRC PC patients undergoing CRS+HIPEC, preoperative assessment of NLR, PLR, and MPV can serve as independent prognostic markers for OS. Incorporating these markers into preoperative evaluations may improve patient selection and outcome prediction.

Risk Scoring System to Predict Mortality in Gastric Cancer with Peritoneal Carcinomatosis

Gastric cancer (GC) with peritoneal carcinomatosis (PC) has a particularly unfavorable prognosis. This limited survival raises doubts about which factors confer an extremely worse outcome and which patients could benefit from more aggressive treatments, in an attempt to improve survival and better control the disease. This study aimed to evaluate the survival outcomes of patients with PC due to GC and develop a prognostic score to predict 6-month mortality. We performed an analysis of clinical stage IV GC with PC. Scores were assigned to risk factors and calculated for each patient from nine variables. Among 326 IVB GC, 211 (64.7%) had PC and were included. After calculating the score, 136 (64.5%) GCs were classified as a low-risk group and 75 (35.5%) as a high-risk group. Median OS was 7.9 and 1.9 months for low- and high-risk patients (p < 0.001). In the high-risk group, 77.3% of the patients died in <6 mo (p < 0.001). Palliative surgery and chemotherapy were associated with better survival, and the prognostic groups maintained statistical significance even when the same type of treatment was performed. In conclusion, the scoring system developed with variables related to patient performance status and clinical data was able to distinguish GC with PC with a high risk of 6-month mortality. Accordingly, verifying and validating our findings in a large cohort of patients is necessary to confirm and guarantee the external validation of the results.

A machine learning approach for predicting textbook outcome after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

INTRODUCTION

Peritoneal carcinomatosis is considered a late-stage manifestation of neoplastic diseases. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) can be an effective treatment for these patients. However, the procedure is associated with significant morbidity. Our aim was to develop a machine learning model to predict the probability of achieving textbook outcome (TO) after CRS-HIPEC using only preoperatively known variables.

METHODS

Adult patients with peritoneal carcinomatosis and who underwent CRS-HIPEC were included from a large, single-center, prospectively maintained dataset (2001-2020). TO was defined as a hospital length of stay ≤14 days and no postoperative adverse events including any complications, reoperation, readmission, and mortality within 90 days. Four models (logistic regression, neural network, random forest, and XGBoost) were trained, validated, and a user-friendly risk calculator was then developed.

RESULTS

A total of 1954 CRS-HIPEC procedures for peritoneal carcinomatosis were included. Overall, 13% (n = 258) achieved TO following CRS-HIPEC procedure. XGBoost and logistic regression had the highest area under the curve (AUC) (0.76) after model optimization, followed by random forest (AUC 0.75) and neural network (AUC 0.74). The top preoperative variables associated with achieving a TO were lower peritoneal cancer index scores, not undergoing proctectomy, splenectomy, or partial colectomy and being asymptomatic from peritoneal metastases prior to surgery.

CONCLUSION

This is a data-driven study to predict the probability of achieving TO after CRS-HIPEC. The proposed pipeline has the potential to not only identify patients for whom surgery is not associated with prohibitive risk, but also aid surgeons in communicating this risk to patients.

Using HPLC for the determination of platinum drugs in biological matrixes after derivatization with diethyldithiocarbamate

Challenges and pitfalls in the application of diethyldithiocarbamate derivatization for LC analysis of cisplatin and oxaliplatin, as well as the suitability of this method for different biological matrices with implications for use in routine practice have been identified. The LC of platinum drugs presents a significant challenge. They are polar compounds with poor retention on reverse phase packings. Cisplatin also exhibits poor absorption in UV and ionization in mass spectrometry. Therefore, we developed and optimized a derivatization approach for the LC analysis of total platinum in plasma, plasma ultrafiltrate, peritoneal fluid, and urine. Derivatization in urine proved to be difficult due to the complexity of the matrix, and extended testing was required. Our results highlight the important issues affecting the efficiency, reliability, and suitability of platinum drug derivatization. Although precolumn derivatization is less selective than its postcolumn counterpart, the application of precolumn derivatization is a simple, rapid, and universal approach for the determination of platinum drugs by HPLC. One of its major advantages is that it allows a more affordable analysis using UV detection without the need for additional high-end instrumentation such as a MS detector.

Treatment of Peritoneal Surface Malignancies by Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Spain: Results of the National Registry of the Spanish Group of Peritoneal Oncologic Surgery (REGECOP)

INTRODUCTION

Treatment of Peritoneal Surface Malignancies (PSM) with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has achieved results never seen before in these patients, which classically have a poor prognosis. The possibility of conducting clinical trials in these diseases is complicated, since some of them are rare, so the analysis of large databases provides very valuable scientific information. The aim of this study is to analyze the global results of the National Registry of the Spanish Group of Peritoneal Oncologic Surgery (REGECOP), whose objective is to register all patients scheduled for HIPEC nationwide.

METHODS

This is a retrospective analysis of the data recorded in the REGECOP from 36 Spanish hospitals from 2001 to 2021. There were 4159 surgical interventions in 3980 patients.

RESULTS

66% are women and 34% are men with a median age of 59 years (range 17-86). 41.5% of the patients were treated for Peritoneal Metastases (PM) of colorectal cancer (CRC); 32.4% were women with ovarian cancer (OC) with PM; 12.8% were treated for pseudomyxoma peritonei (PMP); 6.2% had PM from gastric cancer (GC); 4.9% had PM of non-conventional origin; and, finally, 2.1% of cases were patients diagnosed with peritoneal mesothelioma. The median Peritoneal Cancer Index (PCI) was 9 (0-39), and complete cytoreduction was achieved in 81.7% of the procedures. Severe morbidity (Dindo-Clavien grade III-IV) was observed in 17.7% of surgeries, with 2.1% mortality. Median hospital stay was 11 days (0-259). Median overall survival (OS) was 41 months for CRC patients, 55 months for women with OC, was not reached in PMP patients, was 14 months for GC patients, and 66 months in mesothelioma patients.

CONCLUSIONS

large databases provide extremely useful data. CRS with HIPEC in referral centers is a safe treatment with encouraging oncologic results in PSM.

Gastric Cancer with Peritoneal Metastases: Current Status and Prospects for Treatment

Gastric cancer (GC) has a poor prognostic and only one in four patients will have survived by 5 years after diagnosis. These poor results are due to the fact that most patients are diagnosed in advanced stages; peritoneal metastases (PM) are especially frequent and are difficult to treat. Currently, PM are considered a terminal stage of GC with a poor survival rate and are treated with palliative systemic chemotherapy. Since the beginning of the century, the treatment of PM from different origins has evolved; cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have become the treatment of choice for many malignant diseases that affect the peritoneum. CRS and HIPEC have also been used for patients with GC and PM, achieving survival results that have never been achieved when using systemic chemotherapy alone. The use of HIPEC can even prevent the development of peritoneal recurrences in patients with locally advanced GC as adjuvant therapy, can reduce the volume of peritoneal disease as neoadjuvant therapy, and can control symptoms in a palliative setting. The aim of this review is to collate the current scientific evidence regarding the treatment of PM of GC origin with surgery and intraperitoneal chemotherapy.

First experience with 224Radium-labeled microparticles (Radspherin®) after CRS-HIPEC for peritoneal metastasis in colorectal cancer (a phase 1 study)

Background

Peritoneal metastasis (PM) from colorectal cancer carries a dismal prognosis despite extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). With a median time to recurrence of 11-12 months, there is a need for novel therapies. Radspherin® consists of the α-emitting radionuclide radium-224 (²²⁴Ra), which has a half-life of 3.6 days and is adsorbed to a suspension of biodegradable calcium carbonate microparticles that are designed to give short-range radiation to the serosal peritoneal surface linings, killing free-floating and/or tumor cell clusters that remain after CRS-HIPEC.

Methods

A first-in-human phase 1 study (EudraCT 2018-002803-33) was conducted at two specialized CRS-HIPEC centers. Radspherin® was administered intraperitoneally 2 days after CRS-HIPEC. Dose escalation at increasing activity dose levels of 1-2-4-7-MBq, a split-dose repeated injection, and expansion cohorts were used to evaluate the safety and tolerability of Radspherin®. The aim was to explore the recommended dose and biodistribution using gamma-camera imaging. The results from the planned safety interim analysis after the completion of the dose-limiting toxicity (DLT) period of 30 days are presented.

Results

Twenty-three patients were enrolled: 14 in the dose escalation cohort, three in the repeated cohort, and six in the expansion cohort. Of the 23 enrolled patients, seven were men and 16 were women with a median age of 64 years (28-78). Twelve patients had synchronous PM stage IV and 11 patients had metachronous PM [primary stage II; (6) and stage III; (5)], with a disease-free interval of 15 months (3-30). The peritoneal cancer index was median 7 (3-19), operation time was 395 min (194-515), and hospital stay was 12 days (7-37). A total of 68 grade 2 adverse events were reported for 17 patients during the first 30 days; most were considered related to CRS and/or HIPEC. Only six of the TEAEs were evaluated as related to Radspherin®. One TEAE, anastomotic leakage, was reported as grade 3. Accordion ≥3 grade events occurred in a total of four of the 23 patients: reoperation due to anastomotic leaks (two) and drained abscesses (two). No DLT was documented at the 7 MBq dose level that was then defined as the recommended dose. The biodistribution of Radspherin® showed a relatively even peritoneal distribution.

Conclusion

All dose levels of Radspherin® were well tolerated, and DLT was not reached. No deaths occurred, and no serious adverse events were considered related to Radspherin®.Clinical Trial Registration: Clinicaltrials.gov, NCT03732781.

Synchronizing the release rates of topotecan and paclitaxel from a self-eroding crosslinked chitosan - PLGA platform

This study is a continuation of a previous study in which two model drugs, sodium salicylate (highly water-soluble) and indomethacin (low water-soluble) were loaded into an erodible hydrogel, made of ionically crosslinked chitosan (x-Ct). The erosion rate of the x-Ct matrix was controlled by its immersion in calcium chloride solutions (de-crosslinker) of different concentrations, leading to synchronization of the release rates of the two drugs over 2 h. In the present study, a modified platform was developed in order to (a) synchronize the release rates of the two cytotoxic drugs, topotecan (TT, highly water soluble) and paclitaxel (PTX, poorly water soluble); (b) prolong the erosion duration and the derived concomitant release of the two drugs to several days. TT was loaded into a PLGA sphere, which was co-loaded with calcium chloride (CaCl₂). The sphere was then placed in an aqueous solution of chitosan (Ct) in which PTX was dispersed. A PLGA core-containing hydrogel was then produced by ionically crosslinking the Ct. The formulation screening section of the study includes a statistically designed Fractional Factorial experiment. It was comprised of the following five experimental factors: (a) the type of Ct and (b) its relative amount in the formulation, (c) the type of ionic crosslinker (citric acid or oxalic acid), (d) the concentration of the ionic crosslinker and (e) the co-loaded amounts of CaCl₂ (the constitutional de-crosslinking agent). The difference factor, f1, and the similarity factor, f2, of the TT and PTX release profiles into water, were used as the experimental responses. The computerized prediction models were employed to assess the collective effects of the pre-determined experimental factors on the difference factor, f1, and the similarity factor, f2 (the response factors), by employing a fractional factorial design and multifactorial analysis, without the need to account for the exact mechanisms of the release processes involved. The final composite platform was capable of releasing TT and PTX, at similar (concomitant) rates, over a period of 7 days, a finding which suggests that the novel polymeric platform may serve as a multi-drug implant. An attractive medical application for such a device would be post-operative local treatment that could benefit from localized combination chemotherapy after the removal of malignant tissues, in the surgical treatment of breast cancer, ovarian cancer, glioma and peritoneal carcinomatosis.

Stapled Full-Thickness Diaphragm Resection: A Novel Approach to Diaphragmatic Resection in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

Full-thickness diaphragm resection (FT-DR) during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is sometimes required to achieve a complete cytoreduction. It is conventionally performed with electrocautery with primary repair or mesh repair. FT-DR using a linear cutting stapler is a novel technique that avoids entry to the chest cavity and minimizes the use of electrocautery on the diaphragm. We performed an institutional retrospective review of a prospectively maintained database of 145 patients who underwent CRS-HIPEC between 2013 and 2019. Patients were divided into the Conventional or Stapled group based on the FT-DR approach indicated in the operative report. Of the 145 patients who underwent CRS-HIPEC, 27 underwent FT-DR, with 63% (n = 17) in the Stapled group. There were no significant demographic or oncologic differences between the 2 groups. Patients in the Stapled group underwent tube thoracostomy (13.3% vs 60%; p = 0.008), were diagnosed with pneumonia (12% vs 50%; p = 0.04), required reintubation (6% vs 40%; p = 0.03), and required mechanical ventilation more than 48 hours (6% vs 50%; p = 0.02) less frequently than the Conventional group. There was no difference in pleural recurrence between the 2 groups (Conventional 20% vs Stapled 12%, p = 0.56). Stapled full-thickness diaphragm resection is a novel approach to achieving a complete cytoreduction that excludes the pleural cavity, minimizes diaphragm manipulation, and is associated with improved postoperative pulmonary outcomes in patients undergoing CRS-HIPEC.

In situ gelatinase-responsive and thermosensitive nanocomplex for local therapy of gastric cancer with peritoneal metastasis

Intraperitoneal chemotherapy (IPC) has been considered as an effective therapy for advanced gastric cancer (GC) especially those with peritoneal metastasis, while limited effectiveness, complications caused by chemotherapeutics and repeated infusion procedures restrict the application of IPC. In this study, to enhance the efficacy and safety of IPC, we intended to establish a biocompatible and biodegradable nanocomplex composed of intelligent gelatinase-responsive nanoparticles (NPs) and thermosensitive gel, which were prepared from different compositions of poly (ethyleneglycol)–poly (3-caprolactone) (PEG–PCL). Cancer stem cells (CSCs) inhibitor Salinomycin (SAL) and non-CSC inhibitor Docetaxel (DOC) were co-loaded in the NPs and delivered by liquid PEG-PCL-PEG gel (PECE) at room temperature, which was able to target tumor and formed a gel in situ at body temperature. Compared with free SAL-DOC solution administered at the same dose, PECE NP group inhibited intraperitoneal disseminated gastric cancer growth more remarkably, some of which even achieved complete response (CR) and continued for more than 2 weeks. Cytometric analysis of cellular suspension from abdominal tumor tissues showed that the proportion of CSCs (CD44+CD133+) and the expression of PD-L1 on the tumor cells in the PECE NP group were the lowest. In the allograft mouse models of GC, PECE NP significantly improved the infiltration of M1 macrophages into the tumor bed in vivo. This design may provide biodegradable smart drug-delivery system for potential application in IPC.

Impact of KRAS, BRAF and microsatellite instability status after cytoreductive surgery and HIPEC in a national cohort of colorectal peritoneal metastasis patients

BACKGROUND

Patients with metastatic colorectal cancer (mCRC) carrying BRAF (mutBRAF) or KRAS mutation (mutKRAS) have an inferior prognosis after liver or lung surgery, whereas the prognostic role in the context of peritoneal metastasis (PM) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been less investigated.

METHODS

In total, 257 patients with non-appendiceal PM-CRC were included from the Norwegian National Unit for CRS-HIPEC.

RESULTS

In total, 180 patients received CRS-HIPEC with Mitomycin C, 77 patients received palliative surgery only. In the CRS-HIPEC group, mutBRAF was found in 24.7%, mutKRAS 33.9% and double wild-type 41.4% without differences in survival. MSI was found in 29.3% of mutBRAF cases. Patients with mutBRAF/MSI had superior 5-year survival compared to mutBRAF with MSS (58.3% vs 25.2%, P = 0.022), and better 3-year disease-free survival (DFS) compared to mutKRAS (48.6% vs 17.2%, P = 0.049). Peritoneal Cancer Index and the number of lymph node metastasis were prognostic for OS, and the same two, location and gender prognostic for DFS in multivariate analysis.

CONCLUSIONS

PM-CRC with CRS-HIPEC patients has a surprisingly high proportion of mutBRAF (24.7%). Survival was similar comparing mutBRAF, mutKRAS and double wild-type cases, whereas a small subgroup with mutBRAF and MSI had better survival. Patients with mutBRAF tumours and limited PM should be considered for CRS-HIPEC.

Efficacy and safety in the use of intraperitoneal hyperthermia chemotherapy and peritoneal cytoreductive surgery for pseudomyxoma peritonei from appendiceal neoplasm: A systematic review

The objective of this systematic review is to provide efficacy and safety data in the application of Intra-Abdominal Hyperthermia Chemotherapy (HIPEC) and Cytoreductive Surgery (CRS) in patients with Peritoneal Pseudomyxoma (PMP) of origin in the cecal appendix. The databases Medline and Central Cochrane were consulted. Patients with PMP of origin in the cecal appendix, classified as low grade, high or indeterminate, submitted to HIPEC and CRS. The results were meta-analyzed using the Comprehensive Metanalysis software. Twenty-six studies were selected to support this review. For low-grade PMP outcome, 60-month risk of mortality, Disease-Free Survival (DFS), and adverse events was 28.8% (95% CI 25.9 to 32), 43% (95% CI 36.4 and 49.8), and 46.7% (95% CI 40.7 to 52.8); for high-grade PMP, 60-month risk of mortality, Disease-Free Survival (DFS) and adverse events was 55.9% (95% CI 51.9 to 59.6), 20.1% (95% CI 15.5 to 25.7) and 30% (95% CI 25.2 to 35.3); PMP indeterminate degree, 60-month risk of mortality, Disease-Free Survival (DFS) and adverse events was 32.6% (95% CI 30.5 to 34.7), 61.8% (95% CI 58.8 to 64.7) and 32.9% (95% CI 30.5 to 35.4). The authors conclude that the HIPEC technique and cytoreductive surgery can be applied to selected cases of patients with PMP of peritoneal origin with satisfactory results.

Utility of hyperthermic intraperitoneal chemotherapy in cases of incomplete cytoreductive surgery

INTRODUCTION

Hyperthermic intraperitoneal chemotherapy (HIPEC) during cytoreductive surgery (CRS) is typically reserved for a complete or optimal cytoreduction. There is the potential for therapeutic effect of HIPEC with an incomplete cytoreduction, particularly for near optimal cytoreductions.

METHODS

Retrospective review of incomplete cytoreductions (R2b, R2c) for appendiceal and colorectal primaries. Primary endpoints were overall survival (OS) and progression-free survival (PFS). Subgroup analysis for primary etiology and specific cytoreductive score.

RESULTS

A total of 121 cases of incomplete CRS, 74 CRS alone, and 47 CRS-HIPEC. For the entire study group there was a survival benefit with HIPEC. OS and PFS were 2.3 versus 1.4 (p = 0.001) and 1.6 versus 0.7 (p < 0.0001) respectively for cases with and without HIPEC. Subgroup analysis of appendiceal neoplasms, 43 CRS-HIPEC and 50 CRS alone, found HIPEC benefit persisted; OS and PFS were 2.4 versus 1.5 (p = 0.016) and 1.7 versus 0.8 (p < 0.0001), respectively for cases with and without HIPEC. Benefit most pronounced in low-grade cases with doubling of the OS and PFS (p = 0.004). With colorectal primary cases, 10 CRS-HIPEC and 18 CRS alone, no difference in OS and PFS. When stratifying out by cytoreduction scores, R2b and R2c, HIPEC only provided a benefit for R2b cases; OS and PFS for R2b cases were 2.28 versus 1.01 (p = 0.011) and 1.67 versus 0.75 (p = 0.001), respectively for cases with and without HIPEC.

CONCLUSION

HIPEC has utility for incomplete cytoreductions with appendiceal neoplasms, greatest effect with low-grade appendiceal neoplasms. HIPEC is only beneficial for near optimal cytoreductions (R2b).

Versatile Types of Inorganic/Organic NIR-IIa/IIb Fluorophores: From Strategic Design toward Molecular Imaging and Theranostics

In vivo imaging in the second near-infrared window (NIR-II, 1000-1700 nm), which enables us to look deeply into living subjects, is producing marvelous opportunities for biomedical research and clinical applications. Very recently, there has been an upsurge of interdisciplinary studies focusing on developing versatile types of inorganic/organic fluorophores that can be used for noninvasive NIR-IIa/IIb imaging (NIR-IIa, 1300-1400 nm; NIR-IIb, 1500-1700 nm) with near-zero tissue autofluorescence and deeper tissue penetration. This review provides an overview of the reports published to date on the design, properties, molecular imaging, and theranostics of inorganic/organic NIR-IIa/IIb fluorophores. First, we summarize the design concepts of the up-to-date functional NIR-IIa/IIb biomaterials, in the order of single-walled carbon nanotubes (SWCNTs), quantum dots (QDs), rare-earth-doped nanoparticles (RENPs), and organic fluorophores (OFs). Then, these novel imaging modalities and versatile biomedical applications brought by these superior fluorescent properties are reviewed. Finally, challenges and perspectives for future clinical translation, aiming at boosting the clinical application progress of NIR-IIa and NIR-IIb imaging technology are highlighted.

Complete Cytoreductive Surgery vs. Debulking Surgery for pseudomyxoma peritonei of appendiceal origin: A propensity score-matched study based on a single-center experience

OBJECTIVE

This study aimed to report the prognostic predictors and compare the long-term outcomes of complete cytoreductive surgery (CCRS) vs. debulking surgery (DS) in patients with pseudomyxoma peritonei (PMP) of appendiceal origin.

METHODS

A retrospective analysis of 1008 consecutive patients with PMP undergoing primary surgery from January 2008 to December 2019 was performed. A propensity score-matched (PSM) analysis (1:1) was performed, and oncologic outcomes were compared between the CCRS and DS groups.

RESULTS

Out of 1008 patients, 258 patients were excluded. Baseline characteristics differed significantly between the CCRS and DS groups (total n = 750). After PSM, 106 patients were selected from each group and the baseline characteristics were matched between groups. There were significant differences between groups in operative time, the incidence of major complications (P = 0.017), and the numbers of organs removed. The median follow-up was 28 (1-131) months. Median overall survival (OS) for the 212 patients was 52.0 months (95% CI 40.2-63.8), and 10-year OS was 39.0%. Median OS could not be calculated for the CCRS group; in the DS group, this value was 41 months (P = 0.010). The 10-year OS rate was 54.2% in the CCRS group and 31.2% in the DS group. Multivariate analyses identified CCRS (P = 0.012) and histopathologic subtype (P < 0.001) as independent prognostic factors for OS.

CONCLUSIONS

In this matched-pair analysis of patients with appendiceal PMP, CCRS was safe and associated with better prognosis than DS. The completeness of cytoreduction and histopathologic subtype were two independent prognostic factors for OS.

Hyperthermic Intraperitoneal Chemotherapy for Ovarian and Colorectal Cancer: A Review

Importance

The peritoneal surface is a common site of disease in ovarian and colorectal cancer. Peritoneal metastases carry a poor prognosis, despite maximal therapeutic efforts, including surgical removal of tumor deposits and intravenous chemotherapy. Hyperthermic intraperitoneal chemotherapy (HIPEC) is a single intraoperative procedure that delivers chemotherapy directly into the abdominal cavity, leading to high intracellular drug concentration at the peritoneal surface. This review describes the current knowledge regarding the mechanism of action, safety, and efficacy of HIPEC in the treatment of peritoneal metastases from epithelial ovarian and colorectal cancers and explores current knowledge gaps.

Observations

Toxic effects of HIPEC are limited. Evidence from a randomized trial shows improved recurrence-free and overall survival after HIPEC in patients with ovarian cancer who are ineligible for primary cytoreductive surgery (CRS). The effect of HIPEC for patients with ovarian cancer undergoing primary CRS or CRS for recurrent disease has not yet been determined, and results of ongoing trials must be awaited. A recent study in patients with peritoneal metastases from colorectal cancer did not show a benefit of HIPEC when added to perioperative chemotherapy.

Conclusions and Relevance

Based on available evidence, various international guidelines include the option to add HIPEC to interval CRS for patients with stage III ovarian cancer. The role of HIPEC in colorectal cancer is less well defined. Future studies will need to tailor patient selection, timing, and optimal regimens of HIPEC to improve the effectiveness of this specialized treatment in ovarian, colorectal, and other tumor types.

Review of management and treatment of peritoneal metastases from gastric cancer origin

Gastric cancer (GC) is the third cause of cancer-related deaths in the world, with less than 25% survivors at 5 years. These results are largely related to the high incidence of peritoneal metastases (PM) in these patients. Nowadays, the standard treatment for GC with PM is palliative systemic chemotherapy (SCT) with a survival of 6 months. From the 2000s, the combination of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has been gaining popularity for different neoplastic diseases that involve the peritoneal surface. The use of CRS and HIPEC has been studied for GC with PM, with promising results in selected patients, obtaining survival rates never seen before. Moreover, HIPEC and other intraperitoneal chemotherapy techniques have been used to prevent peritoneal recurrences in patients diagnosed on locally advanced GC without macroscopic PM (adjuvant or prophylactic HIPEC). Even, intraperitoneal chemotherapy [laparoscopic HIPEC and neoadjuvant intraperitoneal and systemic chemotherapy (NIPS)] has been used as neoadjuvant treatment to reduce peritoneal disease burden in order to improve the rate of patients in whom complete cytoreduction can be achieved. Finally, patients with high volume peritoneal disease can be treated by palliative intraperitoneal chemotherapy to control the symptoms resulting from malignant ascites, using laparoscopic HIPEC or pressurized intraperitoneal aerosol chemotherapy (PIPAC). This review aims to update the management of PM from GC origin in these different clinical scenarios, based on the literature and the experience of the authors.

Hyperthermic intraperitoneal chemotherapy in prevention of gastric cancer metachronous peritoneal metastases: a systematic review

Gastric cancer progression resulting in metachronous peritoneal metastasizing is almost always associated with an adverse prognosis. This review discusses various options of preventing metachronous peritoneal metastases in radically operated gastric cancer patients. Also examined are different hyperthermic intraperitoneal chemotherapy (HIPEC) regimens employed in gastric cancer treatment, postoperative morbidity and mortality rates and long-term treatment outcomes. The authors also review their own experience of using HIPEC based on the combination of cisplatin and doxorubicin in doses of 50 mg/m² at 42 °C for 1 h to prevent gastric cancer peritoneal dissemination. As a result, progression-free survival rose from 19.6%±5.6% to 47.1%±6.3% (P_log-rank <0.001) and dissemination-free survival-from 22.7%±6.0% to 51.9%±6.3% (P_log-rank <0.001). It is noted that the combination of the described HIPEC regimen with systemic chemotherapy helped raise metastases-free 3-year survival rate to up to 91.0%±9.0% (P_log-rank =0.025) compared with 48.6%±6.4% for patients who underwent only a combined surgery/HIPEC treatment. HIPEC is a promising combined treatment strategy for radically operated gastric cancer patients that can improve patient survival and decrease peritoneal dissemination rate. However, the number of randomized studies on adjuvant HIPEC are still insufficient for a subgroup assessment of efficacy of the given chemotherapy regimens and generation of evidence-based recommendations on the individual use of chemotherapy agents and their combinations, and HIPEC procedural techniques. Further prospective randomized studies are needed to assess the practicability of complementing HIPEC with adjuvant systemic chemotherapies.

Surgical Navigation for Malignancies Guided by Near-Infrared-II Fluorescence Imaging

Near-infrared (NIR) fluorescence imaging is an emerging noninvasive imaging modality, with unique advantages in guiding tumor resection surgery, thanks to its high sensitivity and instantaneity. In the past decade, studies on the conventional NIR window (NIR-I, 750-900 nm) have gradually focused on the second NIR window (NIR-II, 1000-1700 nm). With its reduced light scattering, photon absorption, and auto-fluorescence qualities, NIR-II fluorescence imaging significantly improves penetration depths and signal-to-noise ratios in bio-imaging. Recently, several studies have applied NIR-II imaging to navigating cancer surgery, including localizing cancers, assessing surgical margins, tracing lymph nodes, and mapping important anatomical structures. These studies have exemplified the significant prospects of this new approach. In this review, several NIR-II fluorescence agents and some of the complex applications for guiding cancer surgeries are summarized. Future prospects and the challenges of clinical translation are also discussed.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in children

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) is treatment of choice for determined group of adult patients. Cytoreduction and HIPEC is usually used in patients with ovarian, gastric and colorectal cancer, appednix cancer, peritoneal mesothelioma and in some tumors of another localization. The experience of cytoreductive surgery and HIPEC  in childhood is limited due to the lower frequency of peritoneal carcinomatosis in pediatric population. However, about 30% of malignant tumors in children develop in peritoneal cavity and pelvis. High recurrence rate are typical for these tumors, particularly due to tumor rupture. Taking into consideration low frequency of epithelioid tumors in children HIPEC is used for patients with other tumor types such as desmoplastic small round cell tumor (DSRCT), germ cell tumors, rhabdomyosarcoma and others. The aim o this paper is the review of the literature and present experience analysis of cytoreductive surgery and HIPEC in children.

Impact of extent of parietal peritonectomy on oncological outcome after cytoreductive surgery and HIPEC

BACKGROUND

In peritoneal surface malignancy (PSM), in spite of optimal cytoreductive surgery (CRS), majority of recurrences that occur are intraperitoneal. In patients with PSM, studies employing fluorescent imaging and microscopic examination have shown normal looking peritoneum may harbor active disease. This study was done to assess the recurrence pattern, oncological outcomes, and morbidity and mortality of the extent of peritonectomy in patients who underwent total parietal peritonectomy (TPP) or involved field peritonectomy (IFP) as a part of the procedure during CRS and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

This was a retrospective analysis of prospectively collected data, from February 2013 to December 2017. A total of 163 patients with PSM underwent TPP or IFP with CRS plus HIPEC. Their oncological outcomes, recurrence pattern, postoperative morbidity and mortality were analyzed.

RESULTS

Of the 163 cases, the primary organs of origin were ovary, colorectal, appendicular pseudomyxoma, stomach, mesothelioma and others (67.4%, 16.5%, 6.1%, 4.9%, 2% and 2%), respectively. TPP was performed in 70 patients and IFP in 93 patients. TPP group had higher mean PCI (16 vs. 14), longer duration of surgery (11 vs. 9 h), and more blood loss (1,243 vs. 675 mL). Overall G3-G4 morbidity was comparable in both groups (42.8% vs. 33.3%) as was mortality (5.7% vs. 4.4%). Kaplan-Meier analysis showed that with a median follow-up of 45 months, TPP group had a recurrence-free survival (RFS) of 26 months and overall survival (OS) was yet to be achieved, whereas the IFP group had a RFS and OS of 21 and 43 months, respectively.

CONCLUSIONS

Performing TPP reduces the chance of missing the microscopic disease, therefore can minimize local recurrence, and better oncological outcomes. TPP can be performed with acceptable morbidity and mortality, at the cost of increased duration of surgery and higher blood loss.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer

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

Prognostic Value of Systemic Inflammatory Indices, NLR, PLR, and MPV, for Predicting 1-Year Survival of Patients Undergoing Cytoreductive Surgery with HIPEC

The neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and mean platelet volume (MPV) have been reported to be associated with the prognosis of various types of tumors. This study evaluated the prognostic value and clinical use of inflammatory markers for predicting 1-year survival in patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). This retrospective study included 160 patients who underwent CRS with HIPEC between July 2014 and April 2017. Data on NLR, PLR, and MPV were collected preoperatively and on postoperative days (POD) 1, 2, 3, 4, and 5. In a multivariate analysis using a cox proportional hazard regression model, higher values of preoperative NLR and MPV, PLR, and MPV on POD 2, 3, and 5 were associated with reduced 1-year survival after CRS with HIPEC. Patients with increased MPV showed lower rates of 1-year survival following CRS with HIPEC. In addition, elevated preoperative NLR and postoperative PLR were correlated with poor survival. These markers are able to stratify patients by risk profile, which may ultimately improve perioperative management and be helpful in improving outcomes following CRS with HIPEC.

Morbidity and Mortality Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Data from the DGAV StuDoQ Registry with 2149 Consecutive Patients

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are performed for well-selected patients with peritoneal surface malignancies. This combined treatment is potentially associated with an increased rate of complications.

OBJECTIVE

The aim of this paper was to analyze the morbidity and mortality of CRS and HIPEC in the German national registry.

METHODS

We present a retrospective analysis of 2149 consecutive patients from 52 hospitals. The data were prospectively documented in the DGAV StuDoQ Registry between February 2011 and December 2016.

RESULTS

Almost two-thirds of all patients had a colorectal malignancy; therefore, the most frequently performed resections were colectomies (54%) and rectal resections (30%). Only 36.2% of all patients had no anastomosis, and fewer than 20% of all patients were older than 70 years of age (16.4%). Enteric fistula and anastomotic leaks occurred in 10.5% of all cases. The reoperation rate was 14.6% (95% confidence interval [CI] 11.51-18.1). Major grade 3 and 4 complications (Clavien-Dindo classification) occurred in 19.3% of all patients, half of which were due to surgical complications. The overall 30-day postoperative hospital mortality was 2.3% (95% CI 1.02-3.85). Multivariate analysis showed an increased risk for morbidity associated with pancreatic resections (odds ratio [OR] 2.4), rectal resection (OR 1.5), or at least one anastomosis (OR 1.35), and mortality with reoperation (OR 8.7) or age > 70 years (OR 3.35).

CONCLUSIONS

CRS and HIPEC are associated with acceptable morbidity and low mortality. These results show that CRS and HIPEC can be safely performed nationwide when close mentoring by experienced centers is provided.

The current practice of cytoreductive surgery and HIPEC for colorectal peritoneal metastases: Results of a worldwide web-based survey of the Peritoneal Surface Oncology Group International (PSOGI)

BACKGROUND

At present, selected patients with resectable colorectal peritoneal metastases (CRC-PM) are increasingly treated with a combination therapy of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study was to investigate the current worldwide practice.

METHODS

HIPEC experts from 19 countries were invited through the Peritoneal Surface Oncology Group International (PSOGI) to complete an online survey concerning their personal expertise and current hospital and countrywide practice.

RESULTS

It is estimated that currently more than 3800 patients with CRC-PM (synchronous and metachronous) are annually treated with CRS and HIPEC in 430 centers. Integration of CRS and HIPEC in national guidelines varies, resulting in large treatment disparities between countries. Amongst the experts, there was general agreement on issues related to indication, surgical technique and follow up but less on systemic chemotherapy or proactive strategies.

CONCLUSION

This international survey demonstrates that CRS and HIPEC is now performed on a large scale for CRC-PM patients. Variation in treatment may result in heterogeneity in surgical and oncological outcomes, emphasising the necessity to reach consensus on several issues of this comprehensive procedure. Future initiatives directed at achieving an international consensus statement are needed.

Complete Response for More than 4 Years following Neoadjuvant FOLFOX and Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for a Patient with Advanced Gastric Cancer with Extensive Peritoneal Carcinomatosis

Background

Peritoneal carcinomatosis is usually a terminal disease with short median survival in patients with gastric cancer. Systemic FOLFOX is one of the most used regimens in the first-line treatment of metastatic gastric cancer. However, there is scarce evidence that cytoreductive surgery (CRS) and intraperitoneal heated chemotherapy (HIPEC) improves oncological outcomes of patients with advanced gastric cancer.

Methods

Herein we present a case of a young woman with advanced gastric cancer with omental and peritoneal metastases who achieved an excellent response after 6 months of FOLFOX followed by CRS and HIPEC.

Results

A 53-year-old woman was diagnosed with advanced gastric carcinoma, with extensive omental caking and several peritoneal implants measuring 2 cm at the largest diameter. The patient received mFOLFOX6 for 6 months with excellent clinical and radiographic response. She was then submitted to a D2 total gastrectomy followed by CRS and HIPEC with mitomycin. The final pathology report showed a focal adenocarcinoma in the stomach measuring 0.4 mm with no residual tumor in the peritoneum (ypT1ypN0). The patient has been well and disease free for more than 4 years.

Conclusion

While still controversial, CRS followed by HIPEC may be a curative therapeutic option for highly selected patients.

Peritoneal Carcinomatosis Targeting with Tumor Homing Peptides

Over recent decades multiple therapeutic approaches have been explored for improved management of peritoneally disseminated malignancies—a grim condition known as peritoneal carcinomatosis (PC). Intraperitoneal (IP) administration can be used to achieve elevated local concentration and extended half-life of the drugs in the peritoneal cavity to improve their anticancer efficacy. However, IP-administered chemotherapeutics have a short residence time in the IP space, and are not tumor selective. An increasing body of work suggests that functionalization of drugs and nanoparticles with targeting peptides increases their peritoneal retention and provides a robust and specific tumor binding and penetration that translates into improved therapeutic response. Here we review the progress in affinity targeting of intraperitoneal anticancer compounds, imaging agents and nanoparticles with tumor-homing peptides. We review classes of tumor-homing peptides relevant for PC targeting, payloads for peptide-guided precision delivery, applications for targeted compounds, and the effects of nanoformulation of drugs and imaging agents on affinity-based tumor delivery.

Data on the quality of life after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancies: does it concern patients with gastric cancer?

Introduction.So far there are no reports devoted exclusively to the quality of life after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in metastatic gastric cancer. Current literature concerning this issue was, thus, reviewed in order to: 1) search for such data concerning metastatic gastric cancer; 2) assess if the latest reviews evenly pertain to all peritoneal surface malignancies; and 3) conclude if they are a reliable source of data for patients with metastatic gastric cancer.

Materials and Methods.The electronic PubMed/MEDLINE and EMBASE databases were retrieved for studies concerning the influence of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy on quality of life in patients with metastatic gastric cancer and regardless of initial diagnosis. The data on the number of patients with particular tumours were analysed and the results were presented in the form of a table.

Results.Approximately half of all patients encompassed by the reviews had a form of primary peritoneal surface malignancies. Within peritoneal metastases, the most numerous were colorectal (21-24%) and ovarian cancers (5-15%). Gastric cancers and sarcomas were the smallest defined subgroups (4% each).

Conclusions.The promising outcomes in quality of life after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in primary peritoneal surface malignancies might differ from rarely reported ones in metastatic gastric cancer. The problem needs further, gastric cancer-devoted investigations.

Treatment of peritoneal carcinomatosis with photodynamic therapy: Systematic review of current evidence

BACKGROUND

Peritoneal carcinomatosis results when tumour cells implant and grow within the peritoneal cavity. Treatment and prognosis vary based on the primary cancer. Although therapy with intention-to-cure is offered to selective patients using cytoreductive surgery with chemotherapy, the prognosis remains poor for most of the patients. Photodynamic therapy (PDT) is a cancer-therapeutic modality where a photosensitiser is administered to patients and exerts a cytotoxic effect on cancer cells when excited by light of a specific wavelength. It has potential application in the treatment of peritoneal carcinomatosis.

METHODS

We systematically reviewed the evidence of using PDT to treat peritoneal carcinomatosis in both animals and humans (Medline/EMBASE searched in June 2017).

RESULTS

Three human and 25 animal studies were included. Phase I and II human trials using first-generation photosensitisers showed that applying PDT after surgical debulking in patients with peritoneal carcinomatosis is feasible with some clinical benefits. The low tumour-selectivity of the photosensitisers led to significant toxicities mainly capillary leak syndrome and bowel perforation. In animal studies, PDT improved survival by 15-300%, compared to control groups. PDT led to higher tumour necrosis values (categorical values 0-4 [4=highest]: PDT 3.4±1.0 vs. control 0.4±0.6, p<0.05) and reduced tumour size (residual tumour size is 10% of untreated controls, p<0.001).

CONCLUSION

PDT has potential in treating peritoneal carcinomatosis, but is limited by its narrow therapeutic window and possible serious side effects. Recent improvement in tumour-selectivity and light delivery systems is promising, but further development is needed before PDT can be routinely applied for peritoneal carcinomatosis.

Recommendations and consensus on the treatment of peritoneal metastases of colorectal origin: a systematic review of national and international guidelines

AIM

This systematic review aimed to provide an overview of (inter)national guidelines on the treatment of peritoneal metastases of colorectal cancer origin (PMCRC) and to determine the degree of consensus and available evidence with identification of topics for future research.

METHOD

A systematic search of MEDLINE, Embase, PubMed as well as Tripdatabase, National Guideline Clearinghouse, BMJ Best Practice and Guidelines International Network was performed to identify (inter)national guidelines and consensus statements from oncological or surgical societies on PMCRC. The quality of guidelines was assessed using the AGREE-II score. Topics followed by recommendations were extracted from the guidelines. The recommendations, highest level of supporting evidence and the degree of consensus were determined for each topic.

RESULTS

Twenty-one guidelines were included, in most (15) of which cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) was recommended in selected patients based on level 1b evidence. Substantial consensus was also reached on the benefit of multidisciplinary team discussion and the achievability of a (near) complete cytoreduction (CC0-1) without supporting evidence. Both evidence and consensus were lacking regarding other aspects including preoperative positron emission tomography/CT, second look surgery in high risk patients, the optimal patient selection for CRS/HIPEC, procedural aspects of HIPEC and (perioperative) systemic therapy.

CONCLUSION

In currently available guidelines, evidence and consensus on the treatment strategy for PMCRC are lacking. Updates of guidelines are ongoing and future (randomized) clinical trials should contribute to multidisciplinary and international consensus on treatment strategies for PMCRC.

Photodynamic Detection of Peritoneal Metastases Using 5-Aminolevulinic Acid (ALA)

In the past, peritoneal metastasis (PM) was considered as a terminal stage of cancer. From the early 1990s, however, a new comprehensive treatment consisting of cytoreductive surgery and perioperative chemotherapy has been established to improve long-term survival for selected patients with PM. Among prognostic indicators after the treatment, completeness of cytoreduction is the most independent predictors of survival. However, peritoneal recurrence is a main cause of recurrence, even after complete cytoreduction. As a cause of peritoneal recurrence, small PM may be overlooked at the time of cytoreductive surgery (CRS), therefore, development of a new method to detect small PM is desired. Recently, photodynamic diagnosis (PDD) was developed for detection of PM. The objectives of this review were to evaluate whether PDD using 5-aminolevulinic acid (ALA) could improve detection of small PM.

Inhibitory effect of intraperitoneal chemotherapy with sustained-release fluorouracil vs fluorouracil injection on peritoneally transplanted MKN-45 tumors in nude mice

AIM

To compare the inhibitory effect of sustained-release fluorouracil (Sinofuan) and fluorouracil injection on peritoneally transplanted MKN-45 tumors in nude mice.

METHODS

Fifty-one nude mice peritoneally transplanted with MKN-45 cells were randomly divided into three groups: control group, fluorouracil injection group (2 mg/nude mouse), and sustained-release fluorouracil group (2 mg/nude mouse). The general status of the nude mice, body mass changes and survival were observed. Ascites volume was measured, the number of tumor cells per milliliter of ascites was counted, and tumor cell apoptosis was detected.

RESULTS

Compared with the control group, the general status of nude mice from the fluorouracil injection group and sustained-release fluorouracil group were better with regard to slower weight gain, delayed systemic symptoms and prolonged survival (P < 0.05). The median survival of mice in the sustained-release fluorouracil group was prolonged compared with the fluorouracil injection group (25 d vs 19 d, P < 0.01). Ascites volume in the sustained-release fluorouracil group was less than that in the fluorouracil injection group [(5.66 mL ± 1.00 mL) vs (8.78 mL ± 1.19 mL), P < 0.01], but the difference in the number of ascitic tumor cells per milliliter between the two groups was not statistically significant [(2.75 × 10⁸/mL ± 0.71 × 10⁸/mL) vs (3.46 × 10⁸/mL ± 0.69 × 10⁸/mL)]. Tumor cell apoptosis rate was significantly higher in the sustained-release fluorouracil group than in the fluorouracil injection group (14.49% ± 0.80% vs 2.03% ± 0.64%, P < 0.01).

CONCLUSION

Sustained-release fluorouracil is better than fluorouracil injection in intraperitoneal chemotherapy for peritoneally transplanted MKN-45 tumors in nude mice.

Cytoreductive surgery and heated intraperitoneal chemotherapy for peritoneal carcinomatosis secondary to mucinous adenocarcinoma of the appendix

Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is a radical but effective treatment option for select peritoneal malignancies. We sought to determine our early experience with this method for peritoneal carcinomatosis secondary to mucinous adenocarcinomas of appendiceal origin. As such, we performed a retrospective clinical study of 30 consecutive patients undergoing CRS with planned HIPEC at the Princess Alexandra Hospital, between June 2009 to December 2012, with mucinous adenocarcinomas of the appendix. CRS was performed in 30 patients, 13 received HIPEC intraoperatively and 17 received early postoperative intra-peritoneal chemotherapy (EPIC) in addition. Mean age was 52.3 years and median hospital stay was 26 days (range 12-190 days). Peritoneal cancer index scores were 0-10 in 6.7% of patients, 11-20 in 20% of patients and >20 in 73.3% of patients. Complete cytoreduction was achieved overall in 21 patients. In total, 106 complications were observed in 28 patients. Ten were grade 3-A, five were grade 3-B and one grade-5 secondary to a fatal PE on day 97. In patients who received HIPEC, there was no difference in disease-free survival (P = 0.098) or overall survival (P = 0.645) between those who received EPIC versus those who did not. This study demonstrates that satisfactory outcomes with regards to morbidity and survival can be achieved with CRS and HIPEC, at a single-centre institution with growing expertise in the technique. Our results are comparable with outcomes previously described in the international literature.

Regional but fatal: Intraperitoneal metastasis in gastric cancer

Peritoneal carcinomatosis appears to be the most common pattern of metastasis or recurrence and is associated with poor prognosis in gastric cancer patients. Many efforts have been made to improve the survival in patients with peritoneal metastasis. Hyperthermic intraperitoneal chemotherapy remains a widely accepted strategy in the treatment of peritoneal dissemination. Several phase II-III studies confirmed that the combined cytoreducitve surgery and hyperthermic intraperitoneal chemotherapy resulted in longer survival in patients with peritoneal carcinomatosis. In addition, proper selection and effective regional treatment in patients with high risk of peritoneal recurrence after resection will further improve prognosis in local advanced gastric cancer patients.

Surgical technology and pharmacology of hyperthermic perioperative chemotherapy

Although cytoreductive surgery (CRS) and hyperthermic perioperative chemotherapy (HIPEC) have not been shown to be effective by themselves, as a combined treatment they are now standard of care for peritoneal metastases from appendiceal cancer and from colorectal cancer as well as peritoneal mesothelioma. The timing of the HIPEC in relation to the CRS is crucial in that the HIPEC is to destroy minimal residual disease that remains following the CRS and prevent microscopic tumor emboli within the abdomen and pelvis from implanting within the resection site, within fibrinous clot, or within blood clot. Proper selection of chemotherapy agents is crucial to the long-term benefit of CRS and HIPEC. One must consider the response expected with the cancer chemotherapy agent, its area under the curve (AUC) ratio indicating the amount of dose intensity within the peritoneal space, and the drug retention within the peritoneal space for a prolonged exposure. Hyperthermia will augment the cytotoxicity of the cancer chemotherapy agents and improve drug penetration. Irrigation techniques should not be overlooked as an important means of reducing the cancer cell burden within the abdomen and pelvis. Multiple technologies for HIPEC exist and these have advantages and disadvantages. The techniques vary from a totally open technique with a vapor barrier over the open abdominal space to a totally closed technique whereby the HIPEC is administered at the completion of the surgical procedure. The open techniques depend on a table-mounted retractor for suspension of the skin edges allowing a reservoir to occur within the abdomen and pelvis. There are nearly a dozen commercially available hyperthermia pumps, all of which seem to perform adequately for HIPEC although there is a variable degree of convenience and documentation of the HIPEC procedure. As the management of peritoneal metastases has progressed over three decades, early cases are now seen in which a laparoscopic CRS and HIPEC may be appropriate. Also, prophylactic use of laparoscopic HIPEC with perforated appendiceal malignancies and T4 colon cancers may be appropriate.

Palliative cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion: current clinical practice or misnomer?

Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS/HIPEC) is being used more and more frequently for the management of peritoneal carcinomatosis. Despite significant improvements in oncologic outcomes and the risk of complications and mortality, CRS/HIPEC remains one of the most morbid treatments offered for advanced cancers. Consequently CRS/HIPEC is still considered controversial by many, even in the setting of cancers that are potentially curable. However, as high volume surgical oncologists become more experienced with CRS/HIPEC, the potential role of "palliative CRS/HIPEC" in the management of peritoneal carcinomatosis is being raised. Given the often limited survival benefit expected after CRS/HIPEC, understanding the impact of the treatment on quality of life (QOL) needs to be an essential part of the decision to proceed and is critical to optimizing recovery afterwards. This article reviews the potential definitions of "palliative CRS/HIPEC" in various clinical contexts and describes the current state of the QOL experience after CRS/HIPEC.

Cytoreductive surgery and intraperitoneal chemotherapy: an evidence-based review-past, present and future

Peritoneal carcinomatosis (PC) has historically been considered a terminal condition with merely palliative treatment achieving a survival rate measured in months. Cytoreductive surgery (CyRS) and intraperitoneal chemotherapy (IPC) have emerged as potentially effective regional treatments with the potential for long-term survival in well-selected patients. The fundamentals of CyRS and IPC are patient selection and complete cytoreduction. Since there is now sufficient evidence for the superiority of CyRS and IPC to systemic chemotherapy alone in a highly select group of patients, surgeons and oncologists should be aware of this modality as a potential benefit for patients with PC. The aim of this report is to highlight cancer-specific evidence in the context of ongoing studies regarding the outcome of this treatment.

[Cytoreductive surgery for malignant peritoneal tumors]

Cytoreductive surgery is an essential part of a multimodality treatment concept for peritoneal metastases. Indications are primary peritoneal tumors like peritoneal mesothelioma or secondaries from colorectal cancer or pseudomyxoma peritonei. Patients with gastric or ovarian carcinoma or abdominal sarcoma with peritoneal seedings can be treated within studies. Tumor entity, tumor load, and tumor distribution are the most critical issues for patient selection. Complete macroscopic cytoreduction is the strongest prognostic factor and can be achieved by parietal and visceral peritonectomy. The operation should be performed in a standardized manner. Due to possible tumor manifestation in all four quadrants of the abdomen and extensive extraperitoneal dissection, extensive surgical and oncological expertise is prerequisite. Treatment in specialized surgical oncology centers is recommended to minimize morbidity and mortality. The German Society for General and Visceral Surgery is certifying centers of competence for surgical treatment of peritoneal malignancies. Data of all patients are documented in the HIPEC register. The inclusion of patients in studies is recommended.

Platelet Dynamics in Peritoneal Carcinomatosis Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Oxaliplatin

The aim of the study was to characterize the platelet count (PLT) dynamics in peritoneal carcinomatosis patients treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal oxaliplatin (HIO). Data from patients treated with CRS alone (N = 18) or CRS and HIO (N = 62) were used to estimate the baseline platelet count (PLT0), rate constants for platelet maturation (k tr ) and platelet random destruction (k s ), feedback on progenitor cell proliferation (γ), and the drug-specific model parameters (α, β). Plasma oxaliplatin concentrations, C p , reduced the proliferation rate of progenitor cells (k prol) according to a power function α × C p (β) . The surgery effect on k prol and k s was explored. The typical values (between subject variability) of the PLT0, k tr , k s , γ, α, and β were estimated to be 237 × 10(9) cells/L (32.9%), 7.09 × 10(-3) h(-1) (47.1%), 8.86 × 10(-3) h(-1) (80.0%), 0.621, 0.88 L/mg (56.9%), and 2.63. Surgery induced a maximal 2.09-fold increase in k prol that was attenuated with a half-life of 8.42 days. Splenectomy decreased k s by 47.5%. Age, sex, body surface area, sex, total proteins, and HIO carrier solution did not impact the model parameters. The model developed suggests that, following CRS and HIO, thrombocytopenia and thrombocytosis were reversible and short-lasting; the severity of the thrombocytopenia and thrombocytosis was inversely correlated, with splenectomized patients having thrombocytopenia of lower severity and thrombocytosis of higher severity; and the HIO dose and treatment duration determine the severity and duration of the thrombocytopenia. Higher HIO dose or longer treatment duration could be used without substantially increasing the risk of major hematological toxicity.

Diagnosis and treatment of peritoneal metastasis of gastric cancer

As the main reason of death in patients with gastric cancer, peritoneal metastasis is still a major problem to be solved. As we all know, peritoneal metastasis is the main form of advanced gastric cancer and gastric cancer recurrence, which involves a complex, multi-stage, multifactorial pathological process. The diagnosis and treatment of peritoneal metastasis of gastric cancer are particularly difficult. The good news is that through active exploration and clinical research, several important achievements have been made and gradually bring the gospel to clinical patients. This paper will review the recent progress in the diagnosis and treatment of peritoneal metastasis of gastric cancer.