Combined Interval Cytoreductive Surgery and Carboplatin-Based Hyperthermic Intraperitoneal Chemotherapy in Advanced Primary High-Grade Serous Ovarian Cancer

Combining interval cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) improves survival in advanced epithelial ovarian carcinoma (EOC). Although limited, growing evidence regarding carboplatin-based HIPEC highlights its potential. This retrospective study included all patients with advanced primary high-grade serous ovarian cancer who underwent interval CRS combined with carboplatin-based HIPEC at our Canadian tertiary care center between 2014 and 2020. We identified 40 patients with a median age of 61 years. The median peritoneal cancer index was 13 and complete cytoreduction was achieved in 38 patients (95%). Median hospital stay was 13 days and there were four admissions to the intensive care unit (10%) and six readmissions (15%). Severe adverse events occurred in eight patients (20%) and there was no perioperative death. Recurrence was seen in 33 patients (82%) with a median DFS of 18.0 months and a median overall survival of 36.4 months. Multivariate analyses showed that age, peritoneal cancer index, completeness of cytoreduction, occurrence of severe complications, and bowel resection did not significantly impact DFS or OS in our cohort. Interval CRS combined with carboplatin-based HIPEC for advanced primary EOC is associated with acceptable morbidity and oncological outcomes. Larger studies are required to determine the long-term outcomes.

Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) for peritoneal mesothelioma: Canadian practices and outcomes

INTRODUCTION

Peritoneal mesothelioma (PM) is a rare malignancy originating from the peritoneal lining. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is the standard-of-care for patients with isolated PM. Due to a paucity of prospective data there are several different HIPEC protocols. The aims of this study are to describe the CRS and HIPEC protocols for PM and patient outcomes across Canada.

METHODS

A multicenter retrospective study was performed on patients diagnosed and treated for PM with CRS and HIPEC in four major peritoneal disease centers in Canada between 2000 and 2021. Data on patient characteristics, treatment patterns, postoperative morbidity, recurrence, and survival were collected.

RESULTS

A total of 72 patients were identified. Mean age was 52 years (17-75) and 37.5% were male. Epithelioid (70.1%) and multicystic (13%) mesothelioma were the most common subtypes. Twenty-one patients (30%) were treated with neoadjuvant chemotherapy. CRS and HIPEC was performed in 64 patients (91.4%). Of these, the mean PCI was 22 (2-39) and cisplatin+doxorubicin was the most common HIPEC regimen (n = 33, 51.6%). A semi-closed coliseum technique was used in 68.8% of HIPECs and the mean duration of surgery was 486 min (90-1052). Clavien-Dindo III or IV complications occurred in 12 patients (16.9%). With a median follow-up of 24 months (0.2-104.4), we found a 5-year overall survival of 61% and a 5-year recurrence-free survival of 35%.

CONCLUSION

CRS and HIPEC is a safe and effective treatment modality for well-selected patients with PM, with some achieving prolonged survival.

Abstract P6-01-39: The impact of the 21-gene Recurrence Score® assay upon physician treatment recommendations in the neoadjuvant setting in lymph node-negative breast cancer patients in a multicenter prospective study in Quebec

Background: Although the role of the 21-gene Breast Recurrence Score® assay is well established to predict response to adjuvant chemotherapy in the setting of node-negative hormone receptor (HR)-positive, HER2-negative breast cancers (BC), fewer studies have evaluated the assay in the neoadjuvant setting. Due to the correlation between a high Recurrence Score® (RS) result and pathological complete response (pCR), the Breast Recurrence Score assay has been used to aid in selecting between chemotherapy (CT) or endocrine therapy. We wanted to further understand the impact of the assay upon physician treatment recommendations and the use of chemotherapy in this patient cohort. Methods: We conducted a multicenter, prospective, observational study in patients with clinically node-negative HR-positive, HER2-negative BC with T2-T3 disease being considered for neoadjuvant therapy. Physicians were required to complete two questionnaires indicating treatment choice, including CT, endocrine therapy, or surgery, prior to and post availability of RS result. Patients were followed up for 6 months after commencement of neoadjuvant therapy. The primary objective was to evaluate the change in the physician’s recommendation for neoadjuvant CT prior to and post assay results. As a secondary objective, we also evaluated the impact of the RS result on physician’s expressed level of confidence. Results: A total of 70 patients were enrolled between April 2018 and November 2021 at five hospital centers, as part of the McPeak Sirois Group of Quebec. The median age of the cohort was 60 years (range, 30 to 79 years). 24.3 % (n=17) of the cohort consisted of patients aged < 50 years, and 75.7% (n=53) were ≥ to 50 years. 29.0% (n=20) of the patients had a RS < 16, 39.1% (n=27) had a RS between 16-25, and 31.9% (n=22) had a RS > 25. For the entire cohort, the RS result led to a net reduction in chemotherapy recommendation by 33.3% (OR (odds of having CT post-RS recommendation versus pre-RS recommendation) = 0.23 [95% CI: 0.12-0.44]; P< 0.0001), and 39.2% net reduction in the use of chemotherapy at 6-month follow-up (OR = 0.18 [95% CI: 0.09-0.35]; P< 0.0001). Furthermore, the RS result led to a 35.3% net reduction in physician recommendation of CT for patients < 50 years (OR = 0.19 [95% CI: 0.04-0.83]; P=0.027) and a 32.7% net reduction for patients ≥ 50 years (OR = 0.24 [95% CI: 0.11-0.50]; P=0.0001). For patients with a RS < 16, there was a reduction in CT recommendation by 75.0%, and by 44.4% for patients with a RS between 16 - 25 (OR = 0.15 [95% CI: 0.06-0.38]; P< 0.0001). Moreover, RS results led to an increase in confidence in physician treatment decisions for 59.4% of patients (OR = 12.53 [95% CI: 5.46-28.78]; P< 0.0001). Conclusion: We determined that the 21-gene Breast Recurrence Score assay altered neoadjuvant treatment decisions, leading to a reduction in the use of chemotherapy by about one-third, regardless of age. Additionally, the assay increased physician confidence in their treatment recommendation for about 60% of patients. This demonstrates the potential clinical utility of the assay to decrease the use of CT in the neoadjuvant setting amongst HR-positive, node-negative BC patients in Quebec.

Citation Format: Mariya Yordanova, Lucas Sideris, Pierre Dubé, Jean-Francois Boileau, Julie Lemieux, Catalin Mihalcioiu, Sylvie Levesque, Marie-Claude Guertin, Erica Patocskai, Rami Younan, André Robidoux, Saima Hassan. The impact of the 21-gene Recurrence Score® assay upon physician treatment recommendations in the neoadjuvant setting in lymph node-negative breast cancer patients in a multicenter prospective study in Quebec [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-01-39.

Impact of the 21-Gene Recurrence Score Assay on Treatment Decisions and Cost in Patients with Node-Positive Breast Cancer: A Multicenter Study in Quebec

BACKGROUND

The 21-gene Breast Recurrence Score (RS) assay, "the assay", has led to a paradigm shift for patients with hormone receptor-positive, node-negative early breast cancer and is emerging as an important tool to assist physician-patient decisions in foregoing chemotherapy in node-positive patients. We wanted to better understand the impact of the RS assay in node-positive patients upon physician treatment decisions and treatment cost in Quebec, Canada.

PATIENTS AND METHODS

We conducted a multicenter, prospective observational trial for Estrogen/Progesterone Receptor (ER/PR)- positive, Human Epidermal Growth Factor Receptor 2 (HER2)-negative breast cancer patients with 1-3 positive lymph nodes. Physicians completed a questionnaire indicating treatment choice prior to and post availability of RS results. The primary endpoint was change in the physician's recommendation for chemotherapy prior to and post assay results. Secondary endpoints included change in physician's expressed level of confidence, and changes in estimated cost of recommended treatments prior to and post assay results.

RESULTS

For the entire cohort, physician recommendation for chemotherapy was reduced by an absolute 67.1% by knowledge of the RS assay result (P < .0001). Physician recommendation of chemotherapy was decreased by 75.9% for patients RS result <14 (P < .0001); and 67.5% for patients with RS result 14-25 (P < .0001). Changes in treatment recommendations were associated with an overall reduction in cost by 73.7% per patient, and after incorporating the cost of the RS test, a cost benefit of $823 CAN at 6-month follow-up.

CONCLUSION

Altogether, we established that the assay led to a two-third reduction in the use of chemotherapy, and was a cost-effective approach for hormone receptor-positive, node-positive breast cancer.

An International Registry of Peritoneal Carcinomatosis from Appendiceal Goblet Cell Carcinoma Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

PURPOSE

Peritoneal carcinomatosis from appendiceal goblet cell carcinoma (A-GCC) is a rare and aggressive form of appendiceal tumor. Cytoreductive surgery (CRS) and hyperthermic intra peritoneal chemotherapy (HIPEC) was reported as an interesting alternative regarding survival compared to surgery without HIPEC and/or systemic chemotherapy. Our aim was to evaluate the impact of CRS and HIPEC for patients presenting A-GCC through an international registry.

METHODS

A prospective multicenter international database was retrospectively searched to identify all patients with A-GCC tumor and peritoneal metastases who underwent CRS and HIPEC through the Peritoneal Surface Oncology Group International (PSOGI). The post-operative complications, long-term results, and principal prognostic factors were analyzed.

RESULTS

The analysis included 83 patients. After a median follow-up of 47 months, the median overall survival (OS) was 34.6 months. The 3- and 5-year OS was 48.5% and 35.7%, respectively. Patients who underwent complete macroscopic CRS had a significantly better survival than those treated with incomplete CRS. The 5-year OS was 44% and 0% for patients who underwent complete, and incomplete CRS, respectively (HR 9.65, p < 0.001). Lymph node involvement and preoperative chemotherapy were also predictive of a worse prognosis. There were 3 postoperative deaths, and 30% of the patients had major complications.

CONCLUSION

CRS and HIPEC may increase long-term survival in selected patients with peritoneal metastases of A-GCC origin, especially when complete CRS is achieved. Ideally, randomized control trials or more retrospective data are needed to confirm CRS and HIPEC as the gold standard in this pathology.

Morbidity associated with the use of oxaliplatin versus mitomycin C in hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis of colorectal or appendiceal origin: a multi-institutional comparative study

Background

The raw costs of mitomycin C (MMC) and oxaliplatin for hyperthermic intraperitoneal chemotherapy (HIPEC) differ substantially. We sought to compare the morbidity and toxicity profiles associated with the use of oxaliplatin and MMC in patients undergoing cytoreductive surgery (CRS) and HIPEC for peritoneal carcinomatosis (PC) of colorectal or appendiceal origin, to evaluate whether the cost-effectiveness of these 2 agents should dictate drug choice.

Methods

We conducted a retrospective multi-institutional study of all patients with PC of colorectal or appendiceal origin treated with CRS-HIPEC using MMC or oxaliplatin from 2010 to 2015. Demographic, perioperative, morbidity, toxicity and cost data were compared between the 2 treatment groups and between cancer-origin subgroups.

Results

Forty-two patients treated with MMC and 76 treated with oxaliplatin were included in the study. Baseline demographic and tumour characteristics were comparable in the 2 groups, except that the patients treated with MMC had higher Charlson Comorbidity Index scores. The MMC group had a higher rate of cancer of colorectal origin (76.2% v. 57.9%, p = 0.047) and longer operative times (553 v. 320 min, p < 0.001). In the subgroup of patients whose cancer was of colorectal origin, patients treated with MMC had a higher transfusion rate (50.0% v. 28.6%, p = 0.023) and lower postoperative baseline hemoglobin level (100 v. 119 g/L, p = 0.002) than those treated with oxaliplatin. There was no difference in hematologic toxicity scores after controlling for postoperative anemia. There was no difference in the rates of major complications and 90-day mortality. However, MMC was less costly than oxaliplatin ($724 v. $8928).

Conclusion

MMC and oxaliplatin are both suitable agents for HIPEC and are associated with comparable morbidity and toxicity profiles, regardless of cancer origin. Thus, we propose that cost-effectiveness should ultimately dictate drug selection.

Two-step cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei with high peritoneal carcinomatosis index

BACKGROUND

Complete cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is the only curative treatment for pseudomyxoma peritonei (PMP) arising from the appendix. High peritoneal carcinomatosis index (PCI) is associated with an increased risk of surgical complications. The objective of this study was to present the results of a planned two-step surgical strategy to decrease postoperative morbidity and improve resectability of patients with very high PCI.

METHODS

All consecutive patients who underwent a planned two-step surgical approach for PMP between January 2012 and March 2020 were retrospectively included. This approach was offered for patients with low-grade PMP with PCI > 28 for which feasibility of a complete CRS in one operation was uncertain. The first surgery included a complete CRS of the inframesocolic compartment and omentectomy. HIPEC was delivered at the second surgery, after complete CRS of the supramesocolic compartment. Postoperative morbidity was assessed using the Clavien-Dindo classification and survival results were also collected.

RESULTS

Eight patients underwent the two-step approach. The median PCI was 33 (29-39) and the median time between the two procedures was 111 days (90-212 days). One patient was deemed unresectable at the second surgery. The rate of major morbidity was 0% for the first step and 25% for the second step, with no mortality. Median follow-up was 53.8 months (3-73 months).

CONCLUSION

A two-step surgical management for low-grade PMP patients with very high PCI is safe and feasible, with acceptable postoperative morbidity and no compromise on oncological outcomes.

Rectal anastomosis and hyperthermic intraperitoneal chemotherapy: Should we avoid diverting loop ileostomy?

INTRODUCTION

Literature on rectal anastomosis and diverting ileostomy in patients treated with hyperthermic intraperitoneal chemotherapy (HIPEC) is limited. This study assesses the safety of rectal anastomoses during cytoreductive surgery (CRS) and HIPEC, with and without fecal diversion, and its morbidity when performed.

MATERIALS AND METHODS

From January 2012 to January 2020, patients with peritoneal metastases who underwent CRS and HIPEC that required a rectal anastomosis were included in this single-hospital retrospective chart review.

RESULTS

84 patients were included, of which 29 had a diverting loop ileostomy. The rectal anastomotic leak (AL) rate for the series was 8.3%. Factors associated with AL were male gender (p = 0.031) and increased BMI (p < 0.0005). Diverting loop ileostomy was associated with a significant decrease of clinically significant rectal AL (0% vs 12.7%, p = 0.045). However, the 90-day readmission rate was higher in this group (37.9% vs 10.9%, p = 0.003). Stoma reversal surgery was performed for all patients, but 3 patients experienced AL (10.7%).

CONCLUSIONS

This study suggests that creation of a diverting loop ileostomy may be an effective strategy to prevent symptomatic rectal AL following CRS with HIPEC. However, it is also associated with an increased readmission rate and increased risk of AL following reversal surgery.

Abstract PS4-27: A prospective multicenter study evaluating the impact of the 21-Gene Breast Recurrence Score® upon physician treatment decision and cost in lymph node-positive breast cancer patients in Quebec

Background: Locoregional lymph node involvement has historically been used as the most important deciding factor for the administration of chemotherapy in the adjuvant setting of breast cancer patients. The 21-gene Breast Recurrence Score® assay (the assay) is emerging as an important tool to assist with chemotherapy decisions amongst hormone receptor (HR)-positive, node-positive breast cancer (BC) patients. Previous studies have suggested that node-positive patients with low Recurrence Score (RS) results do not benefit from chemotherapy. We wanted to better understand the impact of the assay upon physician treatment decisions and treatment cost in this patient cohort.

Methods: We conducted a multicenter prospective observational trial for ER/PR-positive HER2-negative BC patients that have undergone surgical treatment for T1-T3 disease and 1-3 positive lymph nodes. Physicians were required to complete a questionnaire indicating treatment choice prior to and post availability of Recurrence Score results. Patients were enrolled in the study from the time of consent to 6 months after the start of adjuvant therapy. The primary endpoint was change in the physician’s recommendation for chemotherapy prior to and post assay results. Secondary endpoints include the change in recommendation for additional growth factor (GF) supportive therapy, change in physician’s expressed level of confidence, and changes in estimated cost of recommended treatments prior to and post assay results.

Results: 70 patients were enrolled between March 2018 and September 2019 at five hospital centers, as part of the McPeak Sirois Group of Quebec. The median age of the cohort was 61 years (range, 38 to 82 years). 18.5% (n=13) of the cohort consisted of patients &lt; 50 years, and 81.4% (n=57) were &gt; or = to 50 years. 64.3% (n=45) of the patients had one positive lymph node and 35.7% (n=25) of the patients had 2 or 3 positive lymph nodes. 25.7% (n=18) of the patients had a RS &lt; 11 and 68.6% (n=48) had a RS result between 11-25. For the entire cohort, we found that the proportion of patients for whom chemo-hormonal therapy was recommended was reduced by an absolute 67.1% by knowledge of the RS result (OR (odds of having chemo-hormonal therapy post-RS recommendation versus pre-RS recommendation) = 0.03 [95% CI: 0.01-0.08]; P&lt;0.0001). The RS results led to an absolute reduction in physician recommendation in chemo-hormonal therapy by 38.5% for patients &lt; 50 years, and by 73.7% of patients (OR=0.02 [95% CI: 0.01-0.06]; P &lt;0.0001) for patients &gt; or = to 50 years. Changes in treatment recommendation were identified for patients with one positive node, 73.3% (OR=0.02 [95% CI: 0.01-0.07]; P&lt;0.0001); and for patients with two or three positive nodes, 56.0% (OR=0.06 [95% CI: 0.02-0.23]; P&lt;0.0001). Recommendations for GF supportive therapy due to RS results decreased by 42.6% (OR=0.16 [95% CI: 0.07-0.34]; P &lt;0.0001). Moreover, RS results led to an increase in confidence in physician treatment decisions for 68.6% of patients (OR=18.3 [95% CI: 7.90-42.28]; P &lt;0.0001). We found that the cost of chemotherapy, in addition to anti-emetics and GF supportive therapy, decreased by 69.9% per patient (pre-RS mean, $3,968 CAN; versus post-RS mean, $1,196 CAN) (P &lt;0.0001).

Conclusions: Overall, we found that the 21-gene Breast Recurrence Score® assay changed physician treatment decisions in about two-thirds of all patients with hormone receptor-positive, node-positive BC, regardless of the number of positive nodes (up to 3). The assay increased physician confidence and was associated with an important decrease in treatment cost. Taken together, the assay is a cost-effective approach that can decrease the use of chemotherapy amongst HR-positive, node-positive BC patients in Quebec.

Citation Format: Saima Hassan, Rami Younan, Erica Patocskai, Louise Provencher, Brigitte Poirier, Lucas Sideris, Pierre Dubé, Jean-Francois Boileau, Catalin Mihalcioiu, André Robidoux. A prospective multicenter study evaluating the impact of the 21-Gene Breast Recurrence Score® upon physician treatment decision and cost in lymph node-positive breast cancer patients in Quebec [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-27.

Self-directed learning by video as a means to improve technical skills in surgery residents: a randomized controlled trial

BACKGROUND

With their demanding schedules, surgical residents have limited time to practice techniques. The aim is to evaluate the pedagogic model of self-directed learning using video in surgery residents.

METHODS

Informed consent was obtained from all the participants. A randomized controlled trial was conducted in 2018 at Hôpital Maisonneuve-Rosemont (University of Montreal). Participants were general surgery residents. There were 27 eligible residents; 22 completed the study. They were filmed performing an intestinal anastomosis on cadaveric pig bowel. The self-directed learning by video (SDL-V) group was given an expert video, which demonstrated the technique performed by an experienced surgeon. The control group continued with their regular duties. Three weeks later, participants performed a second filmed anastomosis. Two attending surgeons evaluated the residents' filmed anastomosis using the Objective Structured Assessment of Technical Skills scale. After their second anastomosis, all participants had access to the expert video and completed a survey.

RESULTS

Score did not differ significantly between groups during the first (control: 23.6 (4.5) vs. SDL-V: 23.9 (4.5), p = 0.99, presented as mean (SD)) or second filmed anastomosis procedure (control: 27.1 (3.9) vs. SDL-V: 29.6 (3.4) p = 0.28). Both groups improved significantly from pre- to post-intervention (mean difference between the two anastomosis procedure with 95% CI for control: 3.5, [1.1; 5.9] and for SDL-V: 5.8, [3.4: 8.2]). Correlation between the evaluators for score was moderate (r = 0.6, 95% CI: [0.3: 0.8]). The pass/fail global evaluation exhibited poor inter-rater reliability (Kappa: 0.105, 95% CI: [- 0.2:0.4]). On the survey, all participants wanted more expert-made videos of specific surgical techniques.

CONCLUSIONS

Despite a higher final OSATS score for the intervention group, self-directed learning by video failed to produce a statistically significant difference on the overall OSATS scores between the two groups in this small cohort.

The role of intraperitoneal chemotherapy in the surgical management of pancreatic ductal adenocarcinoma: a systematic review

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with poor prognosis, particularly for patients with metastatic disease. Treatment for oligometastatic presentation has been reported in recent literature, but the role of intraperitoneal chemotherapy for patients with peritoneal metastases (PM) remains unclear. We performed a systematic literature search of the PubMed, Cochrane and Embase databases in order to identify clinical trials and case-series reporting on the safety and efficacy of intraperitoneal chemotherapy in patients with PDAC-derived PM. Eight publications reporting on 85 patients were identified, using three different therapeutic strategies. First, 37 patients received cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for PDAC with PM. Grade 3 and 4 complications occurred in 37.8% of patients, without perioperative mortality. Median disease-free survival and overall survival (OS) rates varied from 4 to 36 months and 4 to 62 months, respectively. Secondly, 40 patients with resectable PDAC without PM received prophylactic HIPEC following pancreatic resection, with postoperative morbidity and mortality rates of 30% and 5%, and 5-year OS rates of 23-24%. Finally, eight patients with PDAC-derived peritoneal disease were converted to resectable disease after receiving neoadjuvant intraperitoneal chemotherapy and operated on with curative intent, achieving a median OS of 27.8 months. In conclusion, CRS with HIPEC for PDAC-derived PM appears to be safe, conferring the same postoperative morbidity and mortality as reported on non-pancreatic malignancies. In highly selected patients, it could be considered for short-term disease control. However, long-term survival remains poor. The addition of prophylactic HIPEC for resectable PDAC cannot be recommended.

Canadian guidelines on the management of colorectal peritoneal metastases

Modern management of colorectal cancer (crc) with peritoneal metastasis (pm) is based on a combination of cytoreductive surgery (crs), systemic chemotherapy, and hyperthermic intraperitoneal chemotherapy (hipec). Although the role of hipec has recently been questioned with respect to results from the prodige 7 trial, the role and benefit of a complete crs were confirmed, as observed with a 41-month gain in median survival in that study, and 15% of patients remaining disease-free at 5 years. Still, crc with pm is associated with a poor prognosis, and good patient selection is essential. Many questions about the optimal management approach for such patients remain, but all patients with pm from crc should be referred to, or discussed with, a pm surgical oncologist, because cure is possible. The objective of the present guideline is to offer a practical approach to the management of pm from crc and to reflect on the new practice standards set by recent publications on the topic.

Evidence-Based Strategies for the Treatment of Peritoneal Malignancies during Health Care Resource Restriction: The COVID-19 Pandemic

Background: The COVID-19 pandemic has put enormous pressure on hospital resources, and has affected all aspects of patient care. As operative volumes decrease, cancer surgeries must be triaged and prioritized with careful thought and attention to ensure maximal benefit for the maximum number of patients. Peritoneal malignancies present a unique challenge, as surgical management can be resource intensive, but patients have limited non-surgical treatment options. This review summarizes current data on outcomes and resource utilization to help inform decision-making and case prioritization in times of constrained health care resources. Methods: A rapid literature review was performed, examining surgical and non-surgical outcomes data for peritoneal malignancies. Narrative data synthesis was cross-referenced with relevant societal guidelines. Peritoneal malignancy surgeons and medical oncologists reviewed recommendations to establish a national perspective on case triage and mitigating treatment strategies. Results and Conclusions: Triage of peritoneal malignancies during this time of restricted health care resource is nuanced and requires multidisciplinary discussion with consideration of individual patient factors. Prioritization should be given to patients where delay may compromise resectability of disease, and where alternative treatment options are lacking. Mitigating strategies such as systemic chemotherapy and/or surgical deferral may be utilized with close surveillance for disease stability or progression, which may affect surgical urgency. Unique hospital capacity, and ability to manage the complex post-operative course for these patients must also be considered to ensure patient and system needs are aligned.

Hyperthermic intraoperative thoracoabdominal chemotherapy for stage IVB epithelial ovarian carcinoma

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Full-thickness diaphragmatic infiltration with pleural effusion in advanced epithelial ovarian cancer is challenging.

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Short-term control of malignant pleural effusion with HITAC for advanced epithelial ovarian cancer seems feasible.

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Carboplatin is safe when used as HIPEC or HITAC agent for advanced epithelial ovarian cancer.

Recurrent High-grade Ovarian Immature Teratoma with Peritoneal Dissemination

BACKGROUND

Peritoneal dissemination of ovarian immature teratoma in children is a rare entity and is associated with a poor prognosis. There are no guidelines on the optimal management of these patients with regard to surgery and systemic treatments.

CASE

This is the case of a 16-year-old patient who experienced an early recurrence of immature teratoma with peritoneal dissemination after surgery and systemic chemotherapy failure, and was treated with an aggressive salvage cytoreductive surgery. She was still disease-free 6 months after her second surgery.

SUMMARY AND CONCLUSION

Upfront aggressive surgical management with complete cytoreductive surgery is recommended when patients present with disease recurrence and peritoneal dissemination of ovarian immature teratoma. Such cases should be managed in centers with local expertise in the treatment of peritoneal surface malignancies.

Carboplatin Hyperthermic Intraperitoneal Chemotherapy in the Management of Primary Stage IVB Endometrial Cancer

BACKGROUND

Endometrial cancer presenting with peritoneal metastases carries a poor prognosis. The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to the surgical management of these patients has been studied in recent years, but only with cisplatin.

CASES

This is a series of 3 patients presenting with endometrial cancer and synchronous peritoneal metastases who underwent cytoreductive surgery and carboplatin HIPEC as primary treatment. Complete cytoreductive surgery was achieved for each patient. No grade 3-5 complications were observed. Two patients died at 12 and 18 months, respectively, and 1 patient was alive with disease at 29 months.

CONCLUSION

This case series suggests that the addition of carboplatin HIPEC to the surgical management of peritoneal metastases from endometrial cancer is safe as primary treatment. However, long-term survival remains poor.

A rare case of recurrent epidermoid anal cancer treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy-case report

Background

Anal cancer is a rare cancer with chemoradiation being the mainstay of treatment for locoregional presentation. In North America, the most common subtype is anal squamous cell carcinoma (epidermoid). A surgical approach is considered for persistent or recurrent anal disease and systemic chemotherapy for metastatic disease. We are presenting a unique case of recurrent anal cancer with isolated peritoneal malignancy, an oligometastatic state which is rare in itself. It was treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. There are currently no clear guidelines for the aforementioned presentation. The discussion drew on the feasibility and safety of this approach.

Case presentation

A 68-year-old woman diagnosed with an epidermoid anal cancer (stage 3B) was initially treated with chemoradiation therapy (Standard Nigro Protocol) in 2014. At the 5-year mark post-treatment, she was diagnosed with a recurrent anal epidermoid cancer in the form of isolated peritoneal carcinomatosis proven by biopsy. After declining systemic chemotherapy, she underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with Mitomycin-C©. Peritoneal carcinomatosis index was evaluated at 10, and intraoperative frozen sections were positive for carcinoma of epidermoid origin compatible with anal cancer. A completeness of cytoreduction score of 0 was achieved during the cytoreductive surgery, and her hospital course was unremarkable. She remains disease-free 12 months later.

Conclusions

To our knowledge, this is the first case reporting the disease presentation of anal cancer with oligometastatic dissemination to the peritoneum. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were performed. Thus far, this approach seems to be a safe and feasible option for short-term control of the disease.

Tumour response 3 months after neoadjuvant single-fraction radiotherapy for low-risk breast cancer

Introduction

Standard treatment for early-stage invasive breast cancer (bca) consists of breast-conserving surgery and several weeks of adjuvant radiotherapy (rt). Neoadjuvant single-fraction rt is a novel approach for early-stage bca. We sought to investigate the effect of delaying surgery after neoadjuvant rt with respect to the rate of pathologic response (pr).

Methods

Women 65 years of age or older with a new diagnosis of stage i luminal A bca were eligible for inclusion. A single 20 Gy dose to the primary breast tumour was given, followed by breast-conserving surgery 3 months later. The primary endpoint was the pr rate assessed by microscopic evaluation using the Miller-Payne system.

Results

To date, 10 patients have been successfully treated. Median age of the patients was 72 years (range: 65-84 years). In 8 patients, neoadjuvant rt resulted in a tumour pr with median residual cellularity of 3%. No immediate rt complications other than mild dermatitis were noted.

Conclusions

This study demonstrates a method for delivering single-fraction rt that can lead to a high level of pr in most patients. Continued accrual to this study and subsequent trials are needed to determine the feasibility, safety, and role of this novel technique in the management of early-stage bca.

Abstract P4-12-07: Single pre-operative radiation therapy (SPORT) trial for low risk breast cancer: A phase 1 study comparing pathological findings in immediate versus delayed surgery

Introduction: Estrogen receptor (ER)-positive/HER2-negative breast cancers are known to be less immunogenic than triple negative and HER2-positive breast cancers. As increasing levels of tumor-infiltrating lymphocytes (TILs) have been associated with increased rates of pathological complete response (pCR) and improved prognosis, there is interest in exploring ways to render ER-positive/HER2-negative breast cancers more immunogenic. Few studies have analysed the histological response to neoadjuvant radiation therapy (RT) as the only pre-operative treatment modality; in most case series, chemotherapy was concomitantly given, as these studies focused on the treatment of advanced breast cancer. Aims: The objectives of this study are to assess pathological and immunological responses induced by a single dose of pre-operative RT in early breast cancer. Material and methods: women aged 60 years or older diagnosed with invasive breast carcinoma were prospectively identified. Only cT1N0 unifocal tumors that were low to intermediate grade and ER-positive/HER2 negative were eligible. Patients received a single pre-operative radiation dose of 20Gy in a single fraction. Surgery was performed either 24-72 hours after RT (SPORT group) or 11-13 weeks after RT (SPORT -DS [delayed surgery] group). Assessment of pathological response was performed using the Miller-Payne system and Residual Cancer Burden was calculated. Immunohistochemistry for Ki67 was performed on the biopsy and excision specimens. CD8 immunostain was used to evaluate the immune infiltrate. Both groups (SPORT and SPORT-DS) were compared using the independent t-test and Fisher exact test. Results: a total of thirteen patients were included, with an average age of 73 years (range 60-84). All patients received a single 20Gy radiation dose, and surgery was performed either 24-72 hours after RT (SPORT group, n=5) or on average 95 days after RT in the SPORT-DS group (range 75-133 days; n=8). All patients underwent partial mastectomy with sentinel lymph node biopsy. Histologically, all tumors were invasive ductal carcinomas, except for one invasive micropapillary carcinoma and one invasive tubular carcinoma (both in the SPORT group). Tumor bed changes, similar to what is observed in the post-neoadjuvant chemotherapy setting, were identified in all but one patients in the SPORT-DS group (7/8 patients) but was not seen in the SPORT group (0/5 patients, p=0.005). Using the Miller-Payne system, there was no evidence of response in the SPORT cohort (grade 1/5 in all patients), while 6/8 patients in the SPORT-DS cohort had a partial pathological response (grade 3/5 in 2 patients and grade 4/5 in 4 patients, p = 0.02). No pCR were observed. Comparing Ki67 on the biopsy and surgical specimens, an average decrease of 7.5% in the SPORT group and 6.3% in the SPORT-DS group was observed (p=0.8). A significant lymphocytic infiltrate was not present in any case (stromal TILs &lt;10% in all cases). At an average follow-up of 11 months, there have been no recurrences. Conclusion: This is, to our knowledge, the first series comparing histological findings from immediate and delayed surgery after pre-operative single dose RT. We observed a significant decrease in tumor cellularity with delayed surgery, while no change in cellularity occurred with immediate surgery. The lack of lymphocytic infiltrate does not support immune activation as the mechanism of the ablative effect of 20Gy of radiation. Further follow-up will be needed to determine the prognostic significance of the partial pathological response that was observed in the SPORT-DS cohort.

Citation Format: Marie-Hélène Ngo, David Tiberi, Peter Vavassis, David Nguyen, Bernard Fortin, Mai-Kim Gervais, Lucas Sideris, Pierre Dubé, Guy Leblanc, Michel-Pierre Dufresne, Marie-Christine Guilbert, Michael Yassa. Single pre-operative radiation therapy (SPORT) trial for low risk breast cancer: A phase 1 study comparing pathological findings in immediate versus delayed surgery [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-12-07.

Impact of anesthesia management during cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for the treatment of colorectal peritoneal carcinomatosis on intra- and postoperative outcomes: A systematic review protocol

BACKGROUND

The impact of the anesthesia management during cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of colorectal peritoneal carcinomatosis (CRPC) on postoperative outcomes might be of major importance in the process of postoperative recovery. It might have a significant impact on intra- and postoperative outcomes, but the evaluation of this impact seems to be under-reported. To investigate the question whether the anesthesia management was reported in previous studies done in this population and if it had any impact on postoperative outcomes, we propose to conduct a systematic review of the published literature.

METHODS

For this review, we will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). Medline/PubMed, Embase, EBM Reviews and the Cochrane Database of Systematic Reviews (CDSR) will be systematically consulted for eligible studies without age, gender, ethnic, and language restriction. The goal of this review will be to assess whether anesthesia monitoring, dosing, and analgesia protocols were reported in this literature on this specific procedure and whether the impact of the anesthesia management on intraoperative safety and postoperative recovery was evaluated.

RESULTS

The results of this systematic review will allow to answer the initial question: has the impact of anesthesia management on intraoperative safety and patients' postoperative recovery already been studied and reported in the past for this type of major surgery? And does anesthesia have any impact on postoperative outcomes?

DISCUSSION

In the hypothesis that the impact of anesthesia management on patients' postoperative recovery has never been studied, or very little reported in previous studies in this type of major surgery, it would be justified to conduct a randomized controlled trial on this specific objective.

REGISTRATION

This systematic review protocol was registered in PROSPERO, under the registration number CRD42019124162.

Peritoneal carcinomatosis index predicts survival in colorectal patients undergoing HIPEC using oxaliplatin: a retrospective single-arm cohort study

Abstract

Background

Peritoneal carcinomatosis (PC) from colorectal cancer is associated with poor prognosis. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has improved survival for patients with colorectal peritoneal carcinomatosis. However, standardization of HIPEC protocols, including which chemotherapeutic agent to use, is lacking in the literature. Therefore, we sought to report survival outcomes from colorectal cancer patients undergoing CRS/oxaliplatin-based HIPEC at our institution over the last 10 years.

Methods

Colorectal PC patients treated with CRS/oxaliplatin-based HIPEC 2004–2015 were included. Demographic, clinical, and oncologic data were abstracted from the medical record. Overall (OS) and disease-free survival (DFS) were calculated using Kaplan–Meier analysis. Univariate/multivariate Cox regression analysis was done.

Results

Laparotomy was performed in 113 patients for colorectal PC; 91 completed a curative intent CRS/HIPEC. At 3 and 5 years, OS for the CRS/HIPEC cohort was 75% and 55%, and DFS was 50% and 25%, respectively. On multivariate analysis, incremental increases in peritoneal carcinomatosis index (PCI) were associated with worse OS (p = 0.0001) and DFS (p = 0.0001). Grade III/IV complications were also associated with worse OS.

Conclusions

A standardized regimen of CRS and oxaliplatin-based HIPEC for colorectal PC is effective with favorable OS and DFS and acceptable complication rates.

Combined Mucinous and Neuroendocrine Tumours of the Appendix Managed with Surgical Cytoreduction and Oxaliplatin-based Hyperthermic Intraperitoneal Chemotherapy

Appendiceal neoplasms account for 1% of appendectomy specimens. Common subtypes include mucinous cystadenoma, adenocarcinoma, and neuroendocrine tumors (NETs). The simultaneous presence of appendicular mucinous and NETs is a rare event. Depending on the tumors’ morphological distribution in the affected organ, they are qualified as either “collision” or “combined” tumours. We herein present the case of a 50-year-old male who presented with acute appendicitis and who was subsequently found to have pseudomyxoma peritonei (PMP) due to a perforated combined mucinous and neuroendocrine tumours. The patient was treated by right hemicolectomy and cytoreductive surgery (CRS) with oxaliplatin-based hyperthermic intraperitoneal chemotherapy (HIPEC). He was cancer free 20 months later. Due to the limited clinical experience with this presentation, no formal recommendations exist as to its management other than those applicable to each cancer alone. The efficacity of treatment on the long-term prognosis on these combined tumors is yet to be elucidated.

Long term survival analysis after hyperthermic intraperitoneal chemotherapy with oxaliplatin as a treatment for appendiceal peritoneal carcinomatosis

BACKGROUND AND OBJECTIVES

Complete cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) have been proven to lengthen survival in appendiceal peritoneal carcinomatosis (PC-A). The aim of this study was to analyze survival results of this therapy in our institution over the last 10 years.

METHODS

Data was retrospectively reviewed and analyzed. Treatment consisted of CRS plus HIPEC with oxaliplatin. Ronnett's histologic classification was used (peritoneal mucinous carcinomatosis (PMCA), PMCA with intermediate features (PMCA-I) and disseminated peritoneal adenomucinosis (DPAM)). Overall survival (OS) and disease-free survival (DFS) estimates were calculated using Kaplan-Meier survival curves.

RESULTS

109 patients with PC-A underwent laparotomy with curative intent. Of those, 92 underwent CRS plus HIPEC. Median follow-up was 42 months. The 5 and 10-year OS rates for the HIPEC group were 82.2% and 76.5%. The 5 and 10-year OS estimates for DPAM and PMCA-I subgroups were 100% and 100%, 78.1% and 72.9%, respectively. For the PMCA subgroup, the 3 and 5-year OS were 61.4% and 40.1%, respectively. The 5 and 10-year DFS estimates were 71.9% and 42.7%.

CONCLUSION

CRS plus HIPEC with oxaliplatin represent an effective therapeutic approach for PC-A. Long term OS estimates for patients treated at our institution are encouraging.

Neuroendocrine carcinoma arising in a tailgut cyst

INTRODUCTION

A tailgut cyst, also called retrorectal cystic hamartoma, is a rare congenital lesion that forms most commonly in the retrorectal space. It is presumed to arise from remnants of early embryogenesis.

PRESENTATION OF CASE

The following report describes a unique case of a retrorectal cystic hamartoma in a 53 year-old French Canadian man with a history of low back pain. The tumour underwent malignant transformation into a well-differentiated neuroendocrine carcinoma three years after the beginning of symptoms.

DISCUSSION

This condition can be found at any age, but occurs especially among middle-aged women. Not only is it frequently misdiagnosed, but also several complications associated to the cyst have been reported such as infection and malignant transformation. This is why complete surgical excision of the tailgut cyst is currently recommended.

Rationale for the administration of systemic 5-FU in combination with heated intraperitonal oxaliplatin

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (OX) is the standard of care for selected patients with peritoneal carcinomatosis of colorectal origin. Because 5-FU is mandatory to improve efficacy of OX when used by systemic route, several teams now empirically combine intravenous (IV) 5-FU with HIPEC OX, but this practice has yet to be supported by preclinical data. Using a murine model, we studied the impact of IV 5-FU on peritoneal absorption of HIPEC OX.

METHODS

Under general anesthesia, 24 Sprague-Dawley rats were submitted to 4 different doses of IV 5-FU (0, 100, 400 and 800 mg/m²) and a fixed dose of HIPEC OX (460 mg/m²) perfused at 40 °C during 25 min. At 25 min, samples in different compartments were harvested (peritoneum, portal vein and systemic blood) and the concentrations of 5-FU and OX were measured by high performance liquid chromatography.

RESULTS

Peritoneal absorption of OX was significantly higher (17.0, 20.1, 34.9 and 38.1 nmol/g, p < 0.0001) with increasing doses of 5-FU (0, 100, 400 and 800 mg/m², respectively). Peritoneal absorption of OX reached a plateau between 400 and 800 mg/m² of IV 5-FU.

CONCLUSION

IV 5-FU enhances peritoneal absorption of HIPEC OX. The most efficient dose of IV 5-FU to be used in combination with HIPEC OX seems to be 400 mg/m².

Comparison of open and closed abdomen techniques for the delivery of intraperitoneal pemetrexed using a murine model

BACKGROUND AND OBJECTIVES

Pemetrexed is an appealing agent to use for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). However, the optimal method of pemetrexed delivery still remains undefined. Using a murine model, we compared the use of open and closed abdomen techniques on the absorption of intraperitoneal (IP) pemetrexed in different compartments.

METHODS

Eleven Sprague-Dawley rats were submitted to a fixed dose of IP pemetrexed (1000 mg/m² ) at a perfusion temperature of 40°C during 25 min according to two techniques: open and closed. At the end of perfusion, samples in different compartments were harvested and the concentrations of pemetrexed were measured by high performance liquid chromatography.

RESULTS

Absorption of IP pemetrexed in portal and systemic blood was significantly higher using the open compared to the closed abdomen technique (93.17 vs 52.50 µg/mL, P < 0.001) and (76.26 vs 51.65 µg/mL, P < 0.001), respectively. No difference was found between the two techniques on the peritoneal tissue concentration of pemetrexed (18.07 vs 19.17 µg/g, P = 0.51).

CONCLUSION

Peritoneal absorption of pemetrexed is not modified by the use of either technique. However, systemic concentrations of pemetrexed increased using the open technique, suggesting it could increase systemic toxicity.

Postoperative complications affect long-term outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis

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.

Video Coaching as an Efficient Teaching Method for Surgical Residents-A Randomized Controlled Trial

BACKGROUND

As surgical training is evolving and operative exposure is decreasing, new, effective, and experiential learning methods are needed to ensure surgical competency and patient safety. Video coaching is an emerging concept in surgery that needs further investigation.

DESIGN

In this randomized controlled trial conducted at a single teaching hospital, participating residents were filmed performing a side-to-side intestinal anastomosis on cadaveric dog bowel for baseline assessment. The Surgical Video Coaching (SVC) group then participated in a one-on-one video playback coaching and debriefing session with a surgeon, during which constructive feedback was given. The control group went on with their normal clinical duties without coaching or debriefing. All participants were filmed making a second intestinal anastomosis. This was compared to their first anastomosis using a 7-category-validated technical skill global rating scale, the Objective Structured Assessment of Technical Skills. A single independent surgeon who did not participate in coaching or debriefing to the SVC group reviewed all videos. A satisfaction survey was then sent to the residents in the coaching group.

SETTING

Department of Surgery, HôpitalMaisonneuve-Rosemont, tertiary teaching hospital affiliated to the University of Montreal, Canada.

PARTICIPANTS

General surgery residents from University of Montreal were recruited to take part in this trial. A total of 28 residents were randomized and completed the study.

RESULTS

After intervention, the SVC group (n = 14) significantly increased their Objective Structured Assessment of Technical Skills score (mean of differences 3.36, [1.09-5.63], p = 0.007) when compared to the control group (n = 14) (mean of differences 0.29, p = 0.759). All residents agreed or strongly agreed that video coaching was a time-efficient teaching method.

CONCLUSIONS

Video coaching is an effective and efficient teaching intervention to improve surgical residents' technical skills.

Electrocautery effect on intestinal vascularisation in a murine model

BACKGROUND

The use of electrocautery devices is associated with complications such as perforation or fistulisation when used near intestinal structures. This is likely due to its effect on vascularisation of the bowel wall. To test this hypothesis we established a murine model to quantify the effect of electrocautery injury on the intestinal microvascularisation.

METHODS

Sprague-Dawley rats were subjected to five electrocautery injuries on the small bowel in coagulation mode (30 W intensity) and in cut mode (40 W, 80 W and 200 W intensities) for durations of 1, 2 and 5 s. 5 mg/kg of fluorescein was injected intravenously, the injured bowel segments harvested and the rat sacrificed. The segments were analysed to measure the fluorescence of injured bowel compared to adjacent unharmed tissue.

RESULTS

A significant decrease in bowel wall microvascularisation occurred with increasing intensity (coag 30 W/cut 40 W versus cut 200 W 1 s: p < 0.05) and duration of electrocautery injury (cut 40 W 1/2 s versus 5 s: p < 0.05). There was a 40% perforation rate when decreased bowel wall microvascularisation was 25% or more. Despite similar electrocautery injury, a significantly greater microvascularisation decrease was observed in jejunum compared to ileum (p < 0.05).

CONCLUSION

We successfully established a murine model to quantify the decrease of bowel wall microvascularisation associated with electrocautery use. Unsurprisingly, the decrease in microvascularisation is greater with higher intensity and duration of electrocautery and is associated with more perforations in the experimental model. The jejunum seems more vulnerable to electrocautery injury than the ileum. These observations support caution when using electrocautery devices near intestinal structures.

Impact of electrocautery and hyperthermic intraperitoneal chemotherapy on intestinal microvasculature in a murine model

BACKGROUND

Electrocautery (EC) is used during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Using a murine model, we studied the effect of HIPEC on small bowel EC lesions and surrounding normal tissues.

METHODS

Thirty-two rats were divided into five groups: a control group with EC lesions; EC plus intraperitoneal heated 5% dextrose (D5W); EC plus oxaliplatin (OXA, 460 mg/m(2)); EC plus mitomycin C 10 mg/m(2) (MMC10); EC plus MMC 35 mg/m(2) (MMC35). EC lesions and surrounding tissue microvasculature were analysed after intravenous injection of fluorescein.

RESULTS

In the ileum OXA significantly reduced EC lesions microvasculature compared with the control group; MMC10 caused greater reduction than the control, D5W and MMC35 groups. Surrounding tissue microvasculature was significantly reduced by MMC35 exposure when compared to the control, OXA or MMC10 groups. In the jejunum EC injuries exposed to OXA or MMC10 had significantly reduced microvasculature compared to the control, heated D5W and MMC35 groups. Surrounding tissue microvasculature was significantly reduced by MMC35 exposure when compared to the OXA group. There was no significant microvasculature difference between the EC lesions made before or after HIPEC.

CONCLUSION

HIPEC with OXA and MMC10 potentiates small bowel wall EC injuries. MMC35 reduces surrounding unharmed tissue microvasculature. There was no effect of hyperthermia alone on microvasculature.

Effect of chemotherapy and heat on biomechanical properties of absorbable sutures

BACKGROUND

The quality of tissue repairs depends on tissue integrity, surgical technique, and material properties of the sutures used. Currently, there is no clear consensus on which is the best suture to use during cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy. The aim of this study was to evaluate the impact of heat and chemotherapy on sutures' biomechanical properties.

METHODS

Six different 3.0 absorbable sutures (Biosyn, Dexon II, Maxon, Monocryl, PDS II, and Vicryl Plus) were tested. All suture strands were incubated for a 24-h period in saline, mitomycin-c, and oxaliplatin at 37 and 45°C. Suture loops were then loaded to failure using a servohydraulic testing machine. Data for tensile breaking force (TBF) and elongation rate were collected for all samples.

RESULTS

Under basal condition, Maxon was the strongest of all sutures with a TBF of 59.6 ± 4.3 N (P < 0.01), and no significant difference in TBF was observed between other sutures. Heat alone had no impact on sutures' biomechanical parameters. Exposition to mitomycin-c at 45°C did not significantly affect sutures' basal tensile properties, with Maxon remaining the strongest suture. When incubated in oxaliplatin at 45°C, the six suture types had a similar TBF. In all experimental conditions, multifilament sutures had a significantly lower elongation rate than monofilament sutures, and no correlations were demonstrated between elongation rate and the TBF of sutures.

CONCLUSIONS

This study showed that exposition to heated chemotherapy did not significantly affect absorbable sutures biomechanical properties.

Guidelines on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy arising from colorectal or appendiceal neoplasms

To meet the needs of patients, Canadian surgical and medical oncology leaders in the treatment of peritoneal surface malignancies (psms), together with patient representatives, formed the Canadian HIPEC Collaborative Group (chicg). The group is dedicated to standardizing and improving the treatment of psm in Canada so that access to treatment and, ultimately, the prognosis of Canadian patients with psm are improved. Patients with resectable psm arising from colorectal or appendiceal neoplasms should be reviewed by a multidisciplinary team including surgeons and medical oncologists with experience in treating patients with psm. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy should be offered to appropriately selected patients and performed at experienced centres. The aim of this publication is to present guidelines that we recommend be applied across the country for the treatment of psm.

Broadband, unpolarized repumping and clearout light sources for Sr(+) single-ion clocks

Future transportable optical clocks require compact and reliable light sources. Here, broadband, unpolarized repumper and state clearout sources for Sr⁺ single-ion optical clocks are reported. These turn-key devices require no frequency stabilization or external modulators. They are fiber based, inexpensive, and compact. Key characteristics for clock operation are presented, including optical spectra, induced light shifts, and required extinction ratios. Tests with an operating single-ion standard show a clearout efficiency of 100%. Compared to a laser-based repumper, the achievable fluorescence rates for ion detection are a few tens of percent lower. The resulting ion kinetic temperature is 1-1.5 mK, near the Doppler limit of the ion system. Similar repumper light sources could be made for Ca⁺ (866 nm) and Ba⁺ (650 nm) using semiconductor gain media.

Hyperthermic intraperitoneal chemotherapy with oxaliplatin as treatment for peritoneal carcinomatosis arising from the appendix and pseudomyxoma peritonei: a survival analysis

Background

Appendiceal peritoneal carcinomatosis (PC) is rare and its long-term prognosis is poor. The aim of this study was to evaluate the results of an aggressive treatment approach used in our institution for the last eight years.

Methods

Data from all patients with PC arising from the appendix were prospectively collected and analyzed. Treatment consisted of complete surgical cytoreduction (CRS), followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (460 mg/m²) at 43°C over 30 minutes. Ronnett’s histologic classification was used for tumor grading.

Results

Between February 2003 and April 2011, 78 patients underwent laparotomy with curative intent. The mean follow-up period was 33.7 months. A total of 58 patients received HIPEC, but 11 patients could not have CRS and received no HIPEC. Nine patients with a negative second-look surgery also received no HIPEC. The five-year overall survival for the entire cohort was 66.2%; 100% for the negative second-look patients, 77% for the HIPEC patients and 9% for the unresectable patients (P <0.0001). A total of 15 patients (25.9%) had isolated peritoneal recurrence, no patient had visceral recurrence only, and five patients (8.6%) had both. In regards to the five-year disease-free survival for the HIPEC patients, histologic grade (disseminated peritoneal adenomucinosis 100%, peritoneal mucinous carcinomatosis with intermediate features 40%, peritoneal mucinous carcinomatosis 20%; p =0.0016) and completeness of cytoreduction (CCR-0 56%, CCR-1 24%; P =0.0172) were prognostic factors. There was one postoperative mortality. The major complication rate for patients treated with HIPEC was 40%, including intra-abdominal abcess (17%), hemorrhage (12%) and anastomotic leak (10%). One patient in the HIPEC group experienced temporary grade II neuropathy and grade III thrombocytopenia.

Conclusions

This therapeutic approach seems both feasible and safe in selected patients. Recurrence is, however, frequent and represents a challenge.

High-accuracy measurement of the differential scalar polarizability of a 88Sr+ clock using the time-dilation effect

We report a high-accuracy measurement of the differential static scalar polarizability Δα(0) of the 5s(2)S(1/2)-4d(2)D(5/2) transition of the (88)Sr(+) ion. The high accuracy is obtained by comparing the micromotion-induced positive scalar Stark shift to the negative time-dilation shift. Measurement of the trap drive frequency where these shifts cancel is used to determine Δα(0) without the need to determine the electric field. Δα(0) is a critical parameter for the operation of frequency standards as it determines the blackbody radiation frequency shift coefficient, the largest source of uncertainty in the (88)Sr(+) ion clock. The measured value of Δα(0) is -4.7938(71) × 10(-40) J m(2)/V(2). Taking into account the dynamic correction, the blackbody shift at 300 K is 0.247,99(37) Hz. The contribution of the blackbody shift coefficient to the uncertainty of the ion standard has been reduced by a factor of 24, from 2 × 10(-17) to 8.3 × 10(-19). The revised total uncertainty of our reference standard is 1.2 × 10(-17), limited by the blackbody field evaluation. An additional benefit of the low uncertainty of Δα(0) is the ability to suppress, by a factor of about 200, the net micromotion frequency shifts.

Quality of life in MAP.3 (Mammary Prevention 3): a randomized, placebo-controlled trial evaluating exemestane for prevention of breast cancer

PURPOSE

Exemestane, a steroidal aromatase inhibitor, reduced invasive breast cancer incidence by 65% among 4,560 postmenopausal women randomly assigned to exemestane (25 mg per day) compared with placebo in the National Cancer Institute of Canada (NCIC) Clinical Trials Group MAP.3 (Mammary Prevention 3) trial, but effects on quality of life (QOL) were not fully described.

PATIENTS AND METHODS

Menopause-specific and health-related QOL were assessed by using the four Menopause-Specific Quality of Life Questionnaire (MENQOL) domains and the eight Medical Outcomes Study Short Form Health Survey (SF-36) scales at baseline, 6 months, and yearly thereafter. MENQOL questionnaire completion was high (88% to 98%) in both groups at each follow-up visit. Change scores for each MENQOL and SF-36 scale, calculated at each assessment time relative to baseline, were compared by using the Wilcoxon rank-sum test. Clinically important worsened QOL was defined as a MENQOL change score increase of more than 0.5 (of 8) points and an SF-36 change score decrease of more than 5 (of 100) points from baseline.

RESULTS

Exemestane had small negative effects on women's self-reported vasomotor symptoms, sexual symptoms, and pain, which occurred mainly in the first 6 months to 2 years after random assignment. However, these changes represented only a small excess number of women being given exemestane with clinically important worsening of QOL at one time or another; specifically, 8% more in the vasomotor domain and 4% more each in the sexual domain and for pain. No other between-group differences were observed. Overall, slightly more women in the exemestane arm (32%) than in the placebo arm (28%) discontinued assigned treatment.

CONCLUSION

Exemestane given for prevention has limited negative impact on menopause-specific and health-related QOL in healthy postmenopausal women at risk for breast cancer.

Dysplastic intestinal-type metaplasia of appendiceal endometriosis: a mimic of low grade appendiceal mucinous neoplasm

We report an example of dysplastic intestinal-type metaplasia involving endometriosis of the appendix in a 45 year old woman. One other example of this phenomenon has been reported. As it occurs within the muscular wall of the appendix, confusion with low grade appendiceal mucinous neoplasm (LAMN) may occur. Evidence supporting the metaplastic nature of the intestinal epithelium is offered. As the initial pathological diagnosis was of invasive cancer with perforation of the appendix treatment consisted of peritonectomy and hyperthermic intraperitoneal chemotherapy (HIPEC).

Gastrointestinal stromal tumours: etiology, pathology and clinical management

Investigation of the regulation of cell growth, differentiation and death by signalling pathways has led to a greater understanding of how alterations in these pathways play a critical role in the development of some cancers, and has opened new opportunities for their treatment. In the present review, results with the prototype drug of this class, imatinib (Gleevec, Glivec [formerly STI571]; Novartis, Switzerland), in metastatic gastrointestinal stromal tumours are presented. The present review originated from a conference of the authors held in Montreal, Quebec in June 2003, under the sponsorship of Novartis.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: an emerging treatment option for advanced goblet cell tumors of the appendix

BACKGROUND

The debate remains whether appendiceal goblet cell cancers behave as classical carcinoid or adenocarcinoma. Treatment options are unclear and reports of outcomes are scarce. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) is considered optimal treatment for peritoneal involvement of other epithelial appendiceal tumors.

METHODS

Prospective cohorts of patients treated for advanced appendiceal tumors from three peritoneal malignancy centres were collected (1994-2011). All patients underwent complete CRS+HIPEC, when possible, or tumor debulking. Demographic and outcome data for patients with goblet cell cancers were compared to patients with low- or high-grade epithelial appendiceal tumors treated during the same time period.

RESULTS

Details on 45 goblet cell cancer patients were compared to 708 patients with epithelial appendix lesions. In the goblet cell group, 57.8 % were female, median age was 53 years, median peritoneal cancer index (PCI) was 24, and CRS+HIPEC was achieved in 71.1 %. These details were similar in patients with low- or high-grade epithelial tumors. Lymph nodes were involved in 52 % of goblet cell patients, similar to rates in high-grade cancers, but significantly higher than in low-grade lesions (6.4 %; p < 0.001). At 3 years, overall survival (OS) was 63.4 % for goblet cell patients, intermediate between that for high-grade (40.4-52.2 %) and low-grade (80.6 %) tumors. On multivariate analysis, tumor histology, PCI, and achievement of CRS+HIPEC were independently associated with OS.

CONCLUSIONS

This data supports the concept that appendiceal goblet cell cancers behave more as high-grade adenocarcinomas than as low-grade lesions. These patients have reasonable long-term survival when treated using CRS+HIPEC, and this strategy should be considered.

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy with oxaliplatin for peritoneal carcinomatosis arising from colorectal cancer

BACKGROUND

Peritoneal carcinomatosis (PC) from colorectal cancer is associated with a poor prognosis. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) have improved survival compared to systemic chemotherapy. We evaluate the results of this treatment in our institution.

METHODS

Treatment consisted of complete CRS followed by HIPEC with oxaliplatin (460 mg/m(2) ) in 2 L/m(2) of D5W at 42°C during 30 min.

RESULTS

From 2004 to 2011, 40 patients with PC from colorectal cancer were included and 25 CRS + HIPEC were performed. Six patients had a negative second-look surgery and nine had unresectable disease. Median follow-up was 22.8 months. Overall 3- and 5-year survival rates for the cohort were 56% and 33%. The 3- and 5-year overall survival rates were 61% and 36% for HIPEC group, 82% and 67% for patients with negative second-look, and 22% and 0% for the unresectable group (P = 0.0087). 3-year disease-free survival for HIPEC group was 22%. Major complication and mortality rate for HIPEC group were 20% and 4%. Peritoneal carcinomatosis index (P = 0.0374) and lymph node status (P = 0.027) were prognostic indicators.

CONCLUSIONS

CRS + HIPEC with oxaliplatin for PC from colorectal cancer is an effective treatment with encouraging survival results.

The effect of fluid overload in the presence of an epidural on the strength of colonic anastomoses

BACKGROUND

Despite the beneficial effects of epidurals in intra-abdominal surgery, the incidence of anastomotic leak remains controversial when used. Moreover, studies have also shown that fluid overload may be deleterious to anastomoses. The purpose of this paper is to evaluate the effects of varying intraoperative fluid protocols, in the presence of an epidural, on the burst pressure strength of colonic anastomoses.

METHODS

An epidural was installed in 18 rabbits, divided into three groups. Group 1 received 30 mL/kg/h Ringer's lactate, Group 2 received 100 mL/kg/h Ringer's lactate, and Group 3 received 30 mL/kg/h Pentaspan. Two colo-colonic anastomoses were performed per rabbit. On postoperative day 7 the anastomoses were resected and their burst pressures measured as a surrogate for anastomotic leak.

RESULTS

When comparing the average burst pressures of all three groups, there was a significant difference (P = 0.04). The anastomoses in the 100 mL/kg/h Ringer's lactate group were shown to be the weakest, with 64% of the anastomoses having burst under 120 mm Hg. The rabbits hydrated with Pentaspan had the highest strength, with no anastomoses bursting under 120 mm Hg. This translated into significant burst pressure differences (P = 0.02) between Group 2 and Group 3.

CONCLUSION

These results suggest that fluid overload with a crystalloid, in the presence of an epidural, may be deleterious to the healing of colonic anastomoses, creating a higher risk of anastomotic leak. Intraoperative resuscitation should thus focus on goal-directed euvolemia with appropriate amounts of colloids and/or crystalloids to prevent the risk of weakening anastomoses, especially in patients with epidurals.

88Sr+ 445-THz single-ion reference at the 10(-17) level via control and cancellation of systematic uncertainties and its measurement against the SI second

We describe experiments and measurements on a trapped and laser-cooled single ion of (88)Sr(+) which, when probed on its reference 5s (2)S(1/2)→4d (2)D(5/2) transition at 445 THz, provides an optical frequency standard of evaluated accuracy outperforming the current realization of the SI second. Studies are presented showing that micromotion-associated shifts of the standard can be reduced to the 10(-18) level and uncertainties in the blackbody-induced shifts for the current system are at the low 10(-17) level due to the relatively well-known polarizability of the strontium ion system and careful choice of the trap structure. The current evaluated systematic shifts for the ion transition are at a fractional uncertainty of 2×10(-17). An absolute frequency measurement performed over a two-month period relative to a maser referenced to the SI second via Global Positioning System time transfer has determined the center frequency for the transition at ν(SD)=444 779 044 095 485.5±0.9  Hz (1σ).