Guidelines on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy arising from colorectal or appendiceal neoplasms (original) (raw)
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Journal of Clinical Medicine
Peritoneal carcinomatosis (PC) is a poor prognostic factor for all malignancies. This extent of metastatic disease progression remains difficult to treat with systemic therapies due to poor peritoneal vascularization resulting in limited drug delivery and penetration into tissues. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are surgical interventions that directly target peritoneal tumors and have improved outcomes for PC resulting from appendiceal and colorectal cancer (CRC). Despite these radical therapies, long-term survival remains infrequent, and recurrence is common. The reasons for these outcomes are multifactorial and signal the need for the continued development of novel therapeutics, techniques, and approaches to improve outcomes for these patients. Here, we review landmark historical studies that serve as the foundation for current recommendations, recent discoveries, clinical trials, active research, and areas of future interest in C...
Annals of surgical oncology, 2014
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) used to treat peritoneal surface disease (PSD) from appendiceal cancer have shown variability in survival outcomes. The primary goal of this study was to determine predictors of surgical morbidity and overall survival. The secondary goal was to describe the impact of nodal status on survival after CRS/HIPEC for PSD from low-grade appendiceal (LGA) and high-grade appendiceal (HGA) primary lesions. A retrospective analysis of 1,069 procedures from a prospective database was performed. Patient characteristics, tumor grade, nodal status, performance status, resection status, morbidity, mortality, and survival were reviewed. The study identified 481 CRS/HIPEC procedures: 317 (77.3 %) for LGA and 93 (22.7 %) for HGA lesions. The median follow-up period was 44.4 months, and the 30-day major morbidity and mortality rates were respectively 27.8 and 2.7 %. Major morbidity was jointly predicted by incomplete cyto...
In Vivo
Background/Aim: Up to a third of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC) of appendiceal or colorectal origin receive a stoma during primary surgery. Stoma reversal provides an opportunity for second-look surgery. Patients and Methods: We performed a retrospective analysis of prospectively collected data of patients with colorectal cancer (CRC) or high-grade appendiceal cancer (AC) from 2006 to 2021 from our database. A total of 34 consecutive stoma closure patients with no evidence of preoperative disease recurrence (tumor markers and CT scans) were compared with 141 consecutive redo CRS/HIPEC patients with known recurrence. Results: Eleven patients (32.4%) were identified to have peritoneal recurrence at stoma closure. Time between first and second CRS was 12 months (4 to 64.2) in the stoma closure group vs. 24.6 months (5.8 to 119.8) in the redo group, while median peritoneal cancer index (PCI) was 4 (3 to 6) vs. 8 (1 to 39), respectively (p=0.0143). Conclusion: Second-look laparotomy during stoma closure identified unexpected PC in 32.4% of our patients with significantly lower PCI than planned redo operations. In recent decades, cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for select patients with peritoneal carcinomatosis (PC) has shown improved survival rates compared to systemic chemotherapy with or without palliative surgery (1-5). One meta-analysis has shown that CRS with HIPEC offers a median survival of 29 months in patients with PC, which is significantly longer than the median survival of 17.9 months for standard chemotherapy alone (6). Despite advancements in CRS and HIPEC, peritoneal disease recurrence rates in colorectal cancer (CRC) or highgrade appendiceal cancer (AC) can be as high as 80% and 40%, respectively, within two years of surgery (7, 8). Currently, postoperative monitoring consists primarily of routine cross-sectional imaging by way of computed tomography (CT) scan, combined with serum biochemical markers to diagnose recurrence of disease (9). Patients with recurrent disease may then undergo a second CRS (hereafter, redo CRS). However, recurrence is often difficult to detect by imaging and biochemistry alone as patients are often asymptomatic in the early stages of recurrence, and the sensitivity of CT scanning in detecting peritoneal recurrence approaches 60%, while also being influenced by factors such as size and extent of disease, location of spread, and radiologist expertise (10, 11). It has been established in the literature that the extent of peritoneal disease, as measured by the peritoneal cancer index (PCI), has a significant impact on the patient's prognosis, with a lower burden of peritoneal disease being associated with better CRS outcomes and improvements in morbidity (12). As earlier detection of disease is associated with a lower burden of peritoneal disease, better techniques should be devised to enable earlier 2350
Journal of the American College of Surgeons, 2012
Background-Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has improved the survival of patients with peritoneal surface malignancy. Upon recurrence, a repeat CRS/HIPEC is a treatment option. Study Design-A retrospective analysis of 868 CRS/HIPEC procedures was performed. Type of primary, functional status, completion of resection, hospitalization, morbidity, mortality and survival were reviewed. Results-Sixty-two patients (7.7%) underwent a second CRS/HIPEC including thirty-three patients with appendiceal primaries, 8 ovarian, 7 mesotheliomas, 4 colon cancers and 10 various malignancies. Median follow up was 60.8 months. The median overall survival in months was 85.3 for appendiceal cancer, 52.9 for mesothelioma, 60.1 for ovarian, and 137.4 for colon cancer. R1 resection was achieved in 43.5% after both procedures. Median survival after the second cytoreduction was 52.1 months for appendiceal cancer, 21.8 for mesothelioma, 53.9 for ovarian and 55.7 for colon cancer. The median survival was 55.7 months for R1 resection, 20.3 months for R2a resection, and 15.5 months for R2b-R2c. Median ICU and hospital stay was 1 and 7.5 days, respectively. The 30 day morbidity after the second CRS/HIPEC was 48.4% and mortality was 3.2%. In multivariate analysis the R status of the second CRS/HIPEC (p=0.013) and the interval between the two procedures (p=0.009) were significant in predicting improved survival. Conclusions-In experienced tertiary centers and for selected patients, a repeat CRS/HIPEC procedure has similar morbidity and mortality with the initial cytoreduction. Survival depends primarily on the completion of the repeat cytoreduction and favorable biology of the tumor.
Acta Gastro Enterologica Belgica
Background and study aim: Over the last 20 years, cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has progressively become a therapeutic option for peritoneal carcinomatosis thanks to its favourable oncologic results. The aim of this study is to analyse the overall survival and recurrence-free survival, after complete CRS and closed abdomen technique HIPEC for peritoneal carcinomatosis from colorectal cancer. Patients and methods: This retrospective study collected the data from all patients who underwent a CRS with HIPEC for colorectal cancer at “Cliniques universitaires Saint Luc” from October 2007 to December 2020. Ninety-nine patients were included. Results: The median follow-up was 34 months. Post-operative mortality and Clavien-Dindo grade III/IV morbidity rates were 2.0% and 28.3%. The overall 2-year and 5-year survival rates were 80.1% and 54.4%. Using the multivariate analysis, age at surgery, liver metastases and PCI score >13...
PubMed, 2019
Background: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an effective treatment for selected patients with peritoneal carcinomatosis of colorectal origin. We present our experience with the first 100 consecutive cases of this combined treatment. Methods: CRS/HIPEC procedures were performed between 4/2009-8/2016. HIPEC was initially delivered using the "Open" abdomen technique; beginning in January 2014, HIPEC was delivered using the "Closed" technique. As a chemotherapeutic agent we used Mitomycin-C, perfused for duration of 90 minutes at 41 degrees Celsius. Results: A total of 100 procedures were performed in 94 patients (64% females, median age 62 (22-83) years) with colon (n=89) or rectal (n=5) cancer. Complete cytoreduction (CC score≤1) was achieved in 91 procedures. The average duration of surgery was 7.5±2.3 hours, the median number of organs resected was 2 (0-6) and the median length of hospital stay was 9 (5-101) days. Postoperative complications occurred in 54% of procedures and the incidence of major complications (Clavien-Dindo 3-4) was 12%. Three patients (3%) died within 90 days postoperatively. Higher peritoneal cancer index (PCI) score, higher number of organs resected/anastomoses created and longer duration of surgery were associated with perioperative morbidity (all p≤0.05). The median follow-up period was 2.1 years during which 50 patients died. The median overall survival (OS) and disease free survival were 3.1 years and 10.7 months, respectively; 7 patients survived ≥5 years after surgery. Higher PCI score and occurrence of major postoperative complications were associated with poorer OS. Conclusions: CRS/HIPEC for peritoneal carcinomatosis of colorectal cancer origin is feasible and safe. This treatment may benefit selected patients in terms of OS.
Annals of Surgery, 2007
The aim of this study was to evaluate the results of an aggressive strategy in patients presenting peritoneal carcinomatosis (PC) from colorectal cancer with or without liver metastases (LMs) treated with cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Patients and Methods: The population included 43 patients who had 54 CSϩHIPEC for colorectal PC from 1996 to 2006. Sixteen patients (37%) presented LMs. Eleven patients (25%) presented occlusion at the time of PC diagnosis. Ascites was present in 12 patients (28%). Seventy-seven percent of the patients were Gilly 3 (diffuse nodules, 5-20 mm) and Gilly 4 (diffuse nodulesϾ20 mm). The main endpoints were morbidity, mortality, completeness of cancer resection (CCR), and actuarial survival rates. Results: The CS was considered as CCR-0 (no residual nodules) or CCR-1 (residual nodules Ͻ5 mm) in 30 patients (70%). Iterative procedures were performed in 26% of patients. Three patients had prior to CS ϩ HIPEC, 10 had concomitant minor liver resection, and 3 had differed liver resections (2 right hepatectomies) 2 months after CS ϩ HIPEC. The mortality rate was 2.3% (1 patient). Seventeen patients (39%) presented one or multiple complications (per procedure morbidity ϭ 31%). Complications included deep abscess (n ϭ 6), wound infection (n ϭ 5), pleural effusion (n ϭ 5), digestive fistula (n ϭ 4), delayed gastric emptying syndrome (n ϭ 4), and renal failure (n ϭ 3). Two patients (3.6%) were reoperated. The median survival was 38.4 months (CI, 32.8-43.9). Actuarial 2-and 4-year survival rates were 72% and 44%, respectively. The survival rates were not significantly different between patients who had CS ϩ HIPEC for PC alone (including the primary resection) versus those who had associated LMs resection (median survival, 35.3 versus 36.0 months, P ϭ 0.73). Conclusion: Iterative CS ϩ HIPEC is an effective treatment in PC from colorectal cancer. The presence of resectable LMs associated with PC does not contraindicate the prospect of an oncologic treatment in these patients.
2019
Introduction: Peritoneal carcinomatosis represents an advanced stage of tumor dissemination of abdominal cancers in general and colorectal cancer in particular. The only therapeutic methods currently available for the treatment of this pathology are systemic chemotherapy (palliative character) and cytoreductive surgery (CR) with intraperitoneal chemotherapy. After evaluation of evidence-based medical literature and current guide lines we can state that CR + HIPEC procedure is considered to be the treatment of choice in case of patients with peritoneal carcinomatosis of colorectal, ovarian and mucinous appendicular origin. Material and method: In the present study we prospectively analyzed the immediate postoperative results obtained in the first 50 patients that were treated by our team for peritoneal carcinomatosis of different origin. We described the protocol of selection, the patients characteristics that were included in our CR+HIPEC program and analyzed the complications and d...
Uncommon indications for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy
Pleura and Peritoneum
BackgroundCytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has changed treatment for selected patients with peritoneal metastases (PM) arising from appendiceal, colorectal, epithelial ovarian, primary peritoneal and gastric cancers. However, the results of CRS with HIPEC remain unclear in PM from other tumor histologies.MethodsWe report a series of 10 patients who underwent CRS and HIPEC between 2006 and 2015, for PM arising from uncommon tumor origins.ResultsTen patients with PM from uncommon tumor origins underwent CRS and HIPEC. Median age was 46.5 years. Two patients had ovarian Sertoli-Leydig cell tumors (SLCT) and two had small bowel adenocarcinomas. The other histologies included: ovarian transitional cell carcinoma, ovarian granulosa cell tumor, endometroid adenocarcinoma, endocervical adenocarcinoma, synovial sarcoma, and ovarian leiomyosarcoma. Median peritoneal cancer index was 9 (2–18) and complete cytoreduction was achieved for all pati...