Initial experience with hyperthermic intra peritoneal chemotherapy and cytoreductivesurgery.

BACKGROUND: Promising results were reported with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal carcinomatosis. Experiences in India are not published. This is a preliminary report. MATERIALS AND METHODS: From eight patients with peritoneal metastasis, six patients (5 M, 1 F), aged (40‑62 years) were treated with CRS and HIPEC between May 2010 and August 2011 from a single institution. Three had Mucinous Adenocarcinoma of Appendix and one each with Mesothelioma, Ovarian Cancer and Colonic Cancer. Four were earlier treated with systemic chemotherapy and recurred. Pre‑operative peritoneal cancer index (PCI) was calculated based on recent computerized tomography or positron emission tomography scans. Surgical completeness cytoreduction score (CCS) was classified as macroscopically complete (CCS‑0); optimal residual disease ≤2.5 mm in any region (CCS‑1); or grossly incomplete: Residual disease >2.5 mm (CCS‑2) or >25 mm (CCS‑3). They were treated by closed perfusion technique with mitomycin‑C (MCC) and cisplatin at 41‑42°C, for 60 min. RESULTS: Optimal cytoreduction (residual tumor nodules <2.5 mm i.e. CC0 and CC1) was performed in four patients (66.67%). There was no operative mortality or Grade 3 and 4 toxicity. Patients with PCI <11 are alive without recurrence with overall survival of 26‑31 months. Those with PCI >11 had recurrence with overall survival of 3‑19 months. Two patients died at 3 and 9 months. CONCLUSION: CRS and HIPEC is a promising therapeutic option in selected patients with peritoneal carcinomatosis. These results in six patients are preliminary but encouraging. Patient with low PCI had better disease free survival.

Isolated limb perfusion with hyperthermia and chemotherapy: predictive factors for regional toxicity

OBJECTIVE: Isolated limb perfusion combined with melphalan is an accepted treatment for obtaining locoregional control in advanced melanoma of the extremities and other malignant neoplasias restricted to the limb. This study aims to examine the factors associated with toxicity caused by the regional method. We considered the technical aspects of severe complications associated with the procedure in an attempt to diminish the patient morbidity that occurs during the learning curve. METHODS: We conducted a retrospective analysis of the records of patients who underwent perfusion at the AC Camargo Hospital in São Paulo, Brazil between January 2000 and January 2009. The Wieberdink scale was applied to classify local toxicity and its relation to clinical and laboratory variables. RESULTS: Fifty-eight perfusions were performed in 55 patients. Most patients (86.2%) presented a toxicity level between I and III. Grade V toxicity was seen in five cases (8.6%), four of which occurred in the first 2 years. Creatine phosphokinase, an important predictive factor for toxicity, had an average value of 231.8 for toxicity grades I-III and 1286.2 for toxicity grades IV-V (p = 0.001). There was a relationship between the melphalan dose and toxicity, which was 77 mg (25 to 130 mg) for toxicity grades I-II and 93.5 mg (45 to 120 mg) for toxicity grades IV-V (p = 0.0204). CONCLUSION: It is possible to prevent the toxicity associated with melphalan by adjusting the dose according to the patient's body weight (especially for women and obese patients) and the creatine phosphokinase values in the postoperative period.

Carcinomatosis peritoneal de origen colorrectal. Cirugía citorreductora y quimioterapia hipertérmica intraperitoneal / Colorectal peritoneal carcinomatosis: citoreductive surgery and hyperthermic intraperitoneal chemotherapy

Antecedentes: El pronóstico de los pacientes con carcinomatosis peritoneal de origen colorrectal es pobre. Tradicionalmente, para su tratamiento se utilizó la quimioterapia sistémica mientras que la cirugía estuvo reservada al tratamiento de las complicaciones. Objetivo: Establecer el estado actual de la cirugía citorreductora y la quimioterapia hipertérmica y valorar sus alcances en parámetros objetivos de acuerdo con la bibliografía. Material y Métodos: Se utilizaron para la búsqueda todos los artículos publicados acerca del tema en inglés y francés entre los años 1990 y 2008 en las bases de datos de PubMed de la Biblioteca Nacional de Medicina de los EEUU. Resultados: La cirugía citorreductora actúa sobre las masas neoplásicas macroscópicas, mientras que la quimioterapia hipertérmica intraperitoneal (QTHIP) es útil para tratar la enfermedad residual microscópica. La asociación entre ambas se debe a que la primera intenta resecar todo el tumor visible o, en su defecto, hasta 2 mm de espesor, a fin de permitir la acción de las drogas quimioterápicas, que pueden penetrar esa distancia como máximo en los tejidos tumorales. Los pacientes con un aceptable estado clínico (“performance status”), sin diseminación extraabdominal, con metástasis ganglionares y/o hepáticas resecables, baja carga de enfermedad peritoneal y potencialmente pasibles de una citorreducción completa, se considerarían para este tratamiento combinado. Los factores predictivos más utilizados en la actualidad lo constituyen el Índice de Cáncer Peritoneal (ICP) y la Citorreducción Completa. La mayoría de los autores coincide en admitir que los beneficios de la cirugía citorreductora (CC) más la QTHIP dependen principalmente de la capacidad de la cirugía de alcanzar una resección completa. La quimioterapia intraperitoneal no ha podido, por sí sola, tratar grandes volúmenes de carcinomatosis: solamente se han reportado tratamientos exitosos con el tratamiento combinado...

Background: Colorectal peritoneal carcinomatosis leads to a poor prognosis. Traditionally, its treatment has consisted in systemic chemotherapy, whereas surgery has been reserved to the management of complications. Objective: To establish the current state of cytoreductive surgery (CRS) and hyperthermic chemotherapy (HIPEC), and to assess their implications with objective parameters according to literature. Material and Methods: All papers published in english and french about the subject between 1990 and 2008 in the PubMed database were retrieved. Results: Cytoreductive surgery works over macroscopic neoplastic masses, as on microscopic residual disease HIPEC does. Their association is realted with their goals: the first one tries to resect all visible tumor or at least less than 2 mm, to allow chemoterapic drugs a deep penetration in tumoral tissues. Patients with an adequate performance status, with no extraabdominal spread, with resectable lymph nodes and/or hepatic metastasis, low burden of peritoneal disease and potentially fit for a complete cytoreduction, would be considered for this treatment. Nowadays, the most utilized predictive factors are constituted by the Peritoneal Cancer Index and Completeness of Cytoreduction. Most authors agree in the consideration that CRS plus HIPEC benefits depends mainly on the possibility of a complete surgical resection. Intraperitoneal chemotherapy could not, for its own, treat large tumoral masses: there are only reported successful treatments with the combined modality. At the same time, most papers prove that HIPEC combined with an optimum cytoreductive surgery cures about 25 per cent of the patients considered as unresectable. Benefits in survival related to this treatment are reached in spite of a high morbidity and mortality. The most severe complications are represented by anastomotic fistulas...

Perfusión regional hipertérmica en el melanoma maligno de las extremidades, usando cis platinum y actinomicina D / Regional perfusion hypertermic malignant-melanoma of the extremities utilizing cis platinum and actinomycin D

Debido a la relativa refractariedad del melanoma a la quimioterapia citotóxica sistémica, nuevas formas de tratamiento se han ensayado continuamente a fin de mejorar la supervivencia y disminuir la tasa de recurrencias. En este artículo analizamos tres aspectos: a) La experiencia mundial sobre las diferentes formas de tratamiento del melanoma de las extremidades y, concluímos que, el mejor tratamiento de la lesión primaria consiste en realizar en el mismo acto operatorio: escisión local, vaciamiento ganglionar y perfusión hipertérmica regional. Si el melanoma es recurrente, la terapia ideal consiste en vaciamiento ganglionar (si éste no fue realizado anteriormente) más perfusión; b) Se describen las pautas para selecionar los pacientes que serán sometidos a este procedimiento y detalladamente la técnica de la perfusión, basándonos en la forma como lo describió Oscar Creech en 1958 y como lo planificamos conjuntamente con el Servicio de Cirugía Cardiovascular y Hematología y Oncología; c) Describimos la experiencia que hemos acumulado con este procedimiento practicado en dos pacientes que teníam melanoma en las extremidades inferiores, atendidos el Servicio de Cirugía IV del Hostal Universitario de Caracas. El primero, con melanoma recurrente, fue sometido a perfusión hipertérmica usando Cis-Platinum y Actinomicina D, con respuesta objetiva del 50 por ciento. El segundo caso es una paciente con melanoma primario en el talón izquierdo, a quien se le practicó, en el mismo acto operatorio, escisión local del primario, vaciamiento ganglionar ínguino-ilíaco perfusión hipertérmica del miembro inferior izquierdo usando Cis-Platinum y Actinomicina D. En este caso, se llegó a la desarticulación de la cadera izquierda por trombosis arterial y venosa de los vasos femorales, complicación atribuída a 2 hechos: 1. Anomalía anatómica de los vasos femorales comunes que estaban practicamente ausentes y 2. Falta de heparinización terapéutica en el post-operatorio