High-Risk Peritoneal Mesothelioma: Does Metronomic Chemotherapy Have a Role?

Objective: To evaluate the feasibility, tolerance, and efficacy of OMCT (oral metronomic chemotherapy) after CRS + HIPEC for peritoneal mesothelioma in patients with poor prognostic factors: PCI > 20, incomplete CRS, poor performance status, or progression on systemic chemotherapy. Methods: A retrospective analysis of patients undergoing CRS + HIPEC for peritoneal mesothelioma and receiving OMCT for poor risk factors. Results: Sixteen patients underwent CRS + HIPEC between 2013 and 2017. The median PCI was 31.5. Complete cytoreduction (CC-0/1) was obtained in 8 patients (50%). All 16 received HIPEC except one patient with baseline renal dysfunction.Thirteen patients had PCI > 20 where only 5 had CC-0/1. Of 8 suboptimal cytoreduction (CC-2/3), 7 received OMCT (6 for progression on chemotherapy and one for mixed histology). Three patients had PCI < 20 and all had CC-0/1 clearance. Only one received OMCT for progression on adjuvant chemotherapy. Patients receiving OMCT for progression on adjuvant chemotherapy (ACT) were in poor PS.The median follow-up was 13.4 months. Five are alive with the disease (three are on OMCT). Six are alive without disease (2 are on OMCT). The mean OS was 24.3 months and the mean DFS was 18 months. Outcomes were similar between CC-0/1 and CC-2/3 groups, OMCT vs no OMCT groups.All patients receiving OMCT for progression on neoadjuvant chemotherapy had better survival (alive at 12, 20, 32, 36 months) compared to those receiving OMCT for progression on the ACT (p = 0.012). Conclusion: OMCT is a good alternative in high-volume peritoneal mesothelioma with incomplete cytoreduction and progression on chemotherapy. OMCT may improve outcomes in these scenarios when started early.

Correlation Between Pelvic Peritoneal Disease and Nodal Metastasis in Advanced Ovarian Cancer: Can Intraoperative Findings Define the Need for Systematic Nodal Dissection?

To explore the relationship of peritoneal, and rectal involvement with lymph nodal metastases to identify clinical parameters to guide systematic nodal dissection in advanced ovarian cancer (stage 3c). It is a retrospective study of stage III C epithelial ovarian cancers undergoing cytoreductive surgery with systematic nodal dissection, from January 2011 to December 2016. LS3 score is a cumulative score given for the presence of size 3 lesion (peritoneal disease measuring more than 5 cm) in regions 5, 6, and 7. The depth of rectal involvement was assigned progressive numerical values from 1 (for serosa) to maximum 4 (for mucosa) to generate rectal involvement score. There were 91 patients. 48.35% patients had LS3 lesions in regions 5, 6, 7. Of these, 36% (27/44) had positive nodes. Of the 41 node-positive cases, 43.9% had single and 34.14% had two station involvements. Rectum was involved in 47 patients (51.64%), serosal involvement being the most common type (50.57%). Twenty patients had positive mesorectal nodes (42.55%). The presence of rectal involvement was influenced by the Peritoneal Carcinomatosis Index (PCI) score, the presence of LS3 in lower quadrants (p = 0.008), and LSE score of lower quadrants (p = 0.003). With the increasing depth of rectal infiltration, mesorectal positivity increased significantly (p = 0.000). In multivariate analysis, lower quadrant (regions 5, 6, 7) PCI, LS3 in lower quadrants, LS3 score, rectal involvement score, and the total number of lines of chemotherapy significantly affected different nodal disease parameters. In advanced ovarian cancer, LS3 disease in regions 5, 6, and 7 and rectal involvement directly impact the nodal metastasis and hence mandates a systematic nodal dissection. Mesorectal nodal involvement significantly increases with the increasing depth of rectal involvement necessitating systematic mesorectal nodal clearance for all rectal resections.

Aggressive cervical neuroblastoma with a rare paraneoplastic syndrome: A therapeutic dilemma.

Neuroblastoma is infrequently associated with paraneoplastic syndromes. Amongst the few, opsomyoclonus (Kinsbourne syndrome) is the most common neurological paraneoplastic syndrome and diarrhea secondary to increased secretion of vasoactive intestinal peptide (Kerner-Morrison syndrome), hormonal paraneoplastic syndrome. Hypothalamic dysfunction (HD) is a rare disorder and its manifestation as a paraneoplastic syndrome of neuroblastoma is uncommonly reported. We present an interesting case of an unrelenting cervical neuroblastoma associated with HD, which posed a therapeutic challenge.