Prolonged hyperthermic intraperitoneal chemotherapy duration with 90 minutes cisplatin might increase overall survival in gastric cancer patients with peritoneal metastases.

BACKGROUND: Advanced gastric cancer with synchronous peritoneal metastases (GC-PM) is associated with a poor prognosis. Although cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is a promising approach, only a limited number of Western studies exist. AIM: To investigate the clinicopathological outcomes of patients who underwent CRS-HIPEC for GC-PM. METHODS: A retrospective analysis of patients with GC-PM was conducted. All patients were seen at the Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany between January 2011 and July 2021 and underwent CRS-HIPEC. Preoperative laboratory results, the use of neoadjuvant trastuzumab, and the details of CRS-HIPEC, including peritoneal carcinomatosis index, completeness of cytoreduction, and surgical procedures were recorded. Disease-specific (DSS), and overall survival (OS) of patients were calculated. RESULTS: A total of 73 patients were included in the study. Patients treated with neoadjuvant trastuzumab (n = 5) showed longer DSS (P = 0.0482). Higher white blood cell counts (DSS: P = 0.0433) and carcinoembryonic antigen levels (OS and DSS: P < 0.01), and lower hemoglobin (OS and DSS: P < 0.05) and serum total protein (OS: P = 0.0368) levels were associated with shorter survival. Longer HIPEC duration was associated with more advantageous median survival times [60-min (n = 59): 12.86 mo; 90-min (n = 14): 27.30 mo], but without statistical difference. To obtain additional data from this observation, further separation of the study population was performed. First, propensity score-matched patient pairs (n = 14 in each group) were created. Statistically different DSS was found between patient pairs (hazard ratio = 0.2843; 95% confidence interval: 0.1119-0.7222; P = 0.0082). Second, those patients who were treated with trastuzumab and/or had human epidermal growth factor receptor 2 positivity (median survival: 12.68 mo vs 24.02 mo), or had to undergo the procedure before 2016 (median survival: 12.68 mo vs 27.30 mo; P = 0.0493) were removed from the original study population. CONCLUSION: Based on our experience, CRS-HIPEC is a safe and secure method to improve the survival of advanced GC-PM patients. Prolonged HIPEC duration may serve as a good therapy for these patients.

Prolonged Survival in Peritoneal Metastatic Appendiceal Carcinoma Patients Treated With Combined Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

INTRODUCTION: Primary treatment for peritoneal dissemination of appendiceal cancer is the combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. The endpoints were overall survival and evaluation of prognostic factors. METHODS: Clinicopathological and treatment-related factors were obtained from a prospective database. A total of 84 patients, 55 (65%) primary and 29 (35%) recurrent malignant appendiceal carcinomas with synchronous and metachronous peritoneal metastases, underwent multimodal treatment between 2011 and 2021. The endpoints of the study were overall survival and evaluation of prognostic factors. RESULTS: The median follow-up was 4.8 y; the mean age was 54.5 y (range 25-77), with a sex distribution of 69% female and 31% male. The mean peritoneal cancer index was 11.3. The proportion of mucinous, intestinal-type, signet ring cell, and goblet cell carcinoma was 56%, 23%, 11%, and 10%, respectively. The 5-y survival rate of the whole cohort was 56.7%. In primary and recurrent diseases, the overall median survival was 8.4 and 4.9 y. Significantly improved survival was detected after complete cytoreduction resection (hazard ratio [HR] for CCR-2 versus CCR-0: 9.388, 95% confidence interval [CI] 3.026-29.124, P = 0.001) and initial local operation with undelayed admission to the center (HR 0.262, 95% CI 0.089-0.773; P = 0.015). The five independent factors in Kaplan-Meier analysis and univariable Cox regression analysis associated with significant adverse survival were cancer antigen (CA) 19-9 over 37 IU/mL, signet ring cell and intestinal-type histology, positive nodal status, grading, and peritoneal cancer index >20. Neoadjuvant chemotherapy administration did not impact survival (HR 1.220, 95% CI 0.612-2.432, P = 0.571). CONCLUSIONS: With multimodal treatment, prolonged survival is attainable in stage IV primary and recurrent appendiceal carcinoma with peritoneal dissemination. Direct referral to specialized centers after confirmation of peritoneal metastasis is recommended because prompt definitive treatment may significantly improve survival.

Prognostic Factors in Pseudomyxoma Peritonei with Emphasis on the Predictive Role of Peritoneal Cancer Index and Tumor Markers.

BACKGROUND: Pseudomyxoma peritonei (PMP) is a rare peritoneal condition where mucus-secreting tumorous cells progressively produce a thick, gelatin-like substance. The prognosis of patients with PMP is determined by the degree of cellularity within the mucin (low-grade (LAMN) vs. high-grade (HAMN) histologic features) and by the extent of the disease. METHODS: Prognostic relevance of tumor markers CA19-9 and CEA, gender, Peritoneal Cancer Index (PCI), and completeness of cytoreduction (CC) after cytoreductive surgery were evaluated on 193 consecutive PMP patients, based on a retrospective analysis of prospectively gathered data from a German tertial referral center. RESULTS: We demonstrated that low PCI, CC0 status, low-grade histology, and female gender were independent positive prognostic factors for both overall survival (OS) and progression-free survival (PFS). Furthermore, LAMN patients with achieved CC0 status show significantly better OS and PFS compared to those with CC1 status (p = 0.0353 and p = 0.0026 respectively). In contrast, the duration and drug of hyperthermic intraperitoneal chemotherapy (HIPEC) were not prognostic in any comparison. Increased CA19-9 and CEA levels were significantly associated with HAMN cases, but also predicted recurrence in patients with low-grade histologies. CONCLUSION: Our study confirmed the prognostic role of tumor markers and emphasized the importance of CC status and PCI in a large cohort of PMP- and LAMN patients.

Selection Criteria for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy With Special Emphasis on Laparoscopy as an Efficient Tool.

BACKGROUND/AIM: The aim of the study was to assess diagnostic tools implemented in selecting candidates for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) with special emphasis on diagnostic laparoscopy. PATIENTS AND METHODS: A total of 229 patients underwent laparoscopy between January 2011 and December 2015 with peritoneal carcinomatosis and were analyzed retrospectively to study the role of laparoscopy in selecting patients for CRS and HIPEC. RESULTS: After initial laparoscopy, 101 (44%) of patients underwent CRS and HIPEC with 128 (56%) being aborted. The most prevalent overall exclusion criterion was extensive small bowel disease with a prevalence of 107 (47%) patients. The rate of complete cytoreduction (CCR0 and CCR1) in patients who were deemed initially operable during laparoscopy was 96%. The most prevalent primary tumor site was the stomach with a prevalence of 36,7%. The overall median peritoneal cancer index (PCI) score of the excluded patients were 16.8 and 4.6 in the CRS and HIPEC group. Port-site metastasis was 3.1% and bowel perforation rate 3.0%. CONCLUSION: Laparoscopy is a proper selection tool in patients with peritoneal metastases for multimodal treatment. Sensitivity for detecting non-resectable patients is high and the morbidity and mortality low.

Hyperthermic Intraperitoneal Chemotherapy With Cisplatin and Doxorubicin for 90 Minutes Versus 60 Minutes After Cytoreductive Surgery (CRS). Does the 30-Minute Difference Matter? A Comparative Study in a High Volume Centre.

BACKGROUND/AIM: This study compared the perioperative outcomes after the same combination of hyperthermic intraperitoneal chemotherapy (HIPEC) compounds when administered for 90 min vs. 60 min, while all other therapy variables remained constant. PATIENTS AND METHODS: A total of 120 patients were included with peritoneal surface malignancy who underwent cisplatin (75 mg/m2) and doxorubicin (15 mg/m2) closed HIPEC after cytoreductive surgery. RESULTS: Sixty-five patients (54.2%) in the 60 min and 55 patients (45.8%) in the 90 min HIPEC group were compared. Patients, tumor characteristics, and postoperative complications were comparable. The only significant difference was the rate of chest drain/pleural puncture with an incidence of 18.5% and 34.5% in the 60 min and 90 min group, respectively (p=0.045). After adjustment in a multi-variable regression analysis, the odds for patients with HIPEC 90 min of having chest drain or pleural puncture in comparison to patients with HIPEC 60 min was still higher, but not significant with an OR of 2.238 (95%CI=0.932-5.373; p=0.071). CONCLUSION: HIPEC administered for 90 min is safe and does not increase perioperative morbidity and mortality compared to the 60-min administration.

Current practice and perceptions of safety protocols for the use of intraperitoneal chemotherapy in the operating room: results of the IP-OR international survey.

OBJECTIVES: To assess the risk perception and the uptake of measures preventing environment-related risks in the operating room (OR) during hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC). METHODS: A multicentric, international survey among OR teams in high-volume HIPEC and PIPAC centers: Surgeons (Surg), Scrub nurses (ScrubN), Anesthesiologists (Anest), Anesthesiology nurses (AnesthN), and OR Cleaning staff (CleanS). Scores extended from 0-10 (maximum). RESULTS: Ten centers in six countries participated in the study (response rate 100%). Two hundred and eleven responses from 68 Surg (32%), 49 ScrubN (23%), 45 Anest (21%), 31 AnesthN (15%), and 18 CleanS (9%) were gathered. Individual uptake of protection measures was 51.4%, similar among professions and between HIPEC and PIPAC. Perceived levels of protection were 7.57 vs. 7.17 for PIPAC and HIPEC, respectively (p<0.05), with Anesth scoring the lowest (6.81). Perceived contamination risk was 4.19 for HIPEC vs. 3.5 for PIPAC (p<0.01). Information level was lower for CleanS and Anesth for HIPEC and PIPAC procedures compared to all other responders (6.48 vs. 4.86, and 6.48 vs. 5.67, p<0.01). Willingness to obtain more information was 86%, the highest among CleanS (94%). CONCLUSIONS: Experience with the current practice of safety protocols was similar during HIPEC and PIPAC. The individual uptake of protection measures was rather low. The safety perception was better for PIPAC, but the perceived level of protection remained relatively low. The willingness to obtain more information was high. Intensified, standardized training of all OR team members involved in HIPEC and PIPAC is meaningful.

Re-operations for early postoperative complications after CRS and HIPEC: indication, timing, procedure, and outcome.

PURPOSE: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have become standard of care for many peritoneal malignancies in selected patients. Nevertheless, this aggressive treatment strategy is associated with significant major morbidity. The aim of the present study is to analyze the re-operation rate and clinical outcome following CRS and HIPEC. PATIENTS AND METHODS: In the present study, prospectively documented data of 474 consecutive patients treated with CRS and HIPEC between February 2011 and December 2015 in a high-volume certified reference center for peritoneal malignancies in Germany have been retrospectively analyzed. RESULTS: The re-operation rate was 14.5%. The most frequent reasons for revisional surgery were fascial dehiscence, intraabdominal hemorrhage, and anastomotic leak. Most complications occurred between postoperative day 7 and 9. However, postoperative bleeding was more common within the first 5 days after surgery. The overall in-hospital mortality rate was 2.1% for all patients and 10% after revisional surgery. CONCLUSIONS: CRS and HIPEC are associated with an acceptable re-operation rate and low mortality rate. Most frequently, re-operations are performed on 7-9 days after initial surgery due to fascial dehiscence, pancreatitis, or anastomotic leak. Postoperative bleedings are more common within the first 5 days after surgery.