Optimal surgical management strategy for treatment of primary anorectal malignant melanoma-a systematic review and meta-analysis.

BACKGROUND: Primary mucosal anorectal malignant melanoma (AMM) is an invasive malignancy with poor survival. Management options have been variable, due to limited data and lack of randomised control trials available on the optimal surgical strategy. The aim of this review was to compare local excision versus radical resection. METHODS: A systematic search of articles in PubMed, Ovid, Scopus, and the Cochrane Library database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The outcomes of interest were the impact that surgical strategy had on survival (primary) and recurrence rates (secondary) for the treatment of AMM, comparing sphincter sparing local excision (LE) versus extensive abdominoperineal resection (APR). RESULTS: Ten studies met the predefined criteria. Overall, there were 303 patients, with a median age of 58.2 years. Sixty-one percent (n = 187/303) had radical surgery (abdominoperineal resection) for the primary treatment of AMM. Overall, 5-year survival for the APR and LE was 23% and 32% respectively. Meta-analysis on the median OS noted no statistical difference between the two groups. However, local recurrence occurred in 20.82% and 47.04% in the APR and LE groups respectively. Meta-analysis observed a statistically significant reduction in recurrence when patients had an APR as primary treatment (OR 0.15, 95% CI = 0.08-0.28, p < 0.00001). CONCLUSION: Though local recurrence rates are more common with local excision of AMM, this does not confer an inferior OS when comparing LE versus APR. The decision to proceed with LE vs. APR should be made on a case-by-case basis.

Short-term outcomes in older patients with peritoneal malignancy treated with cytoreductive surgery and HIPEC: Experience with 245 patients from a national centre.

BACKGROUND: Cytoreductive Surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly accepted as the optimal management of selected patients with peritoneal malignancy. There is limited published evidence on outcomes in older patients treated by this complex therapeutic strategy. METHODS: A retrospective review of a prospective database of all patients who underwent CRS with HIPEC in a single institution over seven years. A comparative analysis of outcomes in patients under 65 undergoing CRS and HIPEC with patients ≥65 years was performed. The key endpoints were morbidity, mortality, reintervention rate and length of stay in the high dependency/intensive care (HDU/ICU) units. RESULTS: Overall, 245 patients underwent CRS and HIPEC during the study period, with 76/245 (31%) ≥65 years at the time of intervention. Tumour burden measured by the peritoneal carcinomatosis index (PCI) score was a median of 11 for both groups. Median length of hospital stay in the ≥65-year-old group was 14.5 days versus 13 days in the <65-year-old group (∗p = 0.01). Patients aged ≥65-years spent a median of one more day in the critical care unit ∗(p = 0.001). Significant morbidity (Clavien-Dindo ≥ Grade IIIa) was higher in the ≥65-year than the <65-year group (18.4% versus 11.2%). There were no perioperative deaths in the ≥65-year group. CONCLUSION: This study demonstrates higher perioperative major morbidity in ≥65-year group, but with low mortality in patients undergoing CRS/HIPEC for disseminated intraperitoneal malignancy. This increased morbidity does not translate into higher rates of re-interventions and highlights the importance of optimal patient selection.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases: outcomes from a national centre in the current era.

BACKGROUND: Multimodal therapy incorporating cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) improve survival for selected patients with colorectal peritoneal metastases (CPMs). Many countries have centralised management of these patients, aiming to improve outcomes. There is ongoing debate on the need for and complications associated with HIPEC administration. We report indications and outcomes after CRS/HIPEC treated in a national centre in the modern era. METHODS: A retrospective review of all CPM patients who underwent CRS and HIPEC since the initiation of an Irish national program in 2013. The primary endpoint was the overall survival associated with CRS/HIPEC. RESULTS: During the study period (April 2013-June 2020), 123 patients proceeded to planned CRS/HIPEC for CPM. Median age was 58 (IQR 47-67) and 55 patients (44.7%) were male. In 65 patients (52.8%), CPM was synchronous. In 7/123 (5.8%), disease was unresectable. The median peritoneal cancer index (PCI) was 10 (IQR 5-17). Overall, 104/123 (84.5%) underwent a complete cytoreduction (CC0/CC1). Thirteen out of 123 (10.5%) patients also had a synchronous liver resection. Forty out of 123 (32.5%) patients had adverse pathological features (poorly differentiated or signet ring cells). The median survival in patients after CC0, CC1 and CC2/3 resection was 50, 18 and 11 months respectively (*p = < 0.0001, Log-rank Mantel-Cox). In total, 14/123(11.4%) had a major post-operative complication and 4/123 (3.3%) required re-operation. There was one (0.8%) post-operative death. The median length of stay was 14 days (IQR 9-19). CONCLUSION: This study reports encouraging outcomes in patients with CPM undergoing CRS and HIPEC, especially when complete cytoreduction is achieved.