More Synchronous Peritoneal Disease but Longer Survival in Younger Patients with Carcinomatosis from Colorectal Cancer Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: Colonoscopy to detect colorectal cancer (CRC) is recommended starting at age 50 years; however, CRC rates are increasing in the prescreening population. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been proven effective in select patients with peritoneal carcinomatosis (PC) from CRC, although it has not been evaluated specifically in patients < 50 years. METHODS: CRC patients aged < 50 years at diagnosis undergoing CRS/HIPEC 2007-2017 were compared with those aged ≥ 50 years. Age distribution was analyzed in patients undergoing colectomy alone versus CRS/HIPEC for CRC 1993-2013. RESULTS: A total of 98 patients underwent CRS/HIPEC, of which 44% were < 50 years. Younger patients were more likely to present with synchronous peritoneal metastases (p = 0.050). Receipt of perioperative chemotherapy was comparable (p = not significant [NS]). Charlson Comorbidity Index and ECOG score were similar (p = NS). Tumor grade was similar (p = NS). Peritoneal Carcinomatosis Index, total organs resected, and anastomoses created were comparable (p = NS). Major Clavien-Dindo morbidity and LOS were similar (p = NS). Younger patients survived longer after CRS/HIPEC (p = 0.011). Demographic data from patients undergoing colectomy (n = 225) and CRS/HIPEC (n = 98) showed that age < 50 years was increasingly common with the more aggressive procedure (9% and 44% respectively, p < 0.001). CONCLUSIONS: Younger patients with PC from CRC presented more often with peritoneal metastases at the time of diagnosis. Yet despite similar perioperative features at CRS/HIPEC, they survived longer than older patients. Patients undergoing CRS/HIPEC are overall younger than those undergoing index colectomy.

Signet ring cell features with peritoneal carcinomatosis in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are associated with poor overall survival.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is effective in select patients with peritoneal carcinomatosis (PC). Signet ring cell (SRC) pathology is associated with poor prognosis. The role of CRS/HIPEC in this population is unclear. METHODS: Patients diagnosed with PC due to appendiceal (AC), colorectal (CRC), and gastric cancer (GC) undergoing CRS/HIPEC 2007-2016 were included. RESULTS: A total of 268 patients were referred for CRS/HIPEC. Of the 204 patients who underwent complete CRS/HIPEC, 101 (49.5%) had AC, 85 (41.7%) CRC, and 18 (8.8%) GC. Patients with GC had higher rates of SRC pathology than AC and CRC: 12 (66.7%) vs 16 (15.8%) and 10 (11.7%). The 3-year survival rate after CRS/HIPEC was 5.7% for the SRC group and 66.1% for the non-SRC group (P < 0.001). This was true for both AC and CRC subgroups (P < 0.001 for both). Overall, patients with SRC were more likely to have a peritoneal carcinomatosis index (PCI) score > 15 (P = 0.046). Upon multivariate analysis of the SRC population, PCI > 20 (P = 0.007) and GC (P = 0.008) were found to be independent predictors of poor overall survival. CONCLUSIONS: Performing CRS/HIPEC for PC from gastrointestinal malignancies presenting SRC features is recommended on patients with select diseases of appendiceal and colorectal origins.

Assessing the Implementation of American College of Surgeons Quality Indicators for Pancreatic Cancer Across an Integrated Health System.

PURPOSE: The American College of Surgeons (ACS) recently published quality assurance (QA) indicators for pancreatic cancer care. Implementing quality indicators in a newly formed health system may lead to better patient selection and standardized cancer care. METHODS: Select ACS and internal quality indicators were implemented system wide in 2014. We compared compliance with these measures before and after their implementation at the main hospital and two new affiliate institutions. RESULTS: A total of 506 patients with pancreatic cancer were included. At the main hospital in the pre-QA period, 11 (12.6%) of 87 patients were discussed at our institutional multidisciplinary tumor board meeting; this number rose to 89 (49.7%) of 179 patients (P < .001) after the implementation. Clinical TNM stage was documented in the electronic medical record in 75 patients (86.2%) in the pre-QA group; this number rose to 170 (94.9%; P = .026) in the post-QA era. External imaging of patients undergoing resection was uploaded in 10 (66.7%) of 15 patient cases in the pre-QA period; this number rose to 33 (93.4%) of 35 (P = .020). Rates of time from diagnosis to treatment initiation shorter than 60 days were similar between eras (n = 26, 96.3% v n = 57, 95%). Implementation of QA measures at the affiliate institutions did not result in measurable differences. There were no differences in margin-negative resection rate, lymph node yield, or perioperative mortality after QA implementation at any site. CONCLUSION: The implementation of ACS quality indicators at our main hospital was feasible and effective for several measures, without delaying treatment. Instituting these indicators at lower-volume affiliates was more challenging.