Treading the beaten path with old and new obstacles: a report from the Indian HIPEC registry.

BACKGROUND: The Indian HIPEC registry is a self-funded registry instituted by a group of Indian surgeons for patients with peritoneal metastases (PM) undergoing surgical treatment. This work was performed to • Evaluate outcomes of cytoreductive surgery ± HIPEC in patients enrolled in the registry. • Identify operational problems. METHODS: A retrospective analysis of patients enrolled in the registry from March 2016 to September 2017 was performed. An online survey was performed to study the surgeons' attitudes and existing practices pertaining to the registry and identify operational problems. RESULTS: During the study period, 332 patients were enrolled in 8 participating centres. The common indication was ovarian cancer for three centres and pseudomyxoma peritonei for three others. The median PCI ranged from 3 to 23. A CC-0/1 resection was obtained in 94.7%. There was no significant difference in the morbidity (p = .25) and mortality (p = .19) rates between different centres. There was a high rate of failure-to-rescue (19.3%) patients with complications and the survival in patients with colorectal PM was inferior. A lack of dedicated personnel for data collection and entry was the main reason for only 10/43 surgeons contributing data. The other problem was the lack of complete electronic medical record systems at all centres. CONCLUSIONS: These results validate existing practices and identify country-specific problems that need to be addressed. Despite operational problems, the registry is an invaluable tool for audit and research. It shows the feasibility of fruitful collaboration between surgeons in the absence of any regulatory body or funding for the project.

Should Systematic Infrarenal Para-aortic Dissection Be the Rule in the Pretherapeutic Staging of Primary or Recurrent Locally Advanced Cervix Cancer Patients With a Negative Preoperative Para-aortic PET Imaging?

BACKGROUND: Extended-field chemoradiation is the usual management of patients with locally advanced cervical cancer (LACC) and para-aortic node metastases (PA pN1). It is efficient but not without morbidity. Assessment of PA lymph node positivity by PA lymphadenectomy is the most accurate method to select the candidates for this treatment. Hence, to clarify the dissection pattern, we wanted to test the true incidence of isolated/skip node metastasis, above the level of the inferior mesenteric artery (IMA). MATERIALS AND METHODS: All patients with LACC and negative magnetic resonance imaging and positron emission tomography-computed tomography imaging at the PA level were offered a laparoscopic staging encompassing a diagnostic laparoscopy followed, if negative, by an extraperitoneal PA lymphadenectomy. All nodes were removed from both common iliac bifurcations up to the left renal vein. Node groups, below and above the IMA, were separately sent to the pathologist for definitive examination. RESULTS: From January 2010 to December 2013, 196 stage IB1 with pelvic pN1, IB2, to IVA LACC patients from 2 cancer centers who fulfilled the criteria were included in this institutional review board-approved study after informed consent. Thirty patients (15%) had PA pN1. Only 1 patient had positive nodes exclusively located above the IMA (3.3% of the pN1 group; 95% confidence interval, 0%-9.7%). Complications were observed in 15 (7.6%) of 196 patients. CONCLUSIONS: Given the very low rate of skip metastases above the IMA and the potential additional morbidity of a systematic extended dissection, a bilateral ilioinframesenteric dissection seems to be an acceptable pattern of PA lymphadenectomy in LACC patients.

Occult invasive cervical cancer found after inadvertent simple hysterectomy: is the ideal management: systematic parametrectomy with or without radiotherapy or radiotherapy only?

BACKGROUND: After the diagnosis of occult cervical cancer during simple hysterectomy, is the best treatment option for the patient surgery with or without radiotherapy or radiation therapy only? Our study aims to answer this question. MATERIALS AND METHODS: We retrospectively analyzed 29 patients with occult cervical cancer found after inadvertent simple hysterectomy and who were referred to our cancer center between 2000 and 2010. All of the patients were discussed by the tumor board. Thirteen patients underwent surgery (radical parametrectomy and pelvic lymphadenectomy) using the minimally invasive approach (surgical group), and 16 patients underwent pelvic lymphadenectomy and radiation therapy or concurrent chemoradiation (radiation group). RESULTS: Age, BMI, and the tumor diameter were not statistically different between the surgical and radiation group: 44 and 49 (± 11) years (p = .23), 24.6 (± 6.2) and 26.7 (± 5) (p = 0.33), and 22 (± 13) and 31 (± 11) mm (p = .09), respectively. The 5-year overall and disease-free survivals for the surgical and radiation groups were: 100 and 77 % (p = .04), and 86 and 37 % (p = .02), respectively. These results were statistically significant. CONCLUSIONS: In the case of occult cervical cancer found after simple hysterectomy, radical parametrectomy with pelvic lymphadenectomy using minimally invasive surgery seems to be more efficient than radiation therapy or concurrent chemoradiation, with acceptable minimal morbidity being observed.

Single-port access laparoscopic surgery in gynecologic oncology: outcomes and feasibility.

OBJECTIVES: Single-port access laparoscopic surgery (SPALS) is supposed to simplify and improve the outcomes of current multiport laparoscopic procedures. This retrospective study was performed to assess the actual outcomes of SPALS in 2 simple gynecological oncology procedures, namely, diagnostic laparoscopy and bilateral adnexectomy. METHODS: We conducted a retrospective monocentric study. Case files of only those women who underwent bilateral adnexectomies and diagnostic and/or staging laparoscopy were studied with respect to the operative room time, intraoperative and postoperative complications, postoperative pain, and lengths of hospital stays. The main objective was to assess the feasibility and utility of SPALS surgery in gynecology. The secondary objective was to compare this group with a cohort of patients with multiport conventional laparoscopic surgery (MPCLS) performed during the same period. RESULTS: From December 2009 to March 2013, there were 134 patients who underwent these 2 procedures. Eighty adnexectomies were performed, 41 by SPALS and 39 by MPCLS. Fifty-four diagnostic laparoscopies were performed, with 27 patients in each group. In the group of adnexectomies, operative time was significantly lower in SPALS compared with MPCLS (36 vs 59 minutes, P < 10) and also compared with the postoperative stay (1 vs 2.2 nights, P < 10). By contrast, no significant difference was observed between the 2 methods of access in all the parameters studied in the group of diagnostic laparoscopies. CONCLUSIONS: Our experience demonstrates that SPALS is feasible and safe for simple gynecological procedures. This approach may result in a smooth postoperative course and shorter hospital stay and can thus be promoted to a day care procedure.

A Descriptive Analysis of Patients Undergoing Cytoreductive Surgery for the First Peritoneal Recurrence from Adult Granulosa Cell Tumours: Focus on Disease Distribution, Morphology of Peritoneal Disease and the Role of HIPEC - a Retrospective Study by INDEPSO.

The aim of the present study was to report the clinical outcome and factors affecting survival in patients with first recurrence of AGC treated with cytoreductive surgery with or without HIPEC. The second aim was to study the disease distribution in the peritoneal cavity according to the peritoneal carcinomatosis index (PCI) and the morphology of peritoneal deposits. In this retrospective multicentric study, all patients of adult granulosa cell tumor with peritoneal recurrence were treated with CRS with or without HIPEC. Relevant clinical and demographic data were captured. Multivariable logistic regression was performed to evaluate the factors affecting recurrence after CRS ± HIPEC. Factors affecting survival and second recurrences were evaluated in addition to studying the disease distribution at first recurrence. In the period from January 2013 to December 2021, 30 consecutive patients of recurrent adult type granulosa cell tumor of the ovary undergoing CRS ± HIPEC were included in this study. The median follow-up duration was 55 months [12-96 months]. The median rPFS and rOS were both not reached. HIPEC (p = 0.015) was the only factor independently associated with a longer rPFS. CRS with or without HIPEC can be performed with an acceptable morbidity in patients with the first recurrence from adult granulosa cell tumours. The role of HIPEC, patterns of peritoneal spread and impact of other prognostic factors on the treatment outcome all need further evaluation in larger series of patients.

Cytoreductive Surgery With or Without HIPEC in the Management of Peritoneal Dissemination from Rare Histological Subtypes of Ovarian Cancer - a Retrospective Study by INDEPSO.

The aim of this study was to evaluate the potential role of optimal cytoreductive surgery with or without HIPEC in the management of peritoneal dissemination from rare histological subtypes of ovarian cancer and to report the prognostic factors affecting survival. In this retrospective multicentric study, all patients with diagnosis of locally advanced ca ovary with histology other than high-grade serous carcinoma and those having undergone cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy for the same were included. Factors affecting survival were evaluated in addition to studying the clinicopathological features. In the period from January 2013 to December 2021, 101 consecutive patients of ovarian cancer with rare histology underwent cytoreductive surgery with or without HIPEC. The median OS was not reached (NR), and the median PFS was 60 months. On evaluation of factors affecting overall survival (OS) and progression-free survival (PFS), PCI > 15 was associated with not only a decreased PFS (p = 0.019) but also a decreased OS (P = 0.019) on univariate and multivariate analysis. With respect to histology, the best OS and PFS were seen with granulosa cell tumor, mucinous tumors for which median OS and median PFS were NR respectively. Cytoreductive surgery can be performed with an acceptable morbidity in patients with peritoneal dissemination from ovarian tumors of rare histology. The role of HIPEC and impact of other prognostic factors on the treatment and survival outcome need further evaluation in larger series of patients. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01640-5.

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC): Initial Experience from Indian Centers and a Review of Literature.

Cytoreductive surgery and HIPEC is a therapeutic option that benefits only selected patients with peritoneal metastases (PM). New treatments like pressurized intraperitoneal aerosol chemotherapy (PIPAC) have been developed to overcome some limitations of intraperitoneal chemotherapy and treat patients who are not eligible for a curative approach. The safety and feasibility of the procedure in the first few Indian patients treated with PIPAC, and the technique and the set-up required for PIPAC are described here. From May 2017 to August 2017, data was collected prospectively for all patients undergoing PIPAC at three Indian centers. The patients' characteristic, operative findings, and perioperative outcomes were recorded. Seventeen procedures were performed in 16 patients with peritoneal metastases from various primary sites using standard drug regimens developed for the procedure. The median hospital stay was 1 day, minor and major complications were seen in two patients each (11.7%), and there was one post-operative death. Of the six patients who completed at least 6 weeks of follow-up, there was disease progression in two, unrelated problems in two patients, and a second procedure was performed in one patient. One patient underwent subsequent CRS and HIPEC. Our results show the feasibility and safety of PIPAC in Indian patients with a low morbidity and mortality and short hospital stay. While clinical trials will determine its role in addition to systemic chemotherapy, it can be used in patients who have progressed on one or more lines of systemic chemotherapy and those who have chemotherapy-resistant ascites.

Failure-to-Rescue Following Cytoreductive Surgery with or Without HIPEC is Determined by the Type of Complication-a Retrospective Study by INDEPSO.

To determine factors influencing failure-to-rescue in patients with complications following cytoreductive surgery and HIPEC. A retrospective analysis of patients enrolled in the Indian HIPEC registry was performed. Complications were graded according to the CTCAE classification version 4.3. The 30- and 90-day morbidity were both recorded. Three hundred seventy-eight patients undergoing CRS with/without HIPEC for peritoneal metastases from various primary sites, between January 2013 and December 2017 were included. The median PCI was 11 [range 0-39] and a CC-0/1 resection was achieved in 353 (93.5%). Grade 3-4 morbidity was seen 95 (25.1%) at 30 days and 122 (32.5%) at 90 days. The most common complications were pulmonary complications (6.8%), neutropenia (3.7%), systemic sepsis (3.4%), anastomotic leaks (1.5%), and spontaneous bowel perforations (1.3%). Twenty-five (6.6%) patients died within 90 days of surgery due to complications. The failure-to-rescue rate was 20.4%. Pulmonary complications (p = 0.03), systemic sepsis (p < 0.001), spontaneous bowel perforations (p < 0.001) and PCI > 20 (p = 0.002) increased the risk of failure-to-rescue. The independent predictors were spontaneous bowel perforation (p = 0.05) and systemic sepsis (p = 0.001) and PCI > 20 (p = 0.02). The primary tumor site did not have an impact on the FTR rate (p = 0.09) or on the grade 3-4 morbidity (p = 0.08). Nearly one-fifth of the patients who developed complications succumbed to them. Systemic sepsis, spontaneous bowel perforations, and pulmonary complications increased the risk of FTR and multidisciplinary teams should develop protocols to prevent, identify, and effectively treat such complications. All surgeons pursuing this specialty should perform a regular audit of their results, irrespective of their experience.

Chemotherapy drug extravasation in totally implantable venous access port systems: how effective is early surgical lavage?

PURPOSE: Totally implantable venous access port systems (TIVAPS) are a widely used and an essential tool in the efficient delivery of chemotherapy. Chemotherapy drug extravasation (CDE) can have dire consequences and will delay treatment. The purpose of this study is to both clarify the management of CDE and show the effectiveness of early surgical lavage (ESL). METHODS: Patients who had presented to the Cancer Center of Lille (France) with TIVAPS inserted between January 2004 and April 2013 and CDE had their medical records reviewed retrospectively. RESULTS: Thirty patients and 33 events were analyzed. Implicated agents were vesicants (51.5%), irritants (45.5%) and non-vesicants (3%). Huber needle malpositionning was involved in 27 cases. Surgery was performed in 97% of cases, 87.5% of which were for ESL with 53.1% of the latter requiring TIVAPS extraction. Six patients required a second intervention due to adverse outcomes (severe cases). Vesicants were found to be implicated in four out of six severe cases and oxaliplatin in two others. Extravasated volume was above 50 ml in 80% of cases. Only one patient required a skin graft. CONCLUSIONS: CDEs should be managed in specialized centers. ESL allows for limited tissue contact of the chemotherapy drug whilst using a simple, widely accessible technique. The two main factors that correlate with adverse outcome seem to be the nature of the implicated agent (vesicants) and the extravasated volume (above 50 ml) leading to worse outcomes. Oxaliplatin should be considered as a vesicant.