Fluid administration in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: neither too much nor too little

Abstract Introduction Intraoperative fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy plays an important role in postoperative morbidity. Studies have found an association between overload fluid therapy and increased postoperative complications, advising restrictive intraoperative fluid therapy. Our objective in this study was to compare the morbidity associated with restrictive versus non-restrictive intraoperative fluid therapy. Methods Retrospective analysis of a database collected prospectively in the Anesthesiology Service of Virgen del Rocío Hospital, from December 2016 to April 2019. One hundred and six patients who underwent complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were divided into two cohorts according to Fluid Therapy received 1. Restrictive ≤ 9 mL.kg-1.h-1 (34 patients), 2. Non-restrictive ≥ 9 mL.kg-1.h-1 (72 patients). Percentage of major complications (Clavien-Dindo grade III-IV) and length hospital stay were the main outcomes variables. Results Of the 106 enrolled patients, 68.9% were women; 46.2% had ovarian cancer, 35.84% colorectal cancer, and 7.5% peritoneal cancer. The average fluid administration rate was 11 ± 3.58 mL.kg-1.h-1. The restrictive group suffered a significantly higher percentage of Clavien-Dindo grade III-IV complications (35.29%) compared with the non-restrictive group (15.27%) (p= 0.02). The relative risk associated with restrictive therapy was 1.968 (95% confidence interval: 1.158-3.346). We also found a significant difference for hospital length of stay, 20.91 days in the restrictive group vs 16.19 days in the non-restrictive group (p= 0.038). Conclusions Intraoperative fluid therapy restriction below 9 mL.kg-1.h-1 in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was associated with a higher percentage of major postoperative complications.

Predictors of recurrence of peritoneal carcinomatosis among patients with colorectal cancer following cytoreductive surgery alone versus cytoreductive surgery plus HIPEC

Background: Peritoneal carcinomatosis (PC) is a lethal regional progression in patients with colorectal cancer (CRC). Treatment with complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) achieves better local control than systemic palliative chemotherapy. Objectives: To assess the efficacy on the prognosis of CRS and HIPEC compared with CRS only and to identify possible clinicopathological factors associated with the recurrence of PC. Methods: The present retrospective study included all colorectal carcinoma cases with PC subjected to CRS with or without HIPC from January 2009 to June 2018 at the National Cancer Institute (NCI), Cairo University, Cairo, Egypt. The outcome is evaluated in terms of recurrence-free survival (RFS) and its predictors. Results: Out of the 61 patients, 45 patients (73.8%) underwent CRS plus HIPEC, and 16 (26.2%) underwent CRS alone. The 1-year RFS was 55.7%, with a median of 12 months. The risk factors for recurrence identified in the univariate analysis were T4 primary tumor, high-grade, positive lymphovascular invasion (LVI), positive extracapsular nodal spread, and patients treated with CRS only, without HIPEC. In the multivariate analysis, the independent risk factors for recurrence were high grade and patients treated with CRS only. Conclusion: T4 primary tumor, high grade, positive LVI, and positive extracapsular nodal spread seemed to be important predictors of recurrence following the treatment of PC. Our study also demonstrated that the addition of HIPEC to CRS improved the RFS. (AU)

Efficacy and safety in the use of intraperitoneal hyperthermia chemotherapy and peritoneal cytoreductive surgery for pseudomyxoma peritonei from appendiceal neoplasm: A systematic review

Abstract The objective of this systematic review is to provide efficacy and safety data in the application of Intra-Abdominal Hyperthermia Chemotherapy (HIPEC) and Cytoreductive Surgery (CRS) in patients with Peritoneal Pseudomyxoma (PMP) of origin in the cecal appendix. The databases Medline and Central Cochrane were consulted. Patients with PMP of origin in the cecal appendix, classified as low grade, high or indeterminate, submitted to HIPEC and CRS. The results were meta-analyzed using the Comprehensive Metanalysis software. Twenty-six studies were selected to support this review. For low-grade PMP outcome, 60-month risk of mortality, Disease-Free Survival (DFS), and adverse events was 28.8% (95% CI 25.9 to 32), 43% (95% CI 36.4 and 49.8), and 46.7% (95% CI 40.7 to 52.8); for high-grade PMP, 60-month risk of mortality, Disease-Free Survival (DFS) and adverse events was 55.9% (95% CI 51.9 to 59.6), 20.1% (95% CI 15.5 to 25.7) and 30% (95% CI 25.2 to 35.3); PMP indeterminate degree, 60-month risk of mortality, Disease-Free Survival (DFS) and adverse events was 32.6% (95% CI 30.5 to 34.7), 61.8% (95% CI 58.8 to 64.7) and 32.9% (95% CI 30.5 to 35.4). The authors conclude that the HIPEC technique and cytoreductive surgery can be applied to selected cases of patients with PMP of peritoneal origin with satisfactory results.

Application and prospect of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal metastasis from colorectal cancer / 中华肿瘤杂志

Colorectal cancer is one of the common malignant tumors in China, and its incidence is increasing with years. As the second most common metastatic site of colorectal cancer, peritoneum is difficult to diagnose early and with a poor prognosis. Systemic intravenous chemotherapy was used as the main treatment strategy for peritoneal metastasis in the past, but its systemic toxic and side effects were obvious, and it could not effectively control tumor progression. In recent years, the continuous development of surgical techniques, concepts, and equipment, as well as the introduction of new chemotherapy drugs and targeted drugs have significantly improved the quality of life and prognosis of patients with peritoneal metastasis of colorectal cancer. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) can effectively eradicated the intraperitoneal free cancer cells and subclinical lesions, while reducing systemic side effects of chemotherapy drugs, and achieve the radical cure of the tumor at the macro and micro levels to the greatest extent. It has been used as the first-line treatment program for peritoneal metastasis of colorectal cancer at home and abroad. This article focuses on the analysis and summary of the survival efficacy, prognostic factor analysis, and chemotherapy safety of CRS+ HIPEC in the treatment of colorectal cancer peritoneal metastasis. The existing problems and controversies of HIPEC therapy are discussed simultaneously.

Analysis of perioperative efficacy and safety of cytoreductive surgery in the treatment of colorectal cancer peritoneal metastases / 中华胃肠外科杂志

Objective: To analyzed perioperative safety of cytoreductive surgery (CRS) for patients with colorectal cancer peritoneal metastasis (CRPM) and to construct a predictive model for serious advese events (SAE). Methods: A descriptive case-series study was conducted to retrospectively collect the clinicopathological data and treatment status (operation time, number of organ resection, number of peritoneal resection, and blood loss, etc.) of 100 patients with peritoneal metastases from colorectal cancer or appendix mucinous adenocarcinoma who underwent CRS at the Sixth Affiliated Hospital of Sun Yat-sen University from January 2019 to August 2021. There were 53 males and 47 females. The median age was 52.0 (39.0-61.8) years old. Fifty-two patients had synchronous peritoneal metastasis and 48 had metachronous peritoneal metastasis. Fifty-two patients received preoperative neoadjuvant therapy. Primary tumor was located in the left colon, the right colon and the rectum in 43, 28 and 14 cases, respectively. Fifteen patients had appendix mucinous adenocarcinoma. Measures of skewed distribution are expressed as M (range). Perioperative safety was analyzed, perioperative grade III or higher was defined as SAE. Risk factors associated with the occurrence of SAEs were analyzed using multivariate logistic regression. A nomogram was plotted by R software to predict SAE, the efficacy of which was evaluated using the area under the ROC curve (AUC) and correction curves. Results: The median peritoneal cancer index (PCI) score was 16 (1-39). Sixty-eight (68.0%) patients achieved complete tumor reduction (tumor reduction score: 0-1). Sixty-two patients were treated with intraperitoneal hyperthermic perfusion chemotherapy (HIPEC). Twenty-one (21.0%) patients developed 37 SAEs of grade III-IV, including 2 cases of ureteral injury, 6 cases of perioperative massive hemorrhage or anemia, 7 cases of digestive system, 15 cases of respiratory system, 4 cases of cardiovascular system, 1 case of skin incision dehiscence, and 2 cases of abdominal infection. No grade V SAE was found. Multivariate logistic regression analysis showed that CEA (OR: 8.980, 95%CI: 1.428-56.457, P=0.019), PCI score (OR: 7.924, 95%CI: 1.486-42.259, P=0.015), intraoperative albumin infusion (OR: 48.959, 95%CI: 2.115-1133.289, P=0.015) and total volume of infusion (OR: 24.729, 95%CI: 3.956-154.562, P=0.001) were independent risk factors for perioperative SAE in CRS (all P<0.05). Based on the result of multivariate regression models, a predictive nomogram was constructed. Internal verification showed that the AUC of the nomogram was 0.926 (95%CI: 0.872-0.980), indicating good prediction accuracy and consistency. Conclusions: CRS is a safe and effective method to treat CRPM. Strict screening of patients and perioperative fluid management are important guarantees for reducing the morbidity of SAE.

Tumor Desmoplásico Intraabdominal de células redondas y pequeñas. Abordaje médico quirúrgico y fisioterapéutico. A propósito de un caso / On the subject of a case: Intra-abdominal desmoplastic small and round cell tumor: a medical-surgical and physiotherapeutic approach

El Tumor Desmoplásico Intraabdominal de células pequeñas y redondas es un tumor agresivo, poco frecuente, el pronóstico es pobre y presenta una supervivencia total de 15% a los 5 años. Se presenta el caso clínico de un paciente con diagnóstico de Tumor Desmoplásico, sometido a cirugía citoreductora y quimioterapia intraperitoneal hipertérmica internado durante 46 días en el Hospital de Clínicas de la Facultad de Ciencias Médicas, donde recibió un tratamiento multidisciplinario. El tratamiento kinésico inició posterior a la cirugía y continuó de manera ambulatoria logrando finalmente la marcha independiente, completándose un total de 20 sesiones. La evolución clínica kinésica quirúrgica demostró la importancia del trabajo interdisciplinario desde el primer contacto con el paciente. A pesar del desenlace desfavorable del paciente, en el tiempo de recuperación post quirúrgico se pudo acceder a las terapéuticas logrando importantes resultados respecto a la independencia física. El reporte presentado corresponde al tercer caso de esta patología, sometido a cirugía en el Hospital de Clínicas de la Facultad de Ciencias Médicas, el aporte de este informe nos permite valorar el manejo integral de un paciente oncológico.

The desmoplastic small round cell tumor is a rare aggressive tumor, the prognosis is poor and it has a total survival of 15% at 5 years. We presented the clinical case of a patient with a diagnosis of desmoplastic tumor, who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, hospitalized for 46 days, where he received multidisciplinary treatment.Physical Therapy treatment began after surgery and continued on an outpatient basis, finally achieving independent walking, completing a total of 20 sessions. The clinical evolution demonstrated the importance of interdisciplinary work from the first contact with the patient. Despite the unfavorable outcome of the patient, in the post-surgical recovery time, therapeutics could be accessed, achieving important results regarding physical independence. The report presented corresponds to the third case of this pathology, submitted to surgery at the Hospital de Clínicas of the Faculty of Medical Sciences, the contribution of this report allows us to assess the comprehensive management of an oncological patient.

Analysis of prognosis and influencing factors of secondary cytoreductive surgery combined with chemotherapy for recurrent ovarian cancer / 中华内分泌外科杂志

Objective:To investigate the prognosis and influencing factors of secondary cytoreductive surgery (SCS) combined with chemotherapy in the treatment of recurrent ovarian cancer.Methods:A total of 102 patients with recurrent ovarian cancer admitted to our hospital from Jun. 2012 to Jun. 2015 were selected and grouped according to treatment methods. 31 patients who received paclitaxel/carboplatin (TC) chemotherapy were included in the control group, and 71 patients who received SCS combined with TC chemotherapy were included in the observation group. Clinical efficacy and 5-year survival outcome of the two groups after treatment, were compared and factors affecting the prognosis of the observation group were analyzed.Results:The total effective rate, 1-year survival rate, 3-year survival rate, and 5-year survival rate of the observation group were significantly higher than those of the control group. The median survival time of the observation group was 52 months and was significantly longer than that of the control group by 17 months ( P<0.05) ; There was no statistical difference between the death group and the survival group in terms of age, pathological type, tissue differentiation, recurrence tumor size, or location of recurrence tumors. The number of patients with FIGO stage IV, more than 3 recurrent tumors, ascites and residual lesion size >1 cm in the death group were significantly larger than those in the survival group. The serum CA125 level of patients in the death group was significantly higher than that in the survival group. Logistic regression analysis showed that the number of recurring tumors>3, with ascites, and residual lesions>1 cm, and high level of CA125 were independent risk factors for death after SCS combined with TC chemotherapy ( P<0.05) . Conclusions:SCS combined with chemotherapy can effectively improve the therapeutic effect, relieve the clinical symptoms, improve the survival rate of patients, and prolong the survival time of patients. The prognosis of SCS combined with chemotherapy is affected by the number of recurrent tumors, the presence or absence of ascites, the size of residual lesions, and CA125 level. The prognosis and survival of patients can be improved by adopting appropriate treatment.

Analysis of prognosis factors and follow-up strategy of ovary metastasis derived from gastric and colorectal cancer / 国际外科学杂志

Objective:To analyze the prognostic factors of Krukenberg tumors derived from the gastric cancer and colorectal cancer, so as to guide comprehensive treatment; looking for objective and sensitive indicators of ovarian metastasis during the follow-up after the surgery for gastric and colorectal cancer, which provides a basis for early diagnosis.Methods:Retrospectively analyzed the clinical data of 75 patients diagnosed with Krukenberg tumor admitted to Beijing Friendship Hospital, Capital Medical University from June 2007 to February 2020. Log-rank method and COX regression analysis were used to find independent prognostic factors. Wilcoxon rank sum test was used to compare the dynamic changes of ovarian imaging and tumor markers and to find the more sensitive indicators in the follow-up of patients with metachronous metastasis.Results:In the 75 cases, the univariate analysis suggested that CA19-9≥123.5 U/mL ( P=0.001), CA12-5≥37.9 U/mL ( P=0.018), Krukenberg tumor of stomach origin ( P=0.037), extra-ovary metastasis ( P=0.014), and without cytoreductive surgery (CRS) ( P<0.001)were poor prognostic factors. Among them, cytoreductive surgery could significantly improve the prognosis, even if with visible residual lesions, the overall survival was still significantly longer than those who have not undergone cytoreductive surgery ( P=0.004). Multivariate analysis results showed that CA19-9 and cytoreductive surgery ( P=0.001) were independent prognostic factors for patients with Krukenberg tumor; during the postoperative follow-up, ultrasound and CT imaging changes were more sensitive to ovarian metastasis ( P=0.006). Conclusions:CRS can prolong significantly the overall survival (OS) of patients with krukenberg tumor. Patients with simultaneous metastases should not give up the opportunity for surgery, and patients with metachronous metastases should also receive ovary resection procedure, even if with visible residual lesions, the patients can still benefit from the procedure. In the follow-up for gastric and colorectal cancer, attention should be paid to the ovarian ultrasound and CT imaging changes to facilitate early detection of ovarian metastases.

Progress of Surgery on Platinum-sensitive Recurrent Ovarian Cancer / 肿瘤防治研究

The high incidence and fatality rate of recurrent ovarian cancer (ROC) have always been the clinical problem. For part of patients with platinum-sensitive recurrent ovarian cancer, the secondary cytoreductive surgery (SCS) followed by platinum-based combination chemotherapy can prolong their survival time and improve quality of life. Therefore, it's a critical matter to accurately identify the patients who will benefit from surgery treatment. Several predictive models have been proposed for the selection of the patients for SCS. This article summarizes the research progress in the surgical treatment of platinum-sensitive recurrent ovarian cancer in recent years.

Meta analysis of whether cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy can improve survival in patients with colorectal cancer peritoneal metastasis / 中华胃肠外科杂志

Objective: To explore whether the cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) can improve the survival rate of colorectal cancer patients with peritoneal metastasis. Methods: The relevant studies were systematically retrieved from PubMed, Embase, Cochrane Library, CNKI, Wanfang, VIP database, and the study of French Elias' team on peritoneal metastasis was retrieved manually. Inclusion criteria: (1) The patients were colorectal cancer peritoneal metastasis. (2) There were CRS+HIPEC treatments (treatment group) and other treatments (control group). (3) Survival analysis data of treatment group and control group were available. (4) Types of studies were randomized controlled trials, cohort studies, or case-control studies. (5) The literature was in Chinese or English. Exclusion criteria: (1) studies without full-text; (2) studies without complete data. The literature screening and data extraction were carried out by two people independently, and the third person decided on the literature with differences. The extracted data included authors, year of publication, number of patients, time of enrollment, time of follow-up, studies design, treatment regimen, hazard ratio (HR) and 95% CI of treatment group and control groups. If the HR and 95% CI of the treatment group and control group were not provided in the literature, Engauge Digitizer 11.1 software was used to extract the time of follow-up and the survival rate at the corresponding time point from the survival curves of both groups, and the HR and 95% CI of both groups were calculated by combining the number of both groups. The quality of study was evaluated by Newcastle-Ottawa scale (NOS) or Cochrane collaboration's tool for assessing risk bias. STATA 15.1 software was used for statistical analysis. HR and 95% CI of both groups were pooled and analyzed. Inter-trial heterogeneity was assessed by Q test and I(2) statistics. When there was no significant heterogeneity (Q test: P≥0.10), fixed-effect model was used for pooled analysis. When significant heterogeneity existed (Q test: P<0.10), random effect model was used for pooled analysis, and subgroup analysis was used to find out the source of heterogeneity. Sensitivity analysis was used to evaluate the stability of the pooled results. Publication bias was assessed by Egger's test and Begg's test (P<0.05 indicated publication bias) and it is reflected by the visual symmetry of Begg's funnel plot on the natural logarithm of HR. Results: A total of 10 studies were enrolled in the meta-analysis, including 1 randomized controlled trial and 9 cohort studies. The risk of bias in 1 randomized controlled trial was uncertain, and 9 cohort studies were all higher than 7 points, indicating high quality literatures. There were 781 patients in treatment group receiving CRS+HIPEC and 2452 patients in control group receiving other treatment, including tumor cytoreductive surgery (CRS), palliative chemotherapy (PC) and intraperitoneal chemotherapy (IPC). The results of pooled analysis by random effect model showed that the OS rate in treatment group was significantly higher than that in control group (HR=0.43, 95% CI: 0.34-0.54), but the heterogeneity of the study was high (P=0.024, I(2)=52.9%). The subgroup analysis of different control treatments showed that the OS rate in treatment group was significantly higher than that in CRS control group (HR=0.63, 95% CI: 0.44-0.90), in PC control group (HR=0.37, 95% CI: 0.32-0.43), in CRS+ IPC control group (HR=0.60, 95% CI: 0.37-0.96), and the heterogeneity of each subgroup was low (CRS control group: P=0.255, I(2)=22.9%; PC control group: P=0.222, I(2)=29.9%; CRS+IPC control group: P=0.947, I(2)=0). Due to the low heterogeneity of subgroups, fixed-effect models were used to pool and analysis. The results of sensitivity analysis revealed that there was little difference between the pooled analysis results after each study was deleted, suggesting that the pooled analysis results were more reliable. Publication bias detection of each study showed Begg's test (P=0.088) >0.05 and Egger's test (P=0.138)>0.05. According to the Begg's funnel plot, the scatter point distribution was basically symmetric, indicating that there was no publication bias in the included study. Conclusion: CRS+HIPEC can improve the OS of patients with colorectal cancer peritoneal metastasis.

Efficacy of 1 384 cases of peritoneal carcinomatosis underwent cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy / 中华胃肠外科杂志

Objective: Peritoneal carcinomatosis refers to a group of heterogeneous (primary or secondary) malignancies in the surface of the peritoneum. Cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is a comprehensive treatment strategy aiming at peritoneal carcinomatosis. This study analyzed the efficacy and safety of CRS+HIPEC in patients with peritoneal carcinomatosis, and explored prognostic factors. Methods: In this descriptive case-series study, the clinicopathological data of 1384 consecutive patients with peritoneal carcinomatosis treated in Zhongnan Hospital of Wuhan University (330 patients) and Shijitan Hospital of Capital Medical University (1054 patients) from January 2004 to January 2020 were collected retrospectively. Treatment patterns of CRS+HIPEC characteristics (operative time, number of resected organs, number of stripped peritoneum, number of anastomosis, and HIPEC regimens), safety [blood loss volume, postoperative severe adverse event (SAE) and treatment outcome], survival time and prognostic factors influencing survival were analyzed. The SAE was defined as grade III-IV adverse event according to the Peritoneal Surface Oncology Group International Textbook. Perioperative period was defined from the day of CRS+HIPEC to postoperative 30th day. OS was calculated from the day of CRS+HIPEC to the date of death or the last follow-up. Kaplan-Meier method was used for survival analysis, and log-rank test was used for comparison between groups. Cox regression model was used to identify the prognostic factors. Results: Among 1384 peritoneal carcinomatosis patients, 529 (38.2%) were male; median age was 55 (10-87) years old; median body mass index (BMI) was 22.6 kg/m(2); peritoneal carcinomatosis of 164 (11.8%) patients were from gastric cancer, 287 (20.7%) from colorectal cancer, 356 (25.7%) from pseudomyxoma peritonei, 90 (6.5%) from malignant peritoneal mesothelioma, 300 (21.7%) from gynecological cancer or primary peritoneal carcinoma, and 187 (13.5%) from retroperitoneal sarcoma, lung cancer, breast cancer, and other rare tumors. The median duration of CRS+HIPEC was 595 (90-1170) minutes, median number of resected organs was 2 (0-10), median number of resected peritoneal area were 4 (0-9), median peritoneal cancer index (PCI) was 21(1-39). Completeness of cytoreduction (CC) score of 0-1 was observed in 857 cases (61.9%). Regarding HIPEC regimens, there were 917 cases (66.3%) with cisplatin plus docetaxel, 183 cases (13.2%) with cisplatin plus mitomycin, 43 cases (3.1%) with adriamycin plus ifosfamide, and the other 240 cases (17.3%) with modified regimens. Perioperative SAE developed in 331 peritoneal carcinomatosis patients (23.9%) with 500 cases, of whom 21 patients (1.5%) died during the perioperative period due to ineffective treatment, while the others recovered after active treatment. During median follow-up time of 8.6 (0.3-82.7) months, there were 414 deaths (29.9%). The median OS was 38.2 months (95% CI: 30.6-45.8), and the 1-, 3-, 5-year survival rate was 73.5%, 50.4% and 39.3%, respectively. The median OS of peritoneal carcinomatosis patients from gastric cancer, colorectal cancer, pseudomyxoma peritonei, malignant peritoneal mesothelioma and female genital cancer or primary peritoneal carcinomatosis was 11.3 months (95% CI: 8.9-13.8), 18.1 months (95% CI: 13.5-22.6), 59.7 months (95% CI: 48.0-71.4), 19.5 months (95% CI: 6.0-33.0) and 51.7 months (95% CI: 14.6-88.8), respectively, and the difference among groups was statistically significant (P<0.001). Univariate and multivariate analyses revealed that the primary gastric cancer (HR=4.639, 95% CI: 1.692-12.724), primary colorectal cancer (HR=4.292, 95% CI: 1.957-9.420), primary malignant peritoneal mesothelioma (HR=2.741, 95% CI: 1.162-6.466), Karnofsky performance status (KPS) score of 60 (HR=4.606, 95% CI: 2.144-9.895), KPS score of 70 (HR=3.434, 95% CI: 1.977-5.965), CC score of 1 (HR=2.683, 95% CI: 1.440~4.999), CC score of 2-3 (HR=3.661,95% CI: 1.956-6.852) and perioperative SAE (HR=2.588, 95% CI: 1.846-3.629) were independent prognostic factors influencing survival with statistically significant differences (all P<0.05). Conclusions: CRS+HIPEC is an effective integrated treatment strategy for patients with peritoneal carcinomatosis, which can prolong survival with acceptable safety. Preoperative evaluation of patients' general condition is necessary and CRS+HIPEC should be carefully considered to perform for patients with preoperative KPS score <80. During the operation, the optimal CRS should be achieved on condition that safety is granted. In addition, it is necessary to prevent perioperative SAE to reduce the risk of death in peritoneal carcinomatosis patients.

Complete cytoreductive surgery is the key to improving survival of colorectal cancer patients with peritoneal metastases: comment on PROPHYLOCHIP and PRODIGE 7 / 中华胃肠外科杂志

Peritoneal carcinomatosis (PC) is one of the difficult problems in the treatment of colorectal cancer (CRC). Based on several retrospective analyses of large samples and prospective randomized controlled studies (RCTs), NCCN and PSOGI recommend cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for selected CRC patients with mild to moderate PC. There are two important controversial issues in this field: the survival benefit of second-look surgery plus HIPEC for the patients with high risk of PC, and the specific benefit of HIPEC added to CRS for patients with PC. PROPHYLOCHIP found that second-look surgery plus HIPEC in patients at high risk of PC does not result in increased survival. PRODIGE 7 showed that overall survival (OS, 41.7 months vs. 41.2 months, P=0.99) and recurrence-free survival (RFS, 13.1 months vs. 11.1 months, P=0.43) were similar between the HIPEC group and non-HIPEC group, and suggested that HIPEC is not necessary for patients who underwent complete CRS. However, due to a series of problems in the design and implementation of this trial, the conclusion has caused great controversy and has not been widely recognized. Through detailed analysis and in-depth discussion, we believe that the benefit of HIPEC could not be denied according to PRODIGE 7. CRS + HIPEC is the embodiment and model of the concept of "Solid tumor treatment is surgery-based integrated treatment". CRS is the cornerstone of therapeutic strategies with curative intent for CRC PC and complete CRS is the key to improve the prognosis. Furthermore, HIPEC is an effective supplement to CRS.

International guidelines for the treatment of peritoneal cancer: clinical pathways of cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy / 中国肿瘤临床

Peritoneal cancer originates from a wide range of tumor sources and is associated with poor prognosis. Standardized therapy is of great significance in the treatment for patients with peritoneal cancer. The Peritoneal Surface Oncology Group International (PSOGI) instituted guidelines for peritoneal metastases. This article uses the Chinese version, which is divided into four parts: preoperative evaluation, surgery, chemotherapy, and clinical pathway. The preoperative evaluation consists of preoperative computed tomography, prognostic evaluation model, diagnostic laparoscopic exploration, the peritoneal cancer index, and the cytoreduction score. Peritoneal cancer treatment primarily consists of comprehensive treatment with cytoreductive surgery (CRS) and intraperitoneal hyperthermic chemotherapy. However, complete CRS is the key to the long-term survival of patients. Peritoneal cancer chemotherapy generally includes perioperative chemotherapy and regional chemotherapy. Finally, this guide outlines the clinical pathways. The Chinese version of the guidelines was published under the permission of the Secretary-General of the PSOGI Executive Committee.

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei: a single-center experience with 854 patients / 中国肿瘤临床

Pseudomyxoma peritonei (PMP) is a rare clinical syndrome. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is gradually being accepted as the standard treatment for PMP. At Aerospace Hospital, we have been treating patients with PMP since 2008 and performing total peritoneal resection since 2016. This study summarizes the experience at our center and collates past data. Methods: We performed a retrospective analysis of a prospectively maintained database of all patients who had undergone CRS and HIPEC for PMP at our center. Clinical data, such as the surgical approach, completeness of cytoreduction, and surgical complications, were collected. The results from follow-up were analyzed to simultaneously evaluate the clinical value of CRS+HIPEC and peritonectomy procedures. Results: A total of 854 consecutive patients with PMP were included in the study. Their mean age was 50 years. The median modified peritoneal cancer index (PCI) was 29. Of the patients, 25.5% under-

Selection strategy for complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy among patients with gastric cancer with peritoneal metastasis / 中国肿瘤临床

Objective: To construct a predictive model to assess the completeness of cytoreduction (CC) and help guiding selection for cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) in patients with gastric cancer with peritoneal metastasis (GCPM). Methods: GCPM patients treated with CRS+HIPEC at Beijing Shijitan Hospital were enrolled in this study. The major clinicopathologic and therapeutic characteristics were compared between those with complete CRS (CCRS) and incomplete CRS (ICRS). A nomogram based on a Logistic regression model was constructed for predicting the risk of ICRS. The nomogram was evaluated using area under receiver operating characteristic curve (AUC) and validated using the bootstrap resampling method. The probability of CCRS was predicted using the nomogram. Results: Among the included 125 patients with GCPM, 52 had CC0 cytoreduction and 73 had CC1-3 cytoreduction. The median overall survival (mOS) was 30.0 (95% CI: 16.8-43.3) months in the CC0 group, which was significantly longer than the mOS of 7.3 (95% CI: 5.8-8.8) months in the CC1-3 group (P<0.001). As there were no significant differences in OS among the CC1, CC2, and CC3 groups, CC0 patients were included in the CCRS group and CC1-3 patients were included in the ICRS group. Multivariate Logistic regression demonstrated that the time of peritoneal metastasis development (OR=14, 95% CI: 2.0-97.9, P= 0.008), preoperative tumor markers (TM) (OR=6.5, 95% CI: 2.1-37.8, P=0.037), and peritoneal cancer index (PCI) (OR=1.5, 95% CI: 1.3-1.8, P<0.001) were independent predictive factors for ICRS. The AUC of the nomogram was 0.985. Internal validation displayed good accuracy and consistency between the predictions and the actual observations. The cutoffs of PCI, with the probability of CCRS set at ≥ 50%, were ≤16, ≤12, ≤10, and ≤5 for synchronous GCPM with normal TM, synchronous GCPM with abnormal TM, metachronous GCPM with normal TM, and metachronous GCPM with abnormal TM, respectively. Conclusions: Complete CRS+HIPEC improves the survival of some patients with GCPM. A selection strategy based on PCI combined with the time of peritoneal metastasis development and TM may be a practical way for selecting patients with GCPM eligible for CCRS.

Progress on chemotherapy for peritoneal carcinomatosis / 中国肿瘤临床

Peritoneal carcinomatosis is obtaining extensive attention because of its late detection and poor prognosis. Lately, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are widely used for the treatment of this condition and could be effective in some carefully selected patients. Different chemotherapies are combined with CRS or HIPEC, and different drug administration routes are used, such as intraperitoneal or pressurized intraperitoneal aerosol chemotherapy. Furthermore, the results of many clinical trials differed among patients with different types of cancer. Herein, we reviewed recent studies in patients with gastric, colon, and ovarian cancer to evaluate the progress of chemotherapy for peritoneal carcinomatosis.

Advances in treatment of peritoneal metastasis from colorectal cancer / 中国肿瘤临床

Peritoneum is the third common metastatic site of colorectal cancer (CRC) following liver and lung. CRC peritoneal metastasis (PM) has been reckoned as an advanced disease with dismal prognosis. With the development of modern chemotherapeutic modalities, the prognosis of patients with metastatic CRC has been dramatically improved, yet patients with CRC PM achieved few survival benefits. It is the emergence and combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy that prolong the survival of PM cases. What's more, novel treatments, pressurized intraperitoneal aerosol chemotherapy, and intraperitoneal MOC31PE immunotoxin treatment, for instance, have been under investigation and preliminary results are promising. We aim to comprehensively review the literature focusing on the clinical treatment of PM.

Analysis of factors influencing postoperative gastrointestinal function recovery in patients undergoing hyperthermic intraperitoneal chemotherapy / 上海交通大学学报（医学版）

Objective • To investigate the effect of hyperthermic intraperitoneal chemotherapy on postoperative gastrointestinal function recovery in patients with gastrointestinal cancer. Methods • Sixty-two cases of gastrointestinal cancer patients were enrolled who accepted cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in Department of General Surgery, Shanghai Public Health Clinical Center, Fudan University, from July 2014 to June 2017. The gastrointestinal function of patients were evaluated according to the I-FEED scoring system. The patients were divided into normal recovery group (I-FEED score<6, n=38) and delayed recovery group (I-FEED score ≥ 6, n=24). Univariate and multivariate Logistic analyses were performed on characteristic factors that may affect the recovery of postoperative gastrointestinal function including gender, age, presence of diabetes, preoperative albumin, and so on. Results • There were significantly differences in the preoperative serum albumin level (P=0.040), intraoperative bleeding (P=0.044), the time of extraction of the peritoneal cavity drainage tube (P=0.026), the time of urethral tube extraction (P=0.021) and the time of hospitalization (P=0.017) in the two groups of patients with normal or delayed gastrointestinal function recovery. Multivariate Logistic regression results suggested that preoperative serum albumin level may be beneficial for the recovery of postoperative gastrointestinal function (OR=0.84, 95% CI 0.17-4.27, P=0.041). Conclusion • The preoperative serum albumin level can be used as an independent predictor of postoperative gastrointestinal functional recovery in patients with gastrointestinal cancer after cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy.

Surgical teratment for gastric cancer patients with liver metastasis / 中华肿瘤杂志

Multidisciplinary therapy is considered as an acceptable option for gastric cancer patients with liver metastases currently, while the effectiveness of surgery is still controversial. Although there was no improved survival for cytoreductive surgery, some evidences showed that some selected patients with the combination surgery of gastric cancer and liver metastases could benefit from curative resection. Compared to cytoreductive surgery for gastric cancer patients with liver metastasis, curative resection did not increase the incidence of complications or mortality. Therefore, surgery-based multidisciplinary therapy would be appropriate for some seleted gastric cancer patients with liver metastasis. In highly selected patients with neoadjuvant chemotherapy, curative resection with both primary and metastatic tumor could improve long-term survival benefits. Furthermore, the long-term survival and quality of life should be considered of equal importance in future studies.

A single-center clinical analysis of 65 cases of pseudomyxoma peritonei from appendiceal origin in the early stage / 中华肿瘤杂志

Objective@#To analyze the efficacy and safety of cytoreduction surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for pseudomyxoma peritonei (PMP) in the early stage.@*Methods@#The clinical data, including pathological features, recurrence and survival of 65 PMP patients in the early stage underwent CRS combined with HIPEC in Aerospace Center Hospital from January, 2011 to December, 2018 were retrospectively analyzed.@*Results@#65 patients with early stage PMP underwent CRS+ HIPEC. Among these patients, 25 were males and 40 were females, and the mean age was 52.5 years. The median peritoneal cancer index was 3 (0-16). The score of completeness of cytoreduction (CC) of 63 patients (96.9%) was 0, and 2 patients (3.1%) was 1. No perioperative death occurred, the incidence of surgical complications above grade 3 was 3.1%. Three patients relapsed during the follow-up period, including 1 patient with low-grade PMP, 1 patient with high-grade PMP, and 1 patient with high-grade PMP accompanied by signet ring cell. The 5-year disease-free survival rate of the whole group was 92.4%.@*Conclusions@#PMP patients in the early stage treated by CRS combined with HIPEC can achieve benefit and safety. A close long-term follow-up is necessary.