Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in appendix cancer A single-center experience.

AIM: The traditional treatment for appendiceal cancer with peritoneal spread is cytoreductive surgery (CRS) but added HIPEC chemotherapy to cytoreductive surgery and has shown that it improves overall survival. The aim of this study was to report the results of CRS and HIPEC treated patients with appendiceal cancers which is based on the experience of at Surgical oncology department. MATERIAL-METHOD: Ankara University School of Medicine, Deparment of Surgical Oncology. The data of patients who underwent CRS + HIPEC for appendiceal cancer between January 2008 - January 2019 was retrospectively analysed. 40 patients who underwent CRS + HIPEC were evaluated retrospectively. Patients with unresectable liver metastasis, large retroperitoneal tumor, tumoral infiltration in the intestinal mesentery and liver hilum were excluded from the study. RESULTS: The mean (±sd) PCI was 17.98 (±8.21). Twenty six patients's completeness of cytoreduction score was 0(65.0%), 10(25.0%) CCS-1, 3(7.5%) CCS-2 and 1(2.5%) CCS-3. There was statistically significant difference with prognosis between ccr score, ASA, lymphovascular invasion, PCI score, albumin categories. CONCLUSIONS: In selected patients survival can be increased. However, it is thought that cytoreductive surgery should be performed even if completeness of cytoreduction score is two. In our study we represent that >17PCI patients could be managed by CRS/HIPEC if the CC score ≤2 can be reached. Our results suggest that the CRS/HIPEC procedure can improve the benefits of larger patient group and provides longer survival. KEY WORDS: Appendiceal Neoplasms, Cytoreductive Surgery, Hyperthermic Intraperitoneal Chemotherapy.

Impact of Muscle Mass Depletion on Surgical Outcomes in Patients with Primary High-grade Serous Ovarian Cancer Undergoing CRS and HIPEC.

OBJECTIVE: To investigate the effect of sarcopenia on surgical outcomes in patients with primary high-grade serous ovarian cancer undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Surgical Oncology, Faculty of Medicine, Ankara University Ankara, Turkey,  from January 2013 to January 2020. METHODOLOGY: Forty patients, who underwent CRS and HIPEC with the diagnosis of primary high-grade serous ovarian cancer and peritoneal carcinomatosis were included in the study. Preoperative staging CT images were used to determine total psoas index values by measuring psoas muscle area at the level of L3 vertebra. Patients with total psoas index values below the cut-off levels were considered sarcopenic. Demographic, clinicopathological and perioperative results were compared between sarcopenic and non-sarcopenic patients. RESULTS: Serious postoperative complications (36.4% vs. 6.9%, p=0.039)  and infective (54.5% vs. 17.2%, p=0.042) and pulmonary (72.7% vs. 34.5%, p=0.040 complications were significantly higher in sarcopenic patients. Hospital stay [20(12-25) vs. 12(9-16.5) days, p=0.017] and ICU stay [4(2-6) vs. 2(1-2.5) days, p=0.013)] were found to be longer in sarcopenic patients. In univariate analysis, advanced age (OR: 1.40 95% CI: 1.07-1.84; p=0.021) and sarcopenia (OR: 7.71% 95 CI: 1.17-51.06; p=0.039) were significantly associated with serious postoperative complications. The presence of sarcopenia (OR: 0.050 95% CI: 0.004-0.675; p=0.024) was found to be independent predictor of serious postoperative complications. CONCLUSION: Sarcopenia can easily be diagnosed without additional cost or radiation exposure with routine preoperative staging CT images. Identification of sarcopenic ovarian cancer patients in preoperative period may affect patient selection, predictability of possible serious complications, elective operation preparation process with a combination of nutrition and exercise therapy, thus postoperative complication rates may be reduced and short-term results may be improved. Key Words: Cytoreductive surgery, Ovarian cancer, Sarcopenia.

A Comparison of the BEAM and MITO/MEL Conditioning Regimens for Autologous Hematopoietic Stem Cell Transplantation in Hodgkin Lymphoma: An Analysis of Efficiency and Treatment-Related Toxicity.

BACKGROUND: Approximately half of patients with relapsed chemosensitive disease achieve robust responses with BEAM (BCNU, etoposide, cytarabine, and melphalan) and autologous stem cell rescue. The scarcity of comparative studies further limits alternative treatment protocols, such as the MITO/MEL (mitoxantrone, melphalan) protocol. PATIENTS AND METHODS: In this retrospective multicenter study, we compared the BEAM and MITO/MEL regimens used before autologous hematopoietic stem cell transplantation (ASCT) in terms of efficacy and side effects in patients with Hodgkin lymphoma. Data met international accreditation rules. Before ASCT, 108 patients received the MITO/MEL, and 34 patients received the BEAM. RESULTS: The median follow-up time was 36 months in the MITO/MEL group (range, 3-178) and 23 months in the BEAM group (range, 4-99). After ASCT, the 3-year expected overall survival and disease-free survival rates were 86.1% and 86.1% for the MITO/MEL group and 91.3% and 76.5% for the BEAM group, respectively. Although 50% of patients developed febrile neutropenia attacks in the MITO/MEL group, this rate was 91.1% in the BEAM group. The grade II and higher rates of hepatic, renal, gastrointestinal, and cardiac toxicities were similar in both groups. However, the rate of pulmonary toxicity was determined to be 1.9% in the MITO/MEL group and 29.4% in the BEAM group (P < .001). CONCLUSION: The MITO/MEL conditioning regimen seems to be as effective as the BEAM regimen but has better tolerability in terms of pulmonary toxicity and may be used as an alternative option if necessary, depending on the comorbidity status of the patient.

The outcomes of isolated ureteral resection and reconstruction in non-urologic cancer patients who underwent cytoreductive surgery (CRC) and hyperthermic intraperitoneal chemotherapy (HIPEC).

BACKGROUND: Urinary system resections are performed during the cytoreductive surgery with hypertermic intraperitoneal chemotherapy (CRS-HIPEC). However, isolated ureter resection and reconstruction results are uncertain. The aim of this study was to evaluate the postoperative outcomes of isolated ureteral resection and reconstructions in patients who underwent CRC and HIPEC procedure. METHODS: A total of 257 patients that underwent CRC and HIPEC between 2015 and 2017 in the Department of Surgical Oncology, Faculty of Medicine, Ankara University, were retrospectively analyzed. Twenty patients that had undergone isolated ureteral resection and reconstruction were included in the study. Predisposing factors were investigated in patients who developed postoperative complications. RESULTS: The mean age of the patients was 55.1 years. The mean follow-up time of all the patients was 11.6 months. Postoperative mortality occurred in two patients. The mean PCI score was 13.9. Postoperative urologic complications were observed in eight patients after ureter reconstruction. There was no statistically significant difference between the groups in terms of reconstruction techniques and postoperative complications (P = 302). There was no correlation between age (P = 0.571) and gender (P = 0.161) with complications. CRS-HIPEC was performed mostly due to gynecologic malignancy. However, there was no correlation between the primary cancer diagnosis and the development of complications (P = 0.514). The hospital stay duration was higher in the group with complications (16.3 vs 8.8 days, P = 0.208). CONCLUSIONS: Ureteral resections and reconstructions can be performed for R0/1 resections in CRS-HIPEC operations. It leads to an increase in hospital stay. But there is no significant difference in the development of complications. In the management of complications, conservative approach was sufficient.

The results of therapeutic plasma exchange in patients with severe hyperthyroidism: a retrospective multicenter study.

Hyperthyroidism characterized by elevated serum levels of circulating thyroid hormones. The aim of hyperthyroidism treatment is to achieve a euthyroid state as soon as possible and to maintain euthyroid status. However, drug withdrawal and utilization of alternative therapies are needed in cases in which leucopenia or impairment in liver functions is observed during medical therapy. In the present study, we aimed to present our cases which underwent therapeutic plasma exchange (TPE) due to severe hyperthyroidism. The results of 22 patients who underwent therapeutic plasma exchange due to hyperthyroidism in Apheresis Units of Erciyes University and Gaziantep University, between 2006 and 2012, were retrospectively reviewed. These cases had severe thyrotoxic values despite anti-thyroid drug use. After TPE, we observed a significant decrease in free thyroxin (FT4) (p<0.001) and free triiodotyhronin (FT3) (p<0.004) levels. There was statistically significant increase in the mean values of TSH levels after TPE (p<0.001). Clinical improvement was achieved in hyperthyroidism by TPE in 20 cases (91%). Both FT3 and FT4 levels remained above the normal limits in two of 22 patients. TPE should be considered as an effective and safe therapeutic option to achieve euthyroid state before surgery or radioactive iodine treatment. TPE is a useful option in cases with severe hyperthyroidism unresponsive to anti-thyroid agents and in those with clinical manifestations of cardiac failure and in patients with severe adverse events during anti-thyroid therapy.

Malpositioning of Hickman catheters, left versus right sided attempts.

BACKGROUND: Central venous catheters (CVC) are frequently used for stem cell collection and recurrent therapeutic hemapheresis procedures for patients with poor peripheral venous access. There is a tendency to prefer a right sided approach for insertion of a CVC via the subclavian route. We designed a sequential randomized study to examine the issue of catheter insertion side and analyzed all the technical data on surgical skill and observed complications. METHOD: Seventy-five patients who are candidates for stem cell collection and high dose chemotherapy underwent placement of Hickman catheters via the percutaneous subclavian vein (SCV) route. One experienced surgeon inserted 12F, double lumen, tunnelled, silicon based catheters in the operation room via fluoroscopic control. All of the procedure related complications, morbidity and mortality were analyzed on the basis of the side of catheter insertion. RESULTS: The total rate of malpositioning in this series was 14.66%. The Jugular vein was the most common malpositioning site (66.6%). We observed a statistically significant difference in malpositioning between left versus right sided attempts, at 5.55% versus 20.51%, respectively (p = 0.032). The routes of malpositioning encountered for left sided attempts were the right SCV and the left internal jugular vein, the right internal jugular vein (n = 5), the left SCV vein (n = 2), and one left internal jugular vein. There was no significant difference between the right and left sided attempts for mechanical complications other than malpositioning (p < 0.05). CONCLUSION: In this study the rate of malpositioning was greater in the right sided approach (p = 0.032) and the other mechanical complication rates did not differ for the two methods. Our results indicate that there is no need for hesitancy in using left sided attempts at CVC insertion.