Ten-year experience with peritoneal mesothelioma.

PURPOSE: Peritoneal mesothelioma is a rare disease that remains confined to the peritoneal surfaces for long. Cytoreductive surgery (CRS) combined with hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) is the most effective treatment and complete cytoreduction is the most significant prognostic indicator of long-term survival. This study attempted to present the results of CRS in combination with hyperthermic intraperitoneal chemotherapy in patients with peritoneal mesothelioma and identify the prognostic indicators of survival. METHODS: The files of patients with peritoneal mesothelioma were retrospectively reviewed. Morbidity, hospital mortality, recurrences, and the sites of recurrence were recorded. Survival and recurrence were correlated to performance status, age, extent of peritoneal dissemination, tumor grade, tumor volume, and completeness of cytoreduction. RESULTS: From 2005-2017, 29 patients underwent 33 cytoreductions for peritoneal mesothelioma. Hospital mortality and morbidity were 3% and 27.3% respectively. The median and 8-year survival were 66 and 62% months, respectively. The completeness of cytoreduction was the single prognostic indicator of survival, and the tumor grade the single prognostic indicator of recurrence. CONCLUSION: CRS combined with HIPEC is the therapeutic strategy that may provide long-term survival.

Cytoreduction and HIPEC for peritoneal carcinomatosis of pancreatic cancer.

PURPOSE: Peritoneal carcinomatosis of pancreatic cancer is generally considered for palliative treatment. The purpose of this study was to report the outcome of cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in patients with pancreatic cancer and peritoneal carcinomatosis. METHODS: Patients with documented resectable peritoneal carcinomatosis of pancreatic cancer underwent cytoreductive surgery in combination with HIPEC from 2008-2016 by the same surgical team. RESULTS: Six patients underwent 8 cytoreductions. Complete or near-complete cytoreduction was possible in 7 cases, and palliative surgery in one case. Gemcitabine was used in 5 cases during HIPEC, and cisplatin+mitomycin-C in 2 others. All patients received adjuvant chemotherapy with gemcitabine. Four patients survived without evidence of recurrence for more than 12 months. CONCLUSIONS: Cytoreductive surgery with HIPEC may be considered a treatment option in highly selected patients with pancreatic cancer and peritoneal carcinomatosis.

Cytoreductive surgery and hyperthermic intraperitenoal chemotherapy (HIPEC) for colorectal and appendiceal carcinomas with peritoneal carcinomatosis.

PURPOSE: Cytoreductive surgery combined with intraperitoneal chemotherapy has been established as the standard treatment for selected patients with peritoneal malignancy. The purpose of the study was the presentation of the 10- year experience with cytoreductive surgery and intraperitoneal chemotherapy in patients with peritoneal carcinomatosis of colorectal and appendiceal origin. METHODS: Clinical and histopathological variables were retrospectively reviewed in a prospectively maintained database. All patients underwent cytoreductive surgery with the purpose of complete or near-complete cytoreduction. The variables were correlated to survival, and recurrences. Morbidity and hospital mortality were recorded. RESULTS: From 2006-2016 100 patients underwent cytoreductive surgery for colorectal and appendiceal carcinomas with peritoneal carcinomatosis. The hospital mortality and morbidity were 2% and 43% respectively. Completeness of cytoreduction (CC) 0 surgery was possible in 51% of the patients. The median and 10-year survival were 13 months and 23% respectively. The completeness of cytoreduction, performance status and the lymph node status were identified as prognostic indicators of survival. The recurrence rate was 55%. The completeness of cytoreduction, the lymph node status, and the use of postoperative adjuvant systemic chemotherapy were identified as prognostic variables of recurrence. CONCLUSION: Nearly half of the patients with peritoneal carcinomatosis of colorectal and appendiceal origin may undergo complete cytoreduction and nearly half of them may enjoy long-term survival.

The effect of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) as an adjuvant in patients with resectable pancreatic cancer.

Background - aims: The long-term survival of pancreatic cancer is poor even after potentially curative resection. The incidence of local-regional failures is high. There is evidence that hyperthermic intraperitoneal intraoperative chemotherapy (HIPEC) is effective in controlling the local-regional failures. The purpose of the study is to identify the effect of HIPEC after surgical removal of pancreatic carcinoma. Patients - Methods: Prospective study including 33 patients with resectable pancreatic carcinomas. All patients underwent surgical resection (R0) and ΗIPEC as an adjuvant. Morbidity and hospital mortality were recorded. The patients were followed-up for 5 years. Survival was calculated. Recurrences and the sites of failure were recorded. RESULTS: The mean age of the patients was 67.8 ± 11.1 years (38-86). The hospital mortality was 6.1% (2 patients) and the morbidity 24.2% (8 patients). The overall 5-year survival was 24%. The mean and median survival was 33 and 13 months, respectively. The median follow-up time was 11 months. The recurrence rate was 60.6% (20 patients). Three patients were recorded with local-regional failures (9.1%) and the others with liver metastases. CONCLUSIONS: It appears that HIPEC as an adjuvant following potentially curative resection (R0) of pancreatic carcinoma may effectively control the local-regional disease. Prospective randomised studies are required.

Lack of significant intraoperative coagulopathy in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) indicates that epidural anaesthesia is a safe option.

PURPOSE: The purpose of this study is to evaluate the fluctuations of coagulation parameters during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) and confirm beyond doubt that epidural anaesthesia is safe with this type of operations. MATERIALS AND METHODS: This is a prospective clinical study of consecutive patients who had cytoreductive surgery and HIPEC. An epidural catheter was inserted into all patients. Peripheral venous blood samples in specific time points of the procedure were tested for complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalised ratio (INR), fibrinogen, D-dimer, and expression of the GpIIb/IIIa platelet receptor. RESULTS: A total of 51 consecutive patients were included in this study. The initial mean (SD) platelet count decreased significantly to a mean of 250.6 (105.4) 10(9)/L (p < 0.001). Fibrinogen levels decreased to 295.9 (127.4) mg/dL (p = 0.009). D-dimer levels increased to 5.3 (3.1) mg/dL (p < 0.001). APTT increased from 30.8 (5.8) s to 35.1 (4.6). The mean INR increased significantly to 1.5 (0.5) (p < 0.001). The total number of GpIIb/IIIa platelet receptors showed no significant variation throughout the measurements and was 72603.2 before HIPEC, 80772.4 during, and 77432.1 after. All the parameters examined, despite significant fluctuations remained in levels that would permit perioperative epidural analgesia. No related complications were recorded. CONCLUSION: Our results support the belief that epidural analgesia is a safe option in cytoreductive surgery and HIPEC despite certain intraoperative fluctuations in coagulation parameters. It is of major importance to regulate any abnormalities observed during surgery. There are no available data regarding the occurrence of coagulopathy in the post-operative period.

Treating peritoneal mesothelioma with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. A case series and review of the literature.

BACKGROUND: Encouraging results on survival of patients with malignant peritoneal mesothelioma have been shown with the use of cytoreductive surgery and perioperative intraperitoneal chemotherapy. This study explores the impact of aggressive surgical treatment on overall survival of peritoneal mesothelioma. METHODS: This is a retrospective analysis of prospectively collected clinical data of all patients with diagnosis of malignant peritoneal mesothelioma treated in a designated referral centre in Greece. All patients were offered cytoreductive surgery and intraperitoneal chemotherapy. Patient's characteristics, operative reports, pathology reports, and discharge summaries were stored in an electronic database and later reviewed and analysed. RESULTS: Cytoreduction for peritoneal mesothelioma was performed on 20 patients (15 men and 5 women) with a mean age of 59.4 years (SD 16.1). Mean peritoneal cancer index was 16.1 (SD 10.4) and the median completeness of cytoreduction score was 2 (range 1-2). Mean overall survival was 46.8 months (SE 4.03) with a mean of 21.4 and median of 18 months of follow-up. Disease-specific survival was 100% for the observed period. Univariate analysis showed the completeness of cytoreduction as the only possible predictor of survival. A median of 10 (range 4-14) peritonectomy procedures were performed per patient. Median hospital stay was 14 (range 10-57 days). Grade III and IV complications occurred post-operatively in 5 patients (25%). Two patients died in the post-operative period of pulmonary embolism and myocardial infarction. CONCLUSION: Cytoreductive surgery with HIPEC has proved the most effective treatment even when taking account of the cost of significant morbidity.

HIPEC in controversial digestive tumors.

Local-regional and peritoneal metastases still develop despite improvements in surgical techniques. Intraperitoneal chemotherapy has been proved to be effective in reducing the rate of local-regional and peritoneal metastases in many malignancies. There is adequate evidence that intraperitoneal perioperative chemotherapy after aggressive resection of locally advanced tumors of the digestive system may be helpful in decreasing the rate of local-regional and peritoneal metastases. Prospective trials and meta-analyses have shown that patients with locally advanced gastric or colorectal carcinomas are offered significant survival benefit and develop reduced number of local-regional metastases with surgery combined with perioperative intraperitoneal chemotherapy. In pancreatic cancer the preliminary results have shown that these patients do not develop local-regional recurrences with R0 resection in combination with hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC). Further studies are required to document these findings.

Intraarterial chemotherapy as an adjuvant treatment in locally advanced gastric cancer.

BACKGROUND AND AIMS: D2 gastrectomy has improved survival in gastric cancer. Adjuvant intravenous chemotherapy, radiotherapy, or multimodal therapy has failed to demonstrate improved survival. The results of intraarterial chemotherapy (IARC) as an adjuvant have been encouraging in a few studies. A prospective randomized trial was designed to evaluate the toxicity and survival in locally advanced gastric cancer using IARC as an adjuvant after potentially curative gastrectomy. PATIENTS AND METHODS: Forty patients with locally advanced gastric cancer were randomly selected to undergo either potentially curative gastrectomy and receive IARC (study group) or gastrectomy only (control group). Clinical and histopathologic data were analyzed and the toxicity related to IARC was recorded. RESULTS: The groups were comparable (p>0.05). Three patients in the study group had minor toxicity. Five-year survival rate for the study and the control group was 52 and 54%, respectively (p>0.05). Mean survival for the study and the control group was 50+/-8 and 62+/-10 months, respectively (p>0.05). The number of recurrences and the failure sites were comparable (p>0.05). CONCLUSION: Intraarterial chemotherapy can be safely applied to gastric cancer patients. As proposed by the protocol, the method cannot be recommended as an adjuvant treatment for locally advanced tumors because it appears that there is no survival benefit compared to potentially curative gastrectomy alone.