Peritoneal carcinomatosis arising from rectal or colonic adenocarcinoma treated with cytoreductive surgery (CRS) hyperthermic intraperitoneal chemotherapy (HIPEC): two different diseases

Purpose: Peritoneal carcinomatosis (PC) from colorectal cancer (CRC) has poor survival. Multi-modal treatment including systemic chemotherapy, cytoreductive surgery (CRS), and hyperthermic intraperitoneal chemotherapy (HIPEC) can be used in selected patients with curative intent. The majority published works consider PC of CRC origin as a homogenous disease. Aim of this study is to stress the different biological behaviors and survival of PC according to colonic or rectal origin. Methods: Data of CRS and HIPEC procedures for PC of CRC origin performed at MD Anderson Cancer Center-Madrid (Spain) have been collected, dividing patients into two groups according to colonic or rectal PC. Clinical, operatory, and postoperatory variables of the two groups have been analyzed to compare survival-related rates and PC origin. Results: In the years 2004-2015, 114 procedures of CRS followed by HIPEC for peritoneal metastasis of different origin have been performed; of these, 36 procedures were for colorectal PC (31 patients in colonic and 5 in rectal group). Two groups are homogenous after analysis of clinical, operatory, and follow-up data. Median survival (OS) is significantly higher in colonic compared to rectal group (47.83 vs. 22.0 months, p 0.008). 3- and 5-year survival rate is 74 and 50% in colonic group vs. 20 and 0% in rectal group. Conclusion: Rectal origin PC has a more aggressive behavior compared to colonic origin, reflecting in a worst prognosis of patients affected by rectal origin PC. According to our data and literature, indications of multi-modal treatment including CRS and HIPEC should be more restrictive for rectal cancer PC. Authors should differentiate colonic and rectal origin of PC when reporting cases in the literature

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Peritoneal carcinomatosis arising from rectal or colonic adenocarcinoma treated with cytoreductive surgery (CRS) hyperthermic intraperitoneal chemotherapy (HIPEC): two different diseases.

PURPOSE: Peritoneal carcinomatosis (PC) from colorectal cancer (CRC) has poor survival. Multi-modal treatment including systemic chemotherapy, cytoreductive surgery (CRS), and hyperthermic intraperitoneal chemotherapy (HIPEC) can be used in selected patients with curative intent. The majority published works consider PC of CRC origin as a homogenous disease. Aim of this study is to stress the different biological behaviors and survival of PC according to colonic or rectal origin. METHODS: Data of CRS and HIPEC procedures for PC of CRC origin performed at MD Anderson Cancer Center-Madrid (Spain) have been collected, dividing patients into two groups according to colonic or rectal PC. Clinical, operatory, and postoperatory variables of the two groups have been analyzed to compare survival-related rates and PC origin. RESULTS: In the years 2004-2015, 114 procedures of CRS followed by HIPEC for peritoneal metastasis of different origin have been performed; of these, 36 procedures were for colorectal PC (31 patients in colonic and 5 in rectal group). Two groups are homogenous after analysis of clinical, operatory, and follow-up data. Median survival (OS) is significantly higher in colonic compared to rectal group (47.83 vs. 22.0 months, p 0.008). 3- and 5-year survival rate is 74 and 50% in colonic group vs. 20 and 0% in rectal group. CONCLUSION: Rectal origin PC has a more aggressive behavior compared to colonic origin, reflecting in a worst prognosis of patients affected by rectal origin PC. According to our data and literature, indications of multi-modal treatment including CRS and HIPEC should be more restrictive for rectal cancer PC. Authors should differentiate colonic and rectal origin of PC when reporting cases in the literature.

HIPECT4: multicentre, randomized clinical trial to evaluate safety and efficacy of Hyperthermic intra-peritoneal chemotherapy (HIPEC) with Mitomycin C used during surgery for treatment of locally advanced colorectal carcinoma.

BACKGROUND: Local relapse and peritoneal carcinomatosis (PC) for pT4 colon cancer is estimated in 15,6% and 36,7% for 12 months and 36 months from surgical resection respectively, achieving a 5 years overall survival of 6%. There are promising results using prophylactic HIPEC in this group of patients, and it is estimated that up to 26% of all T4 colon cancer could benefit from this treatment with a minimal morbidity. Adjuvant HIPEC is effective to avoid the possibility of peritoneal seeding after surgical resection. Taking into account these results and the cumulative experience in HIPEC use, we will lead a randomized controlled trial to determine the effectiveness and safety of adjuvant treatment with HIPEC vs. standard treatment in patients with colon cancer at high risk of peritoneal recurrence (pT4). METHODS/DESIGN: The aim of this study is to determine the effectiveness and safety of adjuvant HIPEC in preventing the development of PC in patients with colon cancer with a high risk of peritoneal recurrence (cT4). This study will be carried out in 15 Spanish HIPEC centres. Eligible for inclusion are patients who underwent curative resection for cT4NxM0 stage colon cancer. After resection of the primary tumour, 200 patients will be randomized to adjuvant HIPEC followed by routine adjuvant systemic chemotherapy in the experimental arm, or to systemic chemotherapy only in the control arm. Adjuvant HIPEC will be performed simultaneously after the primary resection. Mitomycin C will be used as chemotherapeutic agent, for 60 min at 42-43 °C. Primary endpoint is loco-regional control (LC) in months and the rate of loco-regional control (%LC) at 12 months and 36 months after resection. DISCUSSION: We assumed that adjuvant HIPEC will reduce the expected absolute risk of peritoneal recurrence from 36% to 18% at 36 months for T4 colon-rectal carcinoma. TRIAL REGISTRATION: NCT02614534 ( clinicaltrial.gov ) Nov-2015.

Inyección subareolar: potencial causa de falso negativo en la biopsia selectiva de ganglio centinela en cáncer de mama / Subareolar injection: a potential cause of false negative in the selective biopsy of the sentinel node in breast cancer

La biopsia del ganglio centinela (GC) se ha convertido en la prueba estándar para la estadificación ganglionar en el cáncer de mama en estadios precoces. Sin embargo, sigue habiendo dudas en cuanto al mejor método para la inyección del radiotrazador/colorante. Actualmente la inyección subareolar está siendo muy propugnada por su facilidad técnica y mayor tasa de localización del GC frente a las denominadas técnicas profundas (peritumoral, intratumoral) que requieren mayor especialización y mayor utilización de recursos en las lesiones no palpables. Presentamos un caso de discordancia entre ambas técnicas que podría haber ocasionado un resultado falso negativo(AU)

Sentinel node biopsy has become the standard practice in lymph node staging in breast cancer in early stages. However, uncertainty remains regarding the best method of radiotracer/dye injection. Currently, the subareolar injection is being widely used because of its technical simplicity and higher rates of SN location versus the so-called deep techniques (peritumoral, intratumoral) that require greater specialization and greater use of resources in the non-palpable lesions. We present a case of a discrepancy between the two techniques that could have caused a false negative(AU)

[Subareolar injection: a potential cause of false negative in the selective biopsy of the sentinel node in breast cancer]. / Inyección subareolar: potencial causa de falso negativo en la biopsia selectiva de ganglio centinela en cáncer de mama.

Sentinel node biopsy has become the standard practice in lymph node staging in breast cancer in early stages. However, uncertainty remains regarding the best method of radiotracer/dye injection. Currently, the subareolar injection is being widely used because of its technical simplicity and higher rates of SN location versus the so-called deep techniques (peritumoral, intratumoral) that require greater specialization and greater use of resources in the non-palpable lesions. We present a case of a discrepancy between the two techniques that could have caused a false negative.

Electrochemotherapy for treatment of skin and soft tissue tumours. Update and definition of its role in multimodal therapy

Electrochemotherapy (ECT) is a therapeutical procedure based on the induction of cell membrane electroporation, by cell exposure to electric fields lasting a few microseconds, combined with the local or systemic administration of cytotoxic drugs, with an intracellular target and high intrinsic efficacy, but poor cell membrane permeability. ECT is an effective local therapy for any histological tumour that has been used clinically since 2005 and is currently in use in 83 centres all over Europe. In the literature, ECT as a local oncological treatment shows an objective response between 70 and 90% in mucocutaneous primary and metastatic lesions, is cost effective and has few local and systemic side effects. In this manuscript, we present an overview of the European experience in ECT, as well as our own experience in a specialised Spanish oncological centre and in a basic oncological unit in Nicaragua. The purpose is to reflect on the role that this procedure could have in the treatment of skin and mucosal cancer as part of a multidisciplinary approach (AU)

Treatment of peritoneal carcinomatosis from ovarian cancer. Present, future directions and proposals.

Peritoneal carcinomatosis, considered years ago as a final stage of unresectable cancer, can now be managed with curative intention by means of a radical cytoreductive surgical procedure with associated peritonectomy and intraperitoneal chemotherapy, as described by Sugarbaker. Malignant neoplasms such as mesothelioma and pseudomyxoma peritonei, ovarian and colon cancer nowadays are experiencing some new therapeutical approaches. Higher survival rates can be reached in ovarian cancer, which is commonly diagnosed in the presence of peritoneal carcinomatosis, using an optimal cytoreductive radical surgery with intraperitoneal chemotherapy. An actualised review of the treatment of advanced ovarian cancer and a proposal of a national multicentre protocol for the treatment of peritoneal carcinomatosis from ovarian cancer has been performed by a group of Spanish surgeons and oncologists dedicated to a therapeutical approach to this pathology.

Treatment of peritoneal carcinomatosis from ovarian cancer. Present, future directions and proposals

Peritoneal carcinomatosis, considered years ago as a final stage of unresectable cancer, can now be managed with curative intention by means of a radical cytoreductive surgical procedure with associated peritonectomy and intraperitoneal chemotherapy, as described by Sugarbaker. Malignant neoplasms such as mesothelioma and pseudomyxoma peritonei, ovarian and colon cancer nowadays are experiencing some new therapeutical approaches. Higher survival rates can be reached in ovarian cancer, which is commonly diagnosed in the presence of peritoneal carcinomatosis, using an optimal cytoreductive radical surgery with intraperitoneal chemotherapy. An actualised review of the treatment of advanced ovarian cancer and a proposal of a national multicentre protocol for the treatment of peritoneal carcinomatosis from ovarian cancer has been performed by a group of Spanish surgeons and oncologists dedicated to a therapeutical approach to this pathology (AU)

Safety considerations for operating room personnel during hyperthermic intraoperative intraperitoneal chemotherapy perfusion.

The new treatment strategy for Peritoneal Surface Malignancy combines a cytoreductive surgery and perioperative intraperitoneal chemotherapy. Cytoreduction removes all macroscopic tumor. Intraperitoneal chemotherapy avoids implantation of microscopic residual tumor cells on intra-abdominal surfaces when it is administered intraoperatively and/or early in the postoperative period. Delivering cytotoxic drugs directly into the peritoneal cavity maximizes dose intensity and minimizes systemic toxicity. Hyperthermia is selectively cytotoxic for malignant cells and potentiates the effect of chemotherapy. Implementation of this procedure makes the perioperative personnel to face a risk of exposure to cytotoxic agents. Furthermore, peritonectomies and electro-evaporation of tumor nodules are performed with high voltage electrocautery, generating a large amount of surgical smoke during several hours. Inhalation of these fumes may be also a risk for healthcare workers. In this article, we analyse in depth these new risks of the operating room personnel, we review the literature, and we give guidelines for secure performance of cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy, as well as for early postoperative intraperitoneal chemotherapy administration. These new procedures are safe techniques for patients and healthcare workers provided adequate policies are adopted to avoid occupational exposure.

The management of synchronous peritoneal carcinomatosis and hematogenous metastasis from colorectal cancer.

AIMS: Combined local and distant dissemination for colorectal cancer occurs especially in younger patients. New strategies combining maximal cytoreductive surgery with intraperitoneal and systemic chemotherapy have been used in an attempt to prolong survival with an acceptable morbidity and mortality. METHODS: Twenty-seven patients with histologically proven peritoneal carcinomatosis from colorectal cancer had distant metastases in addition to peritoneal carcinomatosis. The goal for treatment in all patients was complete local and distant cytoreduction. Aggressive intraperitoneal and systemic chemotherapy was used. The endpoint for all the analysis was survival from the time of definitive treatment at our Institution. RESULTS: In addition to peritoneal carcinomatosis, 16 patients had liver metastases, six patients had lung metastases, four had liver and lung metastases and one had supraclavicular lymph-node metastases. Median survival time (MST) for the entire group was 15.2 months. Patients that received a complete cytoreductive surgery had a MST of 20.6 months and patients with incomplete cytoreduction had a MST of 9.0 months (p= 0.0471). Post-operative morbidity and mortality was 14.8 and 0%, respectively. CONCLUSION: A group of carefully selected patients with peritoneal carcinomatosis and distant metastases from colorectal cancer may benefit from cytoreductive surgery and intraperitoneal chemotherapy.

Cytoreduction and intraperitoneal chemotherapy for the management of peritoneal carcinomatosis, sarcomatosis and mesothelioma.

Despite new developments in multi-modality treatments, complete resection remains as an absolute requirement for cure of gastrointestinal cancer. We have reported benefits from combined treatment with complete cytoreduction and intraperitoneal chemotherapy. This has been achieved with low morbidity and mortality. Success in the surgical management of peritoneal surface malignancy depends on the surgeon's ability to complete complex cytoreductive procedures so that only microscopic residual disease remains. This paper describes the current strategy that the surgical oncologist should pursue in the treatment of patients with peritoneal carcinomatosis, sarcomatosis and mesothelioma. Technical details required for this surgery include patient position, incision and exposure, complete lysis of adhesion, electroevaporative dissection with irrigation and suction to preserve the translucent quality of tissues, peritonectomy procedures, proper positioning of tubes and drains for intraperitoneal chemotherapy, and reconstructive surgery. Understanding the treatment and mastery of surgical skills to manage the peritoneal surface spread of cancer has led to long-term survival of selected patients. Combination of this treatment strategy with proper patient selection has reduced the mortality and morbidity. The success of cytoreductive surgery and perioperative intraperitoneal chemotherapy depends on a long-term dedication to achieve the full potential of a curative outcome. Our unit has continued to achieve good results over two decades as improved results of treatment have evolved.

Hematoma subcapsular hepático sintomático tras litotricia renal extracorpórea mediante ondas de choque / Symptomatic hepatic subcapsular hematoma following extracorporeal real shock wave lithotripsy

La presentación de un hematoma subcapsular hepático como complicación tras la realización de litotricia renal extracorpórea mediante ondas de choque es bastante infrecuente. Describimos el caso de un enfermo que presentó sintomatología abdominal intensa post-litotricia renal extracorpórea y en el que se descartó la presencia de patología hepática previa, alteraciones en el sistema de coagulación sanguínea así como anomalías en la ejecución de la litotricia extracorpórea como mecanismos etiológicos. Realizamos una revisión bibliográfica debido a la rareza del proceso descrito (AU)

[Symptomatic subcapsular hepatic hematoma after renal extracorporeal shock wave lithotripsy]. / Hematoma subcapsular hepático sintomático tras litotricia renal extracorpórea mediante ondas de choque.

The presentation of a hepatic subcapsular hematoma as a complication following the carrying out of an extracorporeal renal shock wave lithotripsy is fairly uncommon. We would like to describe the case of a patient who showed after extracorporeal renal post-lithotripsy intense abdominal symptoms and in which the presence of any prior hepatic pathology was ruled out, alterations in the blood coagulation system as well as anomalies in the execution of the extracorporeal lithotripsy as etiological mechanisms. We carried out a bibliographical review due to the rarity of the process described.

Preoperative galactography increases the diagnostic yield of major duct excision for nipple discharge.

BACKGROUND: Although most nipple discharge is due to a benign etiology, approximately 10-15% is due to breast carcinoma. The standard management of nipple discharge includes major duct excision, and although this procedure may eliminate future nipple discharge, a specific etiology is not always found. This study investigates the utility of preoperative galactography in targeting the causative lesion. METHODS: During 1994-1996, 46 cases of major duct excision were identified from operating room records. All patients presented with spontaneous nipple discharge from a single duct. In 16 patients both a diagnostic galactogram and a preoperative galactogram with methylene blue were performed to localize the causative lesion and to enable intraoperative identification. Data were obtained by retrospective chart review. Statistical significance was determined by Fisher's exact test. RESULTS: Preoperative galactography was obtained in 7 of 31 patients (23%) with bloody nipple discharge and 9 of 15 patients (60%) with guaiac negative discharge. All patients undergoing preoperative galactography were found to have either a filling defect and/or duct cutoff (n = 13) or duct ectasia (n = 3). All patients with a filling defect and/or duct cutoff on galactogram were found to have a carcinoma or papilloma at surgery. In the three patients with duct ectasia observed on galactogram, the diagnosis was confirmed at surgery. All patients who underwent preoperative galactography were found to have specific pathology that accounted for the nipple discharge versus 20 of 30 patients (67%) who did not undergo preoperative galactography (P = 0.009). CONCLUSIONS: Although major duct excision for nipple discharge may eliminate the presenting symptomatology, a pathologic correlate is not always found. The data from the current study show that localizing the causative lesion by preoperative galactography increases the likelihood that specific pathology will be found at surgery, and suggests that preoperative galactography may be helpful in the evaluation and management of patients presenting with spontaneous nipple discharge. Cancer 1998;82:1874-80. 1998 American Cancer Society.