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.

Sarcoma European and Latin American Network (SELNET) Recommendations on Prioritization in Sarcoma Care During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 outbreak has resulted in collision between patients infected with SARS-CoV-2 and those with cancer on different fronts. Patients with cancer have been impacted by deferral, modification, and even cessation of therapy. Adaptive measures to minimize hospital exposure, following the precautionary principle, have been proposed for cancer care during COVID-19 era. We present here a consensus on prioritizing recommendations across the continuum of sarcoma patient care. MATERIAL AND METHODS: A total of 125 recommendations were proposed in soft-tissue, bone, and visceral sarcoma care. Recommendations were assigned as higher or lower priority if they cannot or can be postponed at least 2-3 months, respectively. The consensus level for each recommendation was classified as "strongly recommended" (SR) if more than 90% of experts agreed, "recommended" (R) if 75%-90% of experts agreed and "no consensus" (NC) if fewer than 75% agreed. Sarcoma experts from 11 countries within the Sarcoma European-Latin American Network (SELNET) consortium participated, including countries in the Americas and Europe. The European Society for Medical Oncology-Magnitude of clinical benefit scale was applied to systemic-treatment recommendations to support prioritization. RESULTS: There were 80 SRs, 35 Rs, and 10 NCs among the 125 recommendations issued and completed by 31 multidisciplinary sarcoma experts. The consensus was higher among the 75 higher-priority recommendations (85%, 12%, and 3% for SR, R, and NC, respectively) than in the 50 lower-priority recommendations (32%, 52%, and 16% for SR, R, and NC, respectively). CONCLUSION: The consensus on 115 of 125 recommendations indicates a high-level of convergence among experts. The SELNET consensus provides a tool for sarcoma multidisciplinary treatment committees during the COVID-19 outbreak. IMPLICATIONS FOR PRACTICE: The Sarcoma European-Latin American Network (SELNET) consensus on sarcoma prioritization care during the COVID-19 era issued 125 pragmatical recommendations distributed as higher or lower priority to protect critical decisions on sarcoma care during the COVID-19 pandemic. A multidisciplinary team from 11 countries reached consensus on 115 recommendations. The consensus was lower among lower-priority recommendations, which shows reticence to postpone actions even in indolent tumors. The European Society for Medical Oncology-Magnitude of Clinical Benefit scale was applied as support for prioritizing systemic treatment. Consensus on 115 of 125 recommendations indicates a high level of convergence among experts. The SELNET consensus provides a practice tool for guidance in the decisions of sarcoma multidisciplinary treatment committees during the COVID-19 outbreak.

Peritoneal metastases of colorectal origin treated by cytoreduction and HIPEC: An overview.

Colorectal peritoneal carcinomatosis was considered a terminal condition with a merely palliative treatment that included only supportive care, palliative surgery and the best systemic chemotherapy. Since the birth of a new approach, cytoreductive surgery with peritonectomy procedures together with hyperthermic intraperitoneal chemotherapy and/or early postoperative intraperitoneal chemotherapy to treat peritoneal carcinomatosis, many research groups contributed with promising results using this procedure being up to date this strategy the only one that has shown curative benefits on colorectal peritoneal carcinomatosis achieving reported overall survival rates up to 64 mo and five-year survival rates up to 51%. The aim of this paper is to expose an updated overview of the therapeutic possibilities of these procedures in colorectal peritoneal metastases in the same way that our Unit of Oncologic Surgery has performed since 1997 with more than four hundred procedures.

Gistosis peritoneal: Papel de la cirugía de citorreducción y quimioterapia intraperitoneal perioperatoria / Peritoneal gistosis: Role of cytoreductive surgery and perioperative intraperitoneal chemotherapy

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Outcome of patients with aggressive pseudomyxoma peritonei treated by cytoreductive surgery and intraperitoneal chemotherapy.

BACKGROUND: Pseudomyxoma peritonei (PMP) is a rare disease with an incidence rate of approximately 1 per million a year. During the past few years, there has been a survival benefit for these patients treated by complete cytoreduction and perioperative chemotherapy. Better survival rates were found in the adenomucinosis group than the carcinomatosis group. The purpose of our study was to analyze the outcome and the prognosis factors of only high-grade PMP. METHODS: We selected 38 patients from a prospective database of 59 with high-grade PMP from appendiceal origin who were treated by cytoreduction surgery and HIPEC at the Hospital University Reina Sofia (Cordoba, Spain) between 1998 and July 2012. Clinical, surgical, analytical, radiological, and histological data were obtained prospectively. Survival curves were calculated using the Kaplan-Meier method, a univariate analysis was performed and the log rank-test was used to analyze the effects of several clinical and pathologic factors on overall survival (OS) and disease-free survival (DFS). RESULTS: Median follow-up time was 32 months (range, 2-170). Median age at diagnosis was 57 years (range, 32-77). In 89.5 % of patients, optimal cytoreduction CC-0 (57.9 %) and CC-1 (31.6 %) was achieved. In the remaining 10.5 %, cytoreduction was classified as CC-2. The median PCI score was 21 (range, 4-38). Morbidity complications ≥ Grade 3 in the CTCAE v 3.0 classification was 18.4 %. One patient died 45 days postsurgery. Median OS at the end of follow-up was 36 months (range, 9-83); overall 5-year survival rate was 58.7 %. In the univariate analysis for OS, significant values were obtained for lymph-node involvement and suboptimal cytoreduction. The 5-year OS was 64.5 % when an optimal cytoreduction was achieved. Median DFS was 36 months (17-54); 3-year DFS rate was 49.1 %. Neoadjuvant therapy did not affect the survival of these patients; there was no difference in the 5-year OS (43 % vs. 75 %, p = 0.068). CONCLUSIONS: In aggressive PMP, cytoreduction with peritonectomy procedure plus HIPEC is a safe procedure that suggests an improvement to the survival rates. Because optimal cytoreduction is a primary prognostic factor for survival rates, this procedure would have to be performed in an experienced center with a low morbidity. Neoadjuvant chemotherapy has not demonstrated benefits in these patients and further research will be required.

Carcinoma suprarrenocortical. Abordaje terapéutico en estadio avanzado / Adrenal cortical carcinoma: therapeutic approach in advanced-stage disease

Presentamos el caso clínico de una mujer de 33 años diagnosticada de carcinoma suprarrenocortical en estadio avanzado. Describimos la forma de presentación clínica, los métodos diagnósticos empleados y el tratamiento, especialmente en su aspecto quirúrgico, que puede precisar en determinadas ocasiones conocimientos y habilidades en cirugía hepática y vascular para intentar conseguir la resección completa del tumor y mejorar la supervivencia en estos pacientes, generalmente muy jóvenes; asimismo, realizamos una actualización bibliográfica diagnosticoterapéutica de esta neoplasia, rara en su frecuencia pero agresiva en su evolución (AU)