Patients with Peritoneal Carcinomatosis from Gastric Cancer Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Is Cure a Possibility?

BACKGROUND: Peritoneal carcinomatosis is an increasingly common finding in gastric carcinoma. Previously, patients were treated as terminal, and median survival was poor. The use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in this context is still highly debatable. OBJECTIVE: The aim of this study was to evaluate the long-term outcomes associated with CRS and HIPEC, and define prognostic factors for cure, if possible. PATIENTS AND METHODS: All patients with gastric carcinomatosis from five French institutions who underwent combined complete CRS and HIPEC and had a minimum follow-up of 5 years were included in this study. Cure was defined as a disease-free interval of more than 5 years from the last treatment until the last follow-up. RESULTS: Of the 81 patients who underwent CRS and HIPEC from 1989 to 2009, 59 had a completeness of cytoreduction score (CCS) of 0 (complete macroscopic resection), and the median Peritoneal Cancer Index (PCI) score was 6. Mitomycin C was the most commonly used drug during HIPEC (88 %). The 5-year overall survival (OS) rate was 18 %, with nine patients still disease-free at 5 years, for a cure rate of 11 %. All 'cured' patients had a PCI score below 7 and a CCS of 0. Factors associated with improved OS on multivariate analysis were synchronous resection (p = 0.02), a lower PCI score (p = 0.12), and the CCS (p = 0.09). CONCLUSION: The cure rate of 11 % for patients with gastric carcinomatosis who are deemed terminal emphasizes that CRS and HIPEC should be considered in highly selected patients (low disease extent and complete CRS).

[Prophylactic surgery in patients mutated BRCA or high risk: retrospective study of 61 patients in the ICO]. / La chirurgie prophylactique chez les patientes mutées BRCA ou à haut risque: étude rétrospective de 61 patientes de l'ICO.

BACKGROUND: Genetic predisposition is involved in only 10% of patients with breast cancer. This study was to evaluate the impact of prophylactic surgery. PATIENTS AND METHODS: This is a retrospective study of 61 patients who received prophylactic breast surgery. Data collection was carried out through the computer file of the ICO. The inclusion criteria were: patients who benefited from a bilateral prophylactic mastectomy. There were no exclusion criteria. Patients received a satisfaction questionnaire to complete. RESULTS: Our study included 61 patients, 67% had a history of breast cancer. Bilateral prophylactic surgery was performed in 40 patients. It was made an average of two interventions, 44.3% of them presented postoperative complications, 18% recovery. Forty-three patients were satisfied with the medical information before surgery. The end result matched the expectations of 54.4% and 67.4% of patients would be ready to start. It was found pain associated with breast surgery in 56.5% of patients and almost half reported a change in their sexual life. DISCUSSION AND CONCLUSION: Prophylactic mastectomy is the most effective technique to prevent the risk of breast cancer. The consequences of such an action are important. It is necessary to better select patients who would benefit most from this type of surgery.

Cytoreductive surgery and HIPEC improve survival compared to palliative chemotherapy for biliary carcinoma with peritoneal metastasis: A multi-institutional cohort from PSOGI and BIG RENAPE groups.

BACKGROUND: Peritoneal metastasis from biliary carcinoma (PMC) is associated with poor prognosis when treated with chemotherapy. OBJECTIVE: To evaluate the impact on survival of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), and compare with conventional palliative chemotherapy for patients with PMC. MATERIAL AND METHODS: A prospective multicenter international database was retrospectively searched to identify all patients with PMC treated with a potentially curative CRS/HIPEC (CRS/HIPEC group). The overall survival (OS) was compared to patients with PMC treated with palliative chemotherapy (systemic chemotherapy group). Survival was analyzed using Kaplan-Meier method and compared with Log-Rank test. RESULTS: Between 1995 and 2015, 34 patients were included in the surgical group, and compared to 21 in the systemic chemotherapy group. In the surgical group, median peritoneal cancer index was 9 (range 3-26), macroscopically complete resection was obtained for 25 patients (73%). There was more gallbladder localization in the surgical group compared to the chemotherapy group (35% vs. 18%, p = 0.001). Median OS was 21.4 and 9.3 months for surgical and chemotherapy group, respectively (p=0.007). Three-year overall survival was 30% and 10% for surgical and chemotherapy group, respectively. CONCLUSION: Treatment with CRS and HIPEC for biliary carcinoma with peritoneal metastasis is feasible and may provide survival benefit when compared to palliative chemotherapy.

Curative cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis and synchronous resectable liver metastases arising from colorectal cancer.

OBJECTIVES: This study describes the outcomes of patients with colorectal peritoneal carcinomatosis (PC) with or without liver metastases (LMs) after curative surgery combined with hyperthermic intraperitoneal chemotherapy, in order to assess prognostic factors. BACKGROUND: Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) increases overall survival (OS) in patients with PC. The optimal treatment both for PC and for LMs within one surgical operation remains controversial. METHODS: Patients with PC who underwent CRS followed by HIPEC were evaluated from a prospective database. Overall survival and disease free survival (DFS) rates in patients with PC and with or without LMs were compared. Univariate and multivariate analyses were performed to evaluate predictive variables for survival. RESULTS: From 1999 to 2011, 22 patients with PC and synchronous LMs (PCLM group), were compared to 36 patients with PC alone (PC group). No significant difference was found between the two groups. The median OS were 36 months [range, 20-113] for the PCLM group and 25 months [14-82] for the PC group (p > 0.05) with 5-year OS rates of 38% and 40% respectively (p > 0.05). The median DFS were 9 months [9-20] and 11.8 months [6.5-23] respectively (p = 0.04). The grade III-IV morbidity and cytoreduction score (CCS) >0 (p < 0.05) were identified as independent factors for poor OS. Resections of LMs and CCS >0 impair significantly DFS. CONCLUSIONS: Synchronous complete CRS of PC and LMs from a colorectal origin plus HIPEC is a feasible therapeutic option. The improvement in OS is similar to that provided for patients with PC alone.

Evaluation of mastectomy with immediate autologous latissimus dorsi breast reconstruction following neoadjuvant chemotherapy and radiation therapy: A single institution study of 111 cases of invasive breast carcinoma.

PURPOSE: The aim of the study was to evaluate morbidity and patient satisfaction following surgically treated skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) following mastectomy with neoadjuvant chemotherapy (NACT), and preoperative radiotherapy (RT), for operable invasive breast cancer. PATIENTS AND METHODS: This retrospective single-institution study included 111 patients who underwent a mastectomy with IBR after RT and/or NACT for invasive breast carcinoma at the Institut de Cancérologie de l'Ouest Paul Papin from January 1997 to January 2012. Only patients with breast reconstruction by autologous latissimus dorsi flap with (LDI) or without (ALD) implant were considered. The primary endpoints were the delay in therapeutic sequence, post-operative complication rate, surgical revision rate, time of hospitalization and the anonymous analysis of the patient satisfaction survey. RESULTS: 111 patients underwent mastectomy after RT. The median age was 48 years old and the median body mass index (BMI) was 23.6. SSM were performed in 94.5% of cases. The median interval between the end of chemotherapy (CT) and the beginning of RT was 30 days while the median interval between the end of RT and surgery was 41 days. The rate of primary complications was 66.6% including seroma secretion (reduced to 10.8% when seroma secretion was excluded). The necrosis rate was 5.4%. The average patient satisfaction score for the reconstruction was 17 out of 20. Five-year disease-free and overall survival rates were 93.2% and 98.3% respectively with a median follow-up of 31.6 months. There was only one case of local relapse diagnosed after seven years of follow-up. CONCLUSION: This study shows that our therapeutic sequence does not appear to increase IBR morbidity and remains within the acceptable safety margins of oncological treatment. It also gives a high quality aesthetic result that helps to maintain patient self-esteem.

Diffuse malignant peritoneal mesothelioma: Evaluation of systemic chemotherapy with comprehensive treatment through the RENAPE Database: Multi-Institutional Retrospective Study.

PURPOSE: Diffuse malignant peritoneal mesothelioma (DMPM) is a severe disease with mainly locoregional evolution. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the reported treatment with the longest survival. The aim of this study was to evaluate the impact of perioperative systemic chemotherapy strategies on survival and postoperative outcomes in patients with DMPM treated with curative intent with CRS-HIPEC, using a multi-institutional database: the French RENAPE network. PATIENTS AND METHODS: From 1991 to 2014, 126 DMPM patients underwent CRS-HIPEC at 20 tertiary centres. The population was divided into four groups according to perioperative treatment: only neoadjuvant chemotherapy (NA), only adjuvant chemotherapy (ADJ), perioperative chemotherapy (PO) and no chemotherapy before or after CRS-HIPEC (NoC). RESULTS: All groups (NA: n = 42; ADJ: n = 16; PO: n = 16; NoC: n = 48) were comparable regarding clinicopathological data and main DMPM prognostic factors. After a median follow-up of 61 months, the 5-year overall survival (OS) was 40%, 67%, 62% and 56% in NA, ADJ, PO and NoC groups, respectively (P = 0.049). Major complications occurred for 41%, 45%, 35% and 41% of patients from NA, ADJ, PO and NoC groups, respectively (P = 0.299). In multivariate analysis, NA was independently associated with worse OS (hazard ratio, 2.30; 95% confidence interval, 1.07-4.94; P = 0.033). CONCLUSION: This retrospective study suggests that adjuvant chemotherapy may delay recurrence and improve survival and that NA may impact negatively the survival for patients with DMPM who underwent CRS-HIPEC with curative intent. Upfront CRS and HIPEC should be considered when achievable, waiting for stronger level of scientific evidence.

Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study.

PURPOSE: The three principal studies dedicated to the natural history of peritoneal carcinomatosis (PC) from colorectal cancer consistently showed median survival ranging between 6 and 8 months. New approaches combining cytoreductive surgery and perioperative intraperitoneal chemotherapy suggest improved survival. PATIENTS AND METHODS: A retrospective multicenter study was performed to evaluate the international experience with this combined treatment and to identify the principal prognostic indicators. All patients had cytoreductive surgery and perioperative intraperitoneal chemotherapy (intraperitoneal chemohyperthermia and/or immediate postoperative intraperitoneal chemotherapy). PC from appendiceal origin was excluded. RESULTS: The study included 506 patients from 28 institutions operated between May 1987 and December 2002. Their median age was 51 years. The median follow-up was 53 months. The morbidity and mortality rates were 22.9% and 4%, respectively. The overall median survival was 19.2 months. Patients in whom cytoreductive surgery was complete had a median survival of 32.4 months, compared with 8.4 months for patients in whom complete cytoreductive surgery was not possible (P <.001). Positive independent prognostic indicators by multivariate analysis were complete cytoreduction, treatment by a second procedure, limited extent of PC, age less than 65 years, and use of adjuvant chemotherapy. The use of neoadjuvant chemotherapy, lymph node involvement, presence of liver metastasis, and poor histologic differentiation were negative independent prognostic indicators. CONCLUSION: The therapeutic approach combining cytoreductive surgery with perioperative intraperitoneal chemotherapy achieved long-term survival in a selected group of patients with PC from colorectal origin with acceptable morbidity and mortality. The complete cytoreductive surgery was the most important prognostic indicator.

Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): A French multicentric survey.

BACKGROUND: Over the last two decades, many surgical teams have developed programs to treat peritoneal carcinomatosis with extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Currently, there are no specific recommendations for HIPEC procedures concerning environmental contamination risk management, personal protective equipment (PPE), or occupational health supervision. METHODS: A survey of the institutional practices among all French teams currently performing HIPEC procedures was carried out via the French network for the treatment of rare peritoneal malignancies (RENAPE). RESULTS: Thirty three surgical teams responded, 14 (42.4%) which reported more than 10 years of HIPEC experience. Some practices were widespread, such as using HIPEC machine approved by the European Community (100%), individualized or centralized smoke evacuation (81.8%), "open" abdominal coverage during perfusion (75.8%), and maintaining the same surgeon throughout the procedure (69.7%). Others were more heterogeneous, including laminar flow air circulation (54.5%) and the provision of safety protocols in the event of perfusate spills (51.5%). The use of specialized personal protective equipment is ubiquitous (93.9%) but widely variable between programs. CONCLUSION: Protocols regarding cytoreductive surgery/HIPEC and the associated professional risks in France lack standardization and should be established.

Clinical experience with 99mTc-MIBI scintimammography in patients with breast microcalcifications.

The aim of this study was to evaluate whether 99mTc-MIBI scintimammography can improve the diagnostic value of mammography for the differentiation of benign and malignant breast microcalcifications. In 41 women presenting 45 clusters of microcalcifications, a 99mTc-MIBI scintimammography was performed before open biopsy. There were 24 malignant lesions (53%). The sensitivity (SE) and specificity (SP) of 99mTc-MIBI scintimammography were 58.3% and 81%, and the positive and negative predictive values (PPV, NPV) were 78% and 63%, respectively. SE and PPV increased for lesions over 10 mm and for the younger patients (under 50 years). No correlation was found between true positive uptake and breast cancer invasiveness: 69% (9/13) for invasive lesions and 45% (5/11) for noninvasive lesions (P = 0.48). 99mTc-MIBI scintimammography was more often positive in high grade than in low- or intermediate-grade ductal carcinoma in situ (P = 0.03). The results were analysed according to the morphologic aspect of the microcalcifications. 99mTc-MIBI scintimammography could not be used for routine evaluation of all the microcalcifications detected by mammography.

p185 overexpression in 220 samples of breast cancer undergoing primary surgery: comparison with c-erbB-2 gene amplification.

In breast cancer, DNA amplification of the oncogene c-erbB-2, encoding for the p185 protein, is associated with a poor prognosis. A retrospective study on a population of 220 cases of primary breast cancer permitted a quantitative measure of p185 oncoprotein overexpression by an immunoenzymetric assay and the determination of c-erbB-2 amplification by the Southern blot method. A correlation existed between the two measurements (r=0.85) using the double cut-off: DNA 2 copies and p185 400 U/mg protein, and only 2.7% of the cases were discordant. 13.2% of the tumors showed p185 overexpression. The percentage of tumors overexpressing p185 was significantly different between the groups with amplified and non-amplified c-erbB-2. We observed a significant correlation between p185 levels and tumor grade (p=0.03), and an inverse correlation with hormonal receptors (p=0.0001). The p185 assay could be an additional prognostic factor to better define patient subgroups with node negative, grade II, and positive or negative hormonal receptors.

Experimental assessment of tumor growth and dissemination of a microscopic peritoneal carcinomatosis after CO2 peritoneal insufflation or laparotomy.

BACKGROUND: Based on clinical observations and previous animal studies, laparoscopic surgery for malignant disease is regarded as controversial. We used a rat model to measure and compare the tumor growth, proliferation, and dissemination of a microscopic peritoneal carcinomatosis after CO(2) intraperitoneal insufflation or laparotomy. METHODS: Peritoneal carcinomatosis was induced in three groups of 27 BD IX rats each with intraperitoneal injections of 106 DHD/K12 cells, an aneuploid tumor cell line. At 48 h after tumor cell injection, the animals were randomly divided into three groups to undergo different types of intervention. All animals were anesthetized for 20 min (Halothane). The control group had no surgical intervention (group C), group I had CO(2) insufflation (7 mmHg),and group L had a midline laparotomy (5-cm). Neither bowel manipulation nor any other traumatic action was performed. Two weeks later, the rats were killed and the incidence, type, and dissemination of carcinomatosis were evaluated. We also measured the tumor's weight. Malignant omentum was sampled for flow cytometry analysis (DNA ploidy, S-phase fraction). RESULTS: The incidence of carcinomatosis did not differ among the groups. The mean score of macroscopic characteristics of the carcinomatosis was 2.8 +/- 1.9 in group L, 2.9 +/- 1.9 in group I, and 3 +/- 1.9 in group C (NS). The location of the implants did not differ, except for parietal peritoneum location, which was more frequent in group L (p < 0.01). The tumor weight was 4.96 g +/- 3.2 in group L, 5.55 g +/- 3.2 in group C, and 5.75 g +/- 3.4 in group I (NS). The percentage of aneuploid cells and S-phase fraction did not differ statistically among the groups. CONCLUSION: These results indicate that CO(2) insufflation does not cause more effects than laparotomy when tumors cells are present before the beginning of the surgery. Further studies are needed to determine the influence of other steps in laparoscopic surgery on tumor growth and dissemination.

[A comparative study of metastatic patterns of ductal and lobular carcinoma of the breast from two matched series (376 patients)]. / Etude comparative de l'évolution métastatique des carcinomes canalaires et lobulaires du sein à partir de deux séries appariées (376 patientes).

Five studies comparing metastatic patterns of lobular and ductal carcinoma have reported conflicting results. These results are based on the evaluation of heterogeneous groups, without taking clinical differences into account. The aim of this clinical study is to compare metastatic patterns of matched ductal and lobular carcinomas. One hundred eighty-eight lobular carcinomas were matched with 188 ductal carcinomas who showed identical ages, menopausal status, TNM, and dates of treatment. Hepatic, lung and brain metastases are more frequent in ductal carcinoma. Metastases to the gastrointestinal system, gynecologic organs, and peritoneum are more characteristic of lobular carcinoma. Life table analysis of overall and disease free survival shows no significant differences. The metastatic patterns of ductal and lobular carcinomas are different, and physicians should be aware that the classical staging of the breast cancer is not fit to lobular carcinoma. fit to lobular carcinoma. Could we define patients presenting high metastatic risks? Could we use CA. 125, sonography, laparoscopy in the staging? Should we change the whole therapeutic approach of lobular carcinoma?

[Is ambulatory surgery suitable for cancer patients?]. / La chirurgie ambulatoire est-elle adaptée aux patients cancéreux?

The aim of this inquiry was to question 50 patients before a traditional hospitalization in a regional center, in order to know their opinion about one-day surgery. Among 44 answers from 41 women and 3 men, 29 were against, 11 favourable and 4 without opinion. After their hospitalization, only 4 changed their mind. The main reasons, in case of unfavourable answer, were lack of security and fear of pain. Psychologic aid in traditional hospitalization is frequently cited (34%). This has to be taken into account in ambulatory cases.

[Breast micro-opacities of lead origin mimicking microcalcifications]. / Micro-opacités mammaires d'origine saturnine mimant des microcalcifications.

After a surgical excision of focal mammary "microcalcification" we noticed that in fact they represented fine lead deposits (mean diameter: 100 microns) resulting from an attempted suicide (22 long rifle) 10 years previously. The leaded nature of these foreign microbodies was demonstrated by a micro-analysis by energy dispersion on histological slides.

[Lymphocytic mastopathy. A case report and review of the literature]. / Mastopathie lymphocytaire. A propos d'une observation et revue de la littérature.

Lymphocyte mastopathy is a benign disease of the breast with characteristic B-cell aggression in the lobules. This cellular aggression generally occurs within a context of autoimmunity, such as insulino-dependent diabetes which is the most frequent.

[Granulomatous mastitis and corynebacteria infection. Two case reports]. / Mastites granulomateuses et corynébactéries. A propos de deux observations.

Diagnosis of granulomatous mastitis must be based on a multidisciplinary approach. First, it's necessary to eliminate carcinomatous mastitis. Usually, the diagnosis is unknown except for tuberculous and sarcoidosis granulomatous mastitis. On observations in two cases of Corynebacterium granulomatous mastitis, we discussed the diagnosis and therapeutic approach. When there is a clinical suspicion of granulomatous mastitis, surgical biopsy with immediate histological analysis and bacteriological culture of mammary tissue should be performed. This multidisiplinary approach should reduce the number of idiopathic granulomatous mastitis observed. Antibiotic treatment is required after biopsy or surgical excision of granuloma.

[Intestinal gas explosion during operation: a case report]. / Explosion peropératoire de gaz intestinaux: à propos d'un cas.

A case of intestinal gas explosion during the course of carcinologic surgery in a 51-year-old patient is reported. This accident, often dramatic, has become exceptional since the use of mannitol for colonic preparation has disappeared. This incident occurred during the course of a total pelvic exenteration performed under general anaesthesia with inhalation of both a mixture oxygen-nitrous oxide and volatile agents. The colon incision with an electrocautery was contemporaneous with a violent deflagration accountable for organic lesions. This case report reminds us that the risk of a dangerous explosion persists in relation with surgical, anaesthetic and individual risk factors.

[Hemihepatectomy]. / Hémihépatectomie.

Controlled right hemi-hepatectomy is a major operation reserved for primary or secondary malignant tumours, a few very large benign tumour and, more rarely, rupture of the right lobe of the liver. The surgical technique of hemi-hepatectomy respects several general rules concerning positioning of the patient, the surgical incision, haemostasis of the various pedicles, biliary stasis and drainage. Six technical variants are discussed together with their advantages and disadvantages and respective indications according to the size, nature and situation of the lesion in relation to the glissonian and hepato-caval pedicles. On the basis of this very detailed basic technique, tactical modalities according to the features of the lesion are proposed: extra or intra-hepatic control of the pedicles, initial or terminal opening of the median fissure, initial or terminal mobilisation of the right hemi-liver, total vascular exclusion. Controlled left hemi-hepatectomy is a less complicated technique which can be performed according to tactical variant identical to those described for right hemi-hepatectomy, but total vascular exclusion is rarely essential.

[In situ carcinoma and condylomata acuminata of the anus. A plea for an exclusive surgical treatment]. / Carcinome in situ et condylomes acuminés de l'anus. Plaidoyer pour un traitement chirurgical exclusif.

Although the association of in situ carcinoma and pointed condylomas of the anus is unfrequent, their etiopathogenetic similarities require the same diagnostic and therapeutic procedures. The treatment is based on surgical exeresis, the only technique that provides reliable histological findings, ensures healing and does not interfere with subsequent surveillance.

[Idiopathic segmental infarction of the greater omentum]. / Infarcissement segmentaire idiopathique du grand épiploon.

Segmental infarction of the omentum is a rare disease, with about 150 published cases, and an unusual cause of "pseudoacute" abdomen. The preoperative diagnosis is difficult because of the rarity and lack of specificity of the syndrome, and it is established after laparotomy, with a few exceptions. The authors report on a personal case and emphasize the importance of systematic exploration in spite of the "innocence" of the organ initially involved, and they describe the few signs that are nontheless suggestive of this provocative and puzzling entity.