Complete Resection Of Macroscopic Disease Research Articles

Classic and Visceral-Sparing Complete Pelvic Peritonectomy for Peritoneal Surface Malignancies: A Video Demonstration in Female Patients.

Cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy has become standard for resectable peritoneal surface malignancies. CRS aims to achieve complete resection of macroscopic disease through peritonectomy procedures and visceral resections. The pelvis is very frequently involved in peritoneal malignancies, making surgical techniques that ensure complete tumor removal an essential part of CRS. This is best achieved through an enbloc pelvic peritonectomy, which frequently includes a hysterectomy and bilateral oophorectomy in women. We created a video to review technical steps and exposure tips to achieve a complete cytoreduction of the pelvis in female patients with enbloc resection of the entire pelvic peritoneum, including the cul-de-sac, the uterus, and the adnexa, with ('classic pelvic peritonectomy') or without ('visceral-sparing pelvic peritonectomy') rectosigmoid resection. The creation of a protective ileostomy in classic pelvic peritonectomy is routine in many centers, while other centers advocate only selective and sparing use of ileostomy. In our center, protective ileostomy is used selectively and is therefore not included in the video. In the first part of the video, we review the rationale, indications, and steps, while in the second part, we show a practical demonstration of both a classic and a visceral-sparing pelvic peritonectomy in female patients. Complete pelvic peritonectomy can be achieved both with or without enbloc resection of the rectosigmoid colon. This technique is an essential part of CRS, and mastery of the technique can help the likelihood of achieving complete tumor removal in advanced or complex involvement of the pelvis.

The current role of secondary cytoreductive surgery for recurrent ovarian cancer.

Ovarian cancer represents worldwide the second most frequent and the most fatal gynecological malignancy, with approximately two thirds of the patients presenting with advanced disease. Cytoreductive surgery, primary or after neoadjuvant chemotherapy, in combination with platinum-based chemotherapy is the standard of care for these patients. Despite the improvement in quality of cytoreductive surgery as well as development of novel drugs and chemotherapy regimens, still most women with ovarian cancer will ultimately develop recurrent disease and die of their disease. In contrast to the management of primary disease, the standard treatment of patients with recurrent ovarian cancer remains a topic of debate. While platinum-based or second line systemic chemotherapy, depending on the time after last platinum treatment, is standard of care, the role of secondary cytoreductive surgery has been a controversial issue for the last decades. Potential outcome benefit must be also weighed against the risk of severe surgical morbidity, impairment of quality of life and costs. In platinum-resistant recurrent disease, i.e., relapse after less than 6 months from the last platinum-based chemotherapy for primary disease, secondary cytoreduction seems generally not to be indicated due to its aggressive biological behavior and the absence of effective systemic treatment. In this comprehensive review, the current role of cytoreductive surgery in platinum-sensitive recurrent ovarian cancer is discussed thoroughly in view of the results of most recent randomized trials and a meta-analysis. There seems to be definitely a role for secondary cytoreductive surgery in selected patients with ovarian cancer recurrence in whom complete resection of macroscopic disease is feasible. However, its role should be continuously reviewed due to the changing systemic treatment of patients with ovarian cancer recurrence over time.

898P - Primary Cytoreductive Surgery (Pcs) Vs Neoadjuvant Chemotherapy (Nact) for Advanced Ovarian Carcinoma (Aoc): Decision Criteria and Efficacy Outcomes

ABSTRACT Aim: PCS is the standard of care for aOC but NACT and interval debulking surgery (IDS) are acceptable treatment options for patients (pts) with stages IIIC and IV OC. Our aims are to characterize OC pts treated with PCS or NACT in our centre and to analyse decision criteria and efficacy outcomes of both strategies. Methods: All pts with ovarian tumours registered at the Southern Portuguese Cancer Registry (ROR-Sul) between 2006-2011 were reviewed for age at diagnosis, histology, FIGO stage, treatment (none, surgery and/or CT), progression free survival (PFS), overall survival (OS), criteria for NACT, number of platinum based CT cycles and residual macroscopic disease. Results: From 345 pts registered with ovarian tumours, 258 were epithelial ovarian cancers (EOC) (75%). EOC pts had a median age of 62 yrs (10-90); 64 (25%) were treated with surgery alone, 53 (21%) with NACT (stages IIIB-3, IIIC-15, IV-29) and 94 (37%) with PCS (25% stages IA-IC; 23% IIA-IIIA; 51% IIIB-IV).Other pts (17%) were not treated at our centre (only pathology review, multidisciplinary decision or death before treatment). For similar stages (IIIB-IV), median age was higher for NACT pts (64 yrs, 36-90) vs 59 yrs (33-82); median number of CT cycles was 8 (NACT) and 6 (PCS). Nine pts in the NACT group progressed and died before IDS. Complete resection of macroscopic disease was achieved in 24 (55%) of NACT pts and in 17 (36%) of PCS pts. Median OS and PFS were 29,2 and 8,1 months (NACT) and 38,1 months and 10,6 months (PCS). Bad prognosis pathology (mucinous/clear cell) was observed in 10 pts (3 NACT, 7 PCS). NACT decision was based on radiological criteria (74% of cases) such as implants >2cm outside the pelvis, lymphadenopathies above renal hilum, pre-sacred retroperitoneal disease or liver metastasis. In 14 pts (26%), comorbidities contraindicated upfront surgery. Conclusions: NACT was mostly decided for older pts with contraindications for upfront surgery and/or with radiologically determined unresectable disease. Observed OS was similar to that observed in trials with more fit pts. OS for the PDS group is in line with previous reports of single centre studies with experience in OC treatment. Disclosure: All authors have declared no conflicts of interest.

Neoadjuvant chemotherapy versus primary debulking surgery in advanced ovarian cancer: Experience in Mexican population.

e15567 Background: Primary debulking surgery is considered the standard of treatment in advanced ovarian cancer (AOC) while neoadjuvant chemotherapy is used in non resectable stages. Methods: We retrospectively analyzed 68 AOC cases from January 2000 to December 2011. 35 received neoadjuvant chemotherapy (NAC) while 33 were resected primarily and received adjuvant chemotherapy (AC). To compare both groups we used T standard test and 2 sided chi -squared. Non parametric variables were analyzed with U Mann – Whitney. Overall survival(OS) was analyzed using Kaplan Meier method with log rank test. We considered statistically significant p<0.05. (SPSS v 17). Results: The median age was 60 (NAC) vs 53(AC) years respectively. The NAC group had more advanced stage disease (FIGO IIIC/IV stage; 71/29% vs 91/9%; p=0.04). The most frequent histologic subtype in both groups was serous - papillary and histologic grade was poorly differentiated in 71 vs 72% (p=0.41). At diagnosis the median levels of ca-125 were 1,896 U/ml for NAC group vs 768 U/ml for AC group (p=0.025). After the primary treatment received the median levels of ca – 125 were 29 U/ml vs 84 U/ml (p=0.76). Platin based chemotherapy was used in 95% vs 70% respectively. Complete resection of macroscopic disease was observed in 68% of NAC vs 63% in AC respectively. No statistical differences were observed in surgical time (median 192 min vs 204 min; p=0.55) and surgical bleeding (468 vs 510ml; p=0.79). Median survival time was 23 +/-26 months for neoadjuvant and 27+/- 35 months for primary surgery (p=0.56). In a subgroup analysis of patients who received 6 neoadjuvant cycles vs perioperatory chemotherapy (3 pre and 3 postoperatory) we observed a significant survival difference, with a median of 62 months (95% CI 12-38) vs 12 months (95% CI 54 – 178) respectively (p=0.010). Conclusions: Non inferior survival or differences in surgical outcomes were observed with neoadjuvant therapy. Significant survival increase was observed in patients who received complete chemotherapy schedule before surgery, this evidence allowed to design a prospective trial in our Institution.

Hyperthermic Intraperitoneal Chemotherapy in the Treatment of Peritoneal Carcinomatosis of Digestive and Peritoneal Origin: Rationale

Up to a few years ago peritoneal carcinomatosis was considered as an “incurable” disease. The aim of this paper is to review the surgical approach with curative intent to carcinomatosis: it consists of complete resection of macroscopic disease (R1), associated with hyperthermic intraperitoneal chemotherapy (HIPEC) to treat residual microscopic disease, and to evaluate its indications. Overall 5-year survival of patients with peritoneal carcinomatosis treated by HIPEC is similar to that of patients with hepatic metastases treated with curative intent. Those patients should no longer be considered as patients with a terminal disease but as patients with a potentially treatable localized disease.

Perioperative blood transfusion does not prevent recurrence in Crohn's disease. A pooled analysis.

The effect of perioperative blood transfusion on the recurrence of Crohn's disease is controversial. Various studies have suggested that perioperative blood transfusions reduce the risk of recurrence; others have failed to find a protective effect. Since all the studies are based on relatively small numbers, we performed a pooled analysis. We contacted the senior authors of seven previously published studies and asked for the original data. Four authors provided their data. The pooled database included 622 patients with a primary and complete resection of macroscopic disease. Recurrence was defined as the need for repeat surgery for disease control. Kaplan-Meier life table analysis was performed. Of the study sample, 366 cases (59%) were female. Disease distribution was as follows: small bowel (47%), small/large bowel (35%), and large bowel only (18%). Three hundred thirty-one patients (53%) received blood in the perioperative period. Mean follow-up was 72.8 months. For the overall sample, the 5-year recurrence rates were 26.9% for the transfused group and 25.2% for the nontransfused (p = 0.456). When the data were stratified by age, gender, disease location, and length of resection, no difference in 5-year recurrence rates between transfused and nontransfused cases could be detected. In this pooled analysis of four retrospective studies on the effect of blood transfusions on the risk of recurrence in Crohn's disease, we were unable to document a protective effect.