Peritoneal Cancer Index Score Research Articles

Optimal duration of neoadjuvant chemotherapy prior to CRS±HIPEC for colorectal cancer: An assessment of survival and postoperative outcomes.

188 Background: Cytoreductive surgery (CRS) with or without heated intraperitoneal chemotherapy (HIPEC) represents a viable treatment option for select patients with colorectal cancer peritoneal metastases. Given high recurrence rates after surgery, it is common practice to administer neoadjuvant chemotherapy (NAC). The optimal duration, however, when considering oncologic value and postoperative outcomes, is not known. Methods: A single institution database (2009-2024) of colorectal cancer patients that underwent CRS±HIPEC was reviewed. Patients with colorectal cancer undergoing CRS±HIPEC for curative intent (completeness of cytoreduction 0 or 1) with known NAC duration were included. Analysis was stratified by NAC duration of 0-3 months or greater than 3 months. Co-primary outcomes were recurrence free survival (RFS) and overall survival (OS). Secondary outcomes included clinically significant complications, defined as Grade 3 or greater adverse events based on Common Terminology Criteria for Adverse Events Version 5.0. Results: From 2009-2024, 108 patients underwent CRS±HIPEC for colorectal cancer. Final analysis included 84 patients that underwent curative intent surgery and had a known duration of NAC ( > 3 months NAC: 55 patients, 0-3 months NAC: 29 patients). Median peritoneal cancer index (PCI) score was similar between the two cohorts ( > 3 months: median PCI 11 versus (vs) 0-3 months: median PCI 12; p = 0.42). Recurrence-free survival was 9 months for the entire cohort and not significantly different based on duration of NAC ( > 3 months: 8 months vs 0-3 months: 15 months, p = 0.14). Overall survival was also similar between both cohorts ( > 3 months: 26 months vs 0-3 months: 37 months; p = 0.11). On univariate analysis, > 3 months of NAC was associated with an increased rate of complications of any severity ( > 3 months: 83.6% vs 0-3 months: 55.2%; p = 0.01), clinically significant complications ( > 3 months: 54.5% vs 0-3 months: 31.0%; p = 0.07), and increased median length of stay ( > 3 months: 10 days vs 0-3 months: 8 days; p = 0.01). When controlling for other perioperative variables on multivariable analysis, > 3 months of NAC trended towards an increased risk of clinically significant complications (HR 1.76, 95% CI 0.59-5.30; p = 0.32). Conclusions: Even with a similar disease burden, as measured by PCI, an extended duration of neoadjuvant chemotherapy prior to CRS±HIPEC does not appear to be associated with any improved recurrence-free or overall survival. Conversely, postoperative outcomes are worse with higher complication rates and increased length of stay. Thus, despite high recurrence rates after CRS±HIPEC for this disease, it still appears that in well selected patients, an extended duration of neoadjuvant chemotherapy may not be the best treatment strategy.

Current status of postoperative morbidity following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal cancer with peritoneal metastasis: a prospective single-center observational study.

This study aimed to evaluate current morbidity rates following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with colorectal cancer and peritoneal metastasis. A total of 42 patients who underwent CRS and HIPEC for colorectal cancer with peritoneal metastasis at a single tertiary referral center between January 2022 and December 2022 were included. Perioperative outcomes and postoperative complications were prospectively assessed. The mean peritoneal cancer index (PCI) was 16.0. The distribution of PCI scores was as follows: <10, 33.3%; 10-19, 26.2%; and ≥ 20, 40.5%. Completeness of the cytoreduction (CCR) scores were as follows: 57.1% of patients achieved CCR-0, 16.7% achieved CCR-1, 7.1% achieved CCR-2, and 19.0% achieved CCR-3. The mean operation time was 9.1 hours, and the median hospital stay was 17.0 days. Postoperative complications occurred within 30 days in 47.6% of cases and between 30 and 60 days in 11.9% of cases. Reoperation within 30 days was required in 5 cases, and 1 patient died within 30 days. The most common complications were pleural effusion (5 patients), anastomosis site leakage (3 patients), and pneumonia (3 patients). Patients with higher PCI scores were more likely to experience complications (P = 0.038). Although CRS and HIPEC are still associated with high morbidity and mortality compared to other colorectal surgeries, outcomes have improved with increased experience. These results suggest that the procedure is becoming a more acceptable treatment option over time.

Tumour Load in Advanced Ovarian Cancer Patients and Its Validation by Radiological Peritoneal Cancer Index (PCI) Score.

To compare the radiological peritoneal cancer index (PCI) score to the surgical PCI score for validating it as a non-invasive method to predict surgical outcomes. A descriptive study. Place and Duration of the Study: Department ofObstetrics and Gynaecology of the Aga Khan University Hospital, Karachi, Pakistan from September 2021 to May 2022. All successive patients diagnosed with advanced-stageovarian cancer were enrolled in the research. Prior to surgery, the severity of ovarian cancer was evaluated using the Sugarbaker Peritoneal Cancer Index score derived from radiological imaging. The score was compared to the surgical PCI score determined during the surgery. The correlation between the scores and residual tumour status was confirmed. The study included a total of 26 patients. The mean age of patients was 50.17 years, with a standard deviation of 11.04. Five (19.2%) patients underwent surgery first, whereas 21(80.8%) needed interval debulking surgery after receiving chemotherapy in the neoadjuvant setting. The interclass correlation value among radiological and surgical (PCI) was 0.52, with a 95% confidence interval ranging from 0.17 to 0.75. The Bland-Altman plot displays the agreement amongst the PCI scores, indicating a bias of 1.115 with a 95% confidence interval of 4.61. Surgical exploration revealed zero residual disease in 90% of persons with a PCI score <10. Patients with a PCI score <10 had significantly brief operative time and reduced blood loss compared to those with a score >10. Patients with a PCI score below 10 had also fewer complications. PCI is an efficient means for anticipating the success of surgery and the existence of residual disease without invasive measures. This can be very helpful in deciding the best time for surgery. Peritoneal cancer index, Advanced ovarian cancer, Carcinomatosis, Prognosis, Tumour load.

Tumour Load in Advanced Ovarian Cancer Patients and Its Validation by Radiological Peritoneal Cancer Index (PCI) Score.

To compare the radiological peritoneal cancer index (PCI) score to the surgical PCI score for validating it as a non-invasive method to predict surgical outcomes. A descriptive study. Place and Duration of the Study: Department ofObstetrics and Gynaecology of the Aga Khan University Hospital, Karachi, Pakistan from September 2021 to May 2022. All successive patients diagnosed with advanced-stageovarian cancer were enrolled in the research. Prior to surgery, the severity of ovarian cancer was evaluated using the Sugarbaker Peritoneal Cancer Index score derived from radiological imaging. The score was compared to the surgical PCI score determined during the surgery. The correlation between the scores and residual tumour status was confirmed. The study included a total of 26 patients. The mean age of patients was 50.17 years, with a standard deviation of 11.04. Five (19.2%) patients underwent surgery first, whereas 21(80.8%) needed interval debulking surgery after receiving chemotherapy in the neoadjuvant setting. The interclass correlation value among radiological and surgical (PCI) was 0.52, with a 95% confidence interval ranging from 0.17 to 0.75. The Bland-Altman plot displays the agreement amongst the PCI scores, indicating a bias of 1.115 with a 95% confidence interval of 4.61. Surgical exploration revealed zero residual disease in 90% of persons with a PCI score <10. Patients with a PCI score <10 had significantly brief operative time and reduced blood loss compared to those with a score >10. Patients with a PCI score below 10 had also fewer complications. PCI is an efficient means for anticipating the success of surgery and the existence of residual disease without invasive measures. This can be very helpful in deciding the best time for surgery. Peritoneal cancer index, Advanced ovarian cancer, Carcinomatosis, Prognosis, Tumour load.

Prognostic factors of early recurrence after complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Although cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) offer the potential for long-term survival in peritoneal carcinomatosis, outcomes following CRS/HIPEC vary significantly. To identify the clinical factors associated with progression-free survival (PFS) after complete CRS/HIPEC in patients with colorectal/high-grade appendiceal, ovarian, and gastric cancers. We retrospectively evaluated the risk of recurrence within 1 year after CRS/HIPEC and its impact on overall survival (OS) in patients recruited between 2015 and 2020. Logistic regression models were used to assess the prognostic factors for the risk of recurrence within 1 year. Kaplan-Meier survival curves and Cox proportional hazards models were used to evaluate the association between recurrence and OS. Of the 80 enrolled patients, 39 had an unfavorable PFS (< 1 year) and 41 had a favorable PFS (≥ 1 year). Simple logistic models revealed that the patients with a completeness of cytoreduction score of 0 (CC-0) or length of CRS ≤ 6 h had a favorable PFS [odds ratio (OR) = 0.141, P = 0.004; and OR = 0.361, P = 0.027, respectively]. In multiple logistic regression, achieving CC-0 was the strongest prognostic factor for a favorable PFS (OR = 0.131, P = 0.005). A peritoneal cancer index score > 12 was associated with a lower rate of achieving CC-0 (P = 0.027). The favorable PFS group had a significantly longer OS (median 81.7 mo vs 17.0 mo, P < 0.001). Achieving CC-0 was associated with a lower early recurrence rate and improved long-term survival. This study underscores the importance of selecting appropriate candidates for CRS/HIPEC to manage peritoneal carcinomatosis.

Preoperative [18F]fluoro-PEG-folate PET/CT in advanced stage epithelial ovarian cancer: A safety and feasibility study

PurposeThe selection for either primary or interval cytoreductive surgery (CRS) in patients with epithelial ovarian cancer (EOC) is currently based on imaging techniques like computed tomography (CT), [18F]fluorodeoxyglucose-positron emission tomography ([18F]FDG-PET), diffusion-weighted magnetic resonance imaging (DW-MRI) and/or diagnostic laparoscopy, but these have limitations. Folate receptor (FR)-targeted PET/CT imaging, using [18F]fluoro-PEG-folate, could improve preoperative assessment, potentially reducing unnecessary laparotomies. This paper presents the first experience with [18F]fluoro-PEG-folate PET/CT imaging in advanced stage EOC, focusing on safety, tolerability, and feasibility for reflecting the extent of disease. MethodsTolerability and safety were monitored after administration of the [18F]fluoro-PEG-folate tracer by measurements of vital function parameters (blood pressure, heart rate, peripheral oxygen saturation, respiratory rate, and temperature). In addition, (serious) adverse events were recorded. Disease burden was quantified using the Peritoneal Cancer Index (PCI) score on preoperative [18F]fluoro-PEG-folate PET/CT and during surgery. PCI scores were compared with intraoperative findings, considering histopathologic results as the gold standard. Tissue specimens were stained for FRα and FRβ. Relative uptake of the radiotracer by EOC lesions and other tissues was quantified using body weighted standardized uptake values (SUV). ResultsThe study was terminated prematurely during the interim analysis after inclusion of eight patients of whom five had completed the study protocol. Although [18F]fluoro-PEG-folate demonstrated safety, efficacy for tumor-specific imaging was limited. Despite clear FRα overexpression, low tracer uptake was observed in EOC lesions, contrasting with high uptake in healthy tissues, posing challenges in specificity and accurately assessing tumor burden. ConclusionsOverall, while [18F]fluoro-PEG-folate was well-tolerated, its clinical utility in the preoperative assessment of the extent of disease in EOC was limited. This highlights the need for further research in developing targeted imaging agents for optimal detection of EOC metastases.Trial registration: Clinicaltrials.gov, NCT05215496. Registered 31 January 2022.

Neoadjuvant and adjuvant pembrolizumab in advanced high-grade serous carcinoma: the randomized phase II NeoPembrOV clinical trial

This open-label, non-comparative, 2:1 randomized, phase II trial (NCT03275506) in women with stage IIIC/IV high-grade serous carcinoma (HGSC) for whom upfront complete resection was unachievable assessed whether adding pembrolizumab (200 mg every 3 weeks) to standard-of-care carboplatin plus paclitaxel yielded a complete resection rate (CRR) of at least 50%. Postoperatively patients continued assigned treatment for a maximum of 2 years. Postoperative bevacizumab was optional. The primary endpoint was independently assessed CRR at interval debulking surgery. Secondary endpoints were Completeness of Cytoreduction Index (CCI) and peritoneal cancer index (PCI) scores, objective and best response rates, progression-free survival, overall survival, safety, postoperative morbidity, and pathological complete response. The CRR in 61 pembrolizumab-treated patients was 74% (one-sided 95% CI = 63%), exceeding the prespecified ≥50% threshold and meeting the primary objective. The CRR without pembrolizumab was 70% (one-sided 95% CI = 54%). In the remaining patients CCI scores were ≥3 in 27% of the standard-of-care group and 18% of the investigational group and CC1 in 3% of the investigational group. PCI score decreased by a mean of 9.6 in the standard-of-care group and 10.2 in the investigational group. Objective response rates were 60% and 72%, respectively, and best overall response rates were 83% and 90%, respectively. Progression-free survival was similar with the two regimens (median 20.8 versus 19.4 months in the standard-of-care versus investigational arms, respectively) but overall survival favored pembrolizumab-containing therapy (median 35.3 versus 49.8 months, respectively). The most common grade ≥3 adverse events with pembrolizumab-containing therapy were anemia during neoadjuvant therapy and infection/fever postoperatively. Pembrolizumab was discontinued prematurely because of adverse events in 23% of pembrolizumab-treated patients. Combining pembrolizumab with neoadjuvant chemotherapy is feasible for HGSC considered not completely resectable; observed activity in some subgroups justifies further evaluation to improve understanding of the role of immunotherapy in HGSC.

Does a high peritoneal cancer index lead to a worse prognosis of patients with advanced ovarian cancer?: a systematic review and meta-analysis based on the latest evidence.

The newest clinical evidence that the relationship between the peritoneal cancer index (PCI) and the postoperative prognosis of advanced ovarian cancer patients remains controversial, and there are no large-sample and multicenter studies to clarify this matter. Therefore, in this paper, we used meta-analysis to systematically assess the postoperative prognostic value of PCI in subjects with advanced ovarian cancer to provide individualized treatment plans and thus improve the prognosis of patients. Literature on the correlation between PCI and the postoperative prognosis in subjects with advanced OC undergoing cytoreductive surgery (CRS) was searched in the Cochrane Library, Pubmed, Embase, and Web of Science from the database inception to April 20, 2023. The search was updated on February 28, 2024. We only included late-stage (FIGO stage: III-IV) patients who did not undergo neoadjuvant chemotherapy (NACT) or hyperthermic intraperitoneal chemotherapy (HIPEC). Afterwards, literature screening and data extraction were conducted using Endnote20 software. The literature quality was assessed using the Newcastle-Ottawa Scale (NOS). Lastly, statistical analysis was performed with STATA 15.0 software. Five studies with 774 patients were included. The result indicated that patients with high PCI had a worse prognosis than those with low PCI. The combined hazard ratio was 2.79 [95%CI: (2.04, 3.82), p<0.001] for overall survival (OS) in patients with high PCI. Further subgroup analysis by the FIGO staging revealed that in stage III [HR: 2.61, 95%CI: (2.00, 3.40), p<0.001] and stage III-IV patients [HR: 2.69, 95%CI: (1.66, 4.36), p<0.001], a high PCI score was significantly associated with a worse prognosis. The PCI score had a greater impact on the OS of patients with higher stages. The combined hazard ratio was 1.89 [95%CI: (1.51, 2.36), p<0.001] for progression-free survival (PFS) in patients with high PCI. PCI may be used as a postoperative prognosis indicator in patients with advanced OC on primary debulking surgery. High PCI indicates a worse prognosis. However, further research is warranted to confirm these findings. https://www.crd.york.ac.uk/prospero/, identifier CRD42023424010.

Comparison of 68Ga-FAPI-04 and 18F-FDG PET/CT in diagnosing ovarian cancer.

This study assesses the diagnostic performance of 68Ga-FAPI-04 PET/CT compared to 18F-FDG PET/CT in primary, recurrent, and metastatic ovarian cancer. Seventy-nine ovarian cancer patients who performed 68Ga-FAPI-04 and 18F-FDG PET/CT were recruited. The target-to-background ratio (TBR), maximum standardized uptake value (SUVmax), the number of positive lesions, visual assessment, the peritoneal cancer index (PCI) score, staging/restaging, and treatment strategies were compared from the corresponding PET/CT. Additionally, we analyzed and contrasted the diagnostic efficacy in both scans. Among all patients, 6 were assessed for initial assessment and 73 for recurrence and metastasis detection. For all lesions, 68Ga-FAPI-04 PET/CT demonstrated greater TBR than 18F-FDG PET/CT. 68Ga-FAPI-04 PET/CT demonstrated higher sensitivity for peritoneal metastases including patient-based and lesion-based analysis (95.00% vs. 83.33%, P = 0.065; 90.16% vs. 60.66%, P < 0.001) and a higher PCI score [median PCI: 6 (4, 12) vs. 4 (2, 8), P < 0.001]. According to the visual assessment, 68Ga-FAPI-04 PET revealed larger extent metastases in 55.93% (33/59) of the patients with peritoneal metastases. 68Ga-FAPI-04 was upstaged in 7 patients (8.86%, 7/79) and discrepancies in both scans caused treatment strategies to change in 11 patients (13.92%, 11/79). 68Ga-FAPI-04 PET/CT outperforms 18F-FDG PET/CT in identifying metastases and can be a potential supplement for managing ovarian cancer patients.

Treatment outcomes and prognostic factors of bowel function recovery after hyperthermic intraperitoneal chemotherapy and cytoreductive surgery for metastatic cancers of the abdomen and pelvis.

e23225 Background: Hyperthermic intraperitoneal chemotherapy (HIPEC) is combined with cytoreductive surgery (CRS) to treat metastatic tumors of the abdomen and pelvis. The risk factors of GI dysmotility after HIPEC and CRS are not well known. Methods: We performed a single-center, retrospective chart review including all patients who had undergone HIPEC and CRS for metastatic cancer of the abdomen and pelvis from 2016-2023 to assess the prognostic factors of bowel function after HIPEC and CRS treatment. Patients were classified into high or low peritoneal cancer burden by a peritoneal cancer index (PCI) score. Statistics: Categorical variables were summarized by count and percentage and continuous variables. Comparisons of categorical and continuous covariables were conducted using Fisher’s exact test and the Wilcoxon rank sum test. Results: 195 patients met the study criteria. Duration of bowel recovery time in the High PCI was significantly higher than in the Low PCI group (median 11.5 days vs 9 days, p = 0.027). Persistent bowel dysfunction at day 30 was (7.47 x) associated with malnutrition (p = 0.001) and (6.95 x) a venting G Tube (p = 0.032) and history of radiation (p = 0.019) and Pre-OP Opioid Use (p = 0.01). Metoclopramide, Erythromycin and Mu Antagonists were used in 32%, 4.7% and 1.2% respectively of patients with bowel dysfunction. Conclusions: Patients with a high PCI score had a statistically significant longer duration of bowel dysfunction. Malnutrition and a history of radiation were statistically higher in patients with prolonged bowel dysfunction. Use of prokinetics and mu receptor antagonists was uncommon. [Table: see text]

Superiority of 18F-FAPI-42 PET/CT in the detection of primary tumor and management of appendiceal neoplasm to 18F-FDG PET/CT and CE-CT

BackgroundIn the present study, we investigated the value of 18F-fibroblast-activation protein inhibitor (FAPI) positron emission tomography/computed tomography (18F-FAPI-42 PET/CT) to preoperative evaluations of appendiceal neoplasms and management for patients.MethodsThis single-center retrospective clinical study, including 16 untreated and 6 treated patients, was performed from January 2022 to May 2023 at Southern Medical University Nanfang Hospital. Histopathologic examination and imaging follow-up served as the reference standard. 18F-FAPI-42 PET/CT was compared to 18F-fluorodeoxyglucose (18F-FDG) PET/CT and contrast-enhanced CT (CE-CT) in terms of maximal standardized uptake value (SUVmax), diagnostic efficacy and impact on treatment decisions.ResultsThe accurate detection of primary tumors and peritoneal metastases were improved from 28.6% (4/14) and 50% (8/16) for CE-CT, and 43.8% (7/16) and 85.0% (17/20) for 18F-FDG PET/CT, to 87.5% (14/16) and 100% (20/20) for 18F-FAPI-42 PET/CT. Compared to 18F-FDG PET/CT, 18F-FAPI-42 PET/CT detected more regions infiltrated by peritoneal metastases (108 vs. 43), thus produced a higher peritoneal cancer index (PCI) score (median PCI: 12 vs. 5, P < 0.01). 18F-FAPI-42 PET/CT changed the intended treatment plans in 35.7% (5/14) of patients compared to CE-CT and 25% (4/16) of patients compared to 18F-FDG PET/CT but did not improve the management of patients with recurrent tumors.ConclusionsThe present study revealed that 18F-FAPI-42 PET/CT can supplement CE-CT and 18F-FDG PET/CT to provide a more accurate detection of appendiceal neoplasms and improved treatment decision making for patients.

A machine learning approach for predicting textbook outcome after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Peritoneal carcinomatosis is considered a late-stage manifestation of neoplastic diseases. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) can be an effective treatment for these patients. However, the procedure is associated with significant morbidity. Our aim was to develop a machine learning model to predict the probability of achieving textbook outcome (TO) after CRS-HIPEC using only preoperatively known variables. Adult patients with peritoneal carcinomatosis and who underwent CRS-HIPEC were included from a large, single-center, prospectively maintained dataset (2001-2020). TO was defined as a hospital length of stay ≤14days and no postoperative adverse events including any complications, reoperation, readmission, and mortality within 90days. Four models (logistic regression, neural network, random forest, and XGBoost) were trained, validated, and a user-friendly risk calculator was then developed. A total of 1954 CRS-HIPEC procedures for peritoneal carcinomatosis were included. Overall, 13% (n=258) achieved TO following CRS-HIPEC procedure. XGBoost and logistic regression had the highest area under the curve (AUC) (0.76) after model optimization, followed by random forest (AUC 0.75) and neural network (AUC 0.74). The top preoperative variables associated with achieving a TO were lower peritoneal cancer index scores, not undergoing proctectomy, splenectomy, or partial colectomy and being asymptomatic from peritoneal metastases prior to surgery. This is a data-driven study to predict the probability of achieving TO after CRS-HIPEC. The proposed pipeline has the potential to not only identify patients for whom surgery is not associated with prohibitive risk, but also aid surgeons in communicating this risk to patients.

Laparoscopic Hyperthermic Intraperitoneal Chemotherapy plus Neoadjuvant Intraperitoneal and Systemic Chemotherapy for Gastric Cancer with Malignant Ascites

Background: Patients with gastric cancer (GC) and malignant ascites (MA) usually have poor outcomes and a high risk of recurrence and mortality, even after curative gastrectomy or chemotherapy. Systemic chemotherapy has been prescribed for patients with GC and MA; however, most of these patients expire within 1 year. Aim: To evaluate the outcomes of laparoscopic hyperthermic intraperitoneal chemotherapy (LHIPEC) plus neoadjuvant intraperitoneal and systemic chemotherapy (NIPS) in the outcomes of GC patients with MA. Methods: We enrolled 62 patients with GC and MA between January 1, 2016, and March 1, 2021. Four patients were excluded because of extraperitoneal metastasis, and two patients were ineligible. A total of 56 patients underwent biweekly staging laparoscopy and LHIPEC with NIPS. We also performed staging laparoscopy to evaluate the effectiveness of LHIPEC + NIPS. Results: The mean survival time of the 56 patients was 20.8 months. The overall complication rate was 33.93%. After the LHIPEC + NIPS intervention, the peritoneal cancer index score (P &lt; 0.001), ascites volume (P = 0.003), and cytology (P &lt; 0.001) significantly improved compared to before the intervention; quality of life (Eastern Cooperative Oncology Group) was also better than before the intervention (P = 0.002), and no discomfort was noted postintervention. Conclusion: LHIPEC + NIPS is feasible for the treatment of GC with MA and may improve patients’ quality of life.

Staging laparoscopy in gastric cancer patients: From a Dutch nationwide Delphi consensus towards a standardized protocol

BackgroundStaging laparoscopy is a common diagnostic tool in gastric cancer, but its performance varies widely. The aim of this study was to gain Dutch nationwide consensus regarding the indications for and execution of staging laparoscopy in patients with gastric cancer. MethodsAll surgeons in the Netherlands specialized in gastric cancer surgery (n = 52) were asked to participate in a Delphi consensus study. The study involved an initial questionnaire with a 3-point Likert scale, an online consensus meeting, and a second questionnaire using a 2-point Likert scale (agree/disagree). Consensus was defined as 70% or more agreement among participants. ResultsIn total, 45 experts completed both questionnaires (87% response rate). Consensus was reached on the indication to perform staging laparoscopy in cT3-4 or cN + or diffuse-type gastric cancer, including Siewert type III oesophagogastric junctional cancer. The experts agreed that if preoperative scans suggest infiltration of surrounding organs (cT4), the tumour's resectability should explicitly be investigated. Consensus was also reached for a systematic peritoneal cavity inspection according to Sugarbaker's Peritoneal Cancer Index (PCI) score. All regions should be inspected routinely, although the omental bursa may be inspected on indication. Aspiration of ascites or peritoneal washing should be performed for cytology. The experts agreed that restaging laparoscopy should be performed before resection in case of progressive disease on preoperative imaging. Without progression, global inspection was considered sufficient. ConclusionsThe results of this Dutch nationwide Delphi consensus study exposed the variability of performing staging laparoscopy in patients with gastric cancer and provided the concept for a standardized protocol.

Retrospective Evaluation of the Prognostic Value of Histological Growth Pattern in Patients with Colorectal Peritoneal Metastases Undergoing Curative-Intent Cytoreductive Surgery.

Two distinct histological growth patterns (HGPs) were described in patients with peritoneal metastasis of colorectal cancer origin (PMCRC) with limited Peritoneal Cancer Index (PCI) ≤ 6 who did not receive neoadjuvant chemotherapy (NAC) and were treated with cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC): pushing HGP (P-HGP) and infiltrating HGP (I-HGP). Patients with dominant P-HGP (> 50%) had significantly better disease-free survival (DFS) and overall survival (OS). We aimed to determine whether these previous observations regarding the prognostic value of HGP in patients with PMCRC with low PCI (≤ 6) are also valid in all operable patients, regardless of whether they received NAC or not and regardless of PCI score. This was a retrospective study including 76 patients who underwent complete CRS ± HIPEC for PMCRC between July 2012 and March 2019. In each patient, up to five of the largest excised peritoneal nodules were analyzed for their tumor-to-peritoneum interface. Correlations between NAC, HGP, and prognosis were further explored. Thirty-seven patients (49%) had dominant P-HGP and 39 (51%) had dominant I-HGP. On univariate analysis, patients with P-HGP ≤ 50% had significantly lower OS than those with dominant P-HGP > 50% (39 versus 60 months; p = 0.014) confirmed on multivariate analysis (hazard ratio 2.4, 95% confidence interval 1.3-4.5; p = 0.006). There were no significant associations between NAC and type of HGP. This study confirms the prognostic value and reproducibility of the two previously reported HGPs in PMCRC. Dominant P-HGP is associated with better DFS and OS in patients undergoing curative-intent CRS ± HIPEC compared with I-HGP, independently of the extent of peritoneal disease burden.

18F-FAPI-42 PET/CT enhances the diagnostic efficacy for peritoneal metastasis of colorectal cancer and guides treatment decisions: an original retrospective study.

Colorectal cancer is the third-most common type of cancer. When peritoneal metastasis (PM) develops, diagnosing metastatic lesions is difficult and the prognosis is poor. This study aimed to compare the value of fluorine-18 fibroblast activation protein-specific inhibitor (18F-FAPI-42) and fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) for detecting PM of colorectal cancer and to guide clinical decision-making. Forty-eight patients with PM who underwent both 18F-FAPI-42 and 18F-FDG PET/CT examinations were studied. The maximum standardized uptake value (SUV max), tumor-to-background ratios (TBRs) and peritoneal cancer index (PCI) of the PM were compared between the two imaging techniques. The intraclass correlation coefficient (ICC) was used to compare the consistency between the PET/CT PCI score and the intraoperative PCI. A receiver-operating characteristic curve was used to predict the accuracy of CC-0 cytoreduction (complete cytoreduction with no visible disease). The sensitivity and accuracy of 18F-FAPI-42 PET/CT for detecting PM were higher than those of 18F-FDG PET/CT (82.1% vs 61.1%, P < 0.01; 84.6% vs 74.5%, P < 0.01). The median SUV max and TBR of PM was greater in 18F-FAPI-42 than in 18F-FDG PET/CT [4.8 (1.9-20.1) vs 4.7 (1.0-11.0), P = 0.02; 4.3 (1.4-14.6) vs 2.9 (0.6-8.0), P < 0.01, respectively]. The median PCI of PM based on 18F-FAPI-42 PET/CT was greater than that based on 18F-FDG PET/CT (15 vs 9, P < 0.01). The ICC for 18F-FAPI-42 PCI was greater than that for 18F-FDG PCI (0.915 vs 0.724, P < 0.01). The cut-off values of the PCI of the PM for 18F-FAPI-42 and 18F-FDG PET/CT to predict CC-0 were <18 and <10, with areas under the curve of 0.80 and 0.79, respectively. 18F-FAPI-42 PET/CT has superior diagnostic efficacy for PM, particularly in the right upper epigastrium and small intestine. The PCI score of 18F-FAPI-42 PET/CT is very close to the intraoperative PCI score and has a high value for predicting CC-0. The individualized management of PM based on the 18F-FAPI-42 PET/CT PCI score is pivotal.

Supragastric lesser sac: an insidious site for surgical exploration during the debulking surgery in advanced ovarian cancer.

Metastases in the supragastric lesser sac (SGLS) are not only occult but are also barriers to complete resection of ovarian cancer. We describe a cohort of patients with SGLS disease undergoing debulking surgery. We identified all patients who underwent evaluation and eventual resection of SGLS disease as part of cytoreductive surgery for stage IIIC-IVB high-grade epithelial ovarian cancer at our institution from January 2018 to August 2022. Thirty-three of 286 patients (11.5%) underwent resection of SGLS disease. Metastases in the SGLS were identified by preoperative imaging in 4 of 33 patients (12.1%). The median peritoneal cancer index score was 22 (range, 9-33). Through surgical exploration, metastases were frequently seen in the right diaphragm (100%), hepatorenal recess (97%), lesser omentum (81.8%), left diaphragm (78.8%), supracolic omentum (75.8%), anterior transverse mesocolon (72.7%), splenic hilum (63.6%), ligamentum teres hepatis (60.6%), and gallbladder fossa (51.5%). The lesser omentum was normal in 6 of 33 (18.2%) patients, despite metastases within the SGLS. A total of 54.5% of patients underwent complex surgery (surgical complexity scores; median, 8; range, 3-14). Complete resections were achieved in 19 (57.6%) patients. No complications were related to the resection of SGLS disease. The median length of progression-free survival was 24.8 months (95% confidence interval=16.6-32.9). Metastases to the SGLS are not uncommon in advanced ovarian cancer, particularly those with widely disseminated disease. Disease in this recess is rarely identified by preoperative imaging and deserves systematic surgical exploration to attain complete cytoreduction.

Unveiling the prognostic significance of malignant ascites in advanced gastrointestinal cancers: a marker of peritoneal carcinomatosis burden.

Ascites is common in advanced gastrointestinal cancers with peritoneal metastases (PM) and negatively impacts patient survival. No study to date has specifically evaluated the relationship between ascites, PM and survival outcomes in metastatic colorectal cancer (mCRC) and metastatic gastric cancer (mGC). This study aims to investigate and elucidate the relationship between malignant ascites, PM and survival outcomes in both mCRC and mGC patients. This is a retrospective analysis of prospectively collected clinical trial data of mCRC and mGC patients with PM. We performed two pooled analyses, firstly of two Italian randomized trials enrolling patients with mCRC eligible for systemic therapy (TRIBE2; VALENTINO), and secondly of gastric cancer and peritoneal metastasis (GCPM) patients who underwent bi-directional therapeutic treatment comprising systemic and peritoneal-directed therapies. Of 900 mCRC patients, 39 (4.3%) had PM with malignant ascites. Compared to the group without PM, median progression-free and overall survival were significantly inferior in the ascites group (hazard ratio (HR) for progression-free survival (PFS) 1.68, 95% confidence interval (CI): 1.21-2.35, p = 0.007; HR for overall survival (OS) 2.14, 95% CI: 1.57-3.01, p < 0.001), but not in the group of PM without ascites (HR for PFS 1.10, 95% CI: 0.91 - 1.34; HR for OS 1.04, 95% CI: 0.84 - 1.30). Of 170 patients with GCPM, those with ascites had higher median Peritoneal Cancer Index scores (23 vs 9, p < 0.001). Median OS was significantly inferior among those with ascites compared to those without (13.0 vs 21.0 months, HR 1.71, 95% CI: 1.16-2.52, p = 0.007). Ascites identifies a subgroup of patients with PM and poor outcomes, for whom tailored research are needed.

Efficacy of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei

Objective: To evaluate the efficacy and safety of cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of pseudomyxoma peritonei (PMP). Methods: In this descriptive case series study, we retrospective analyzed the records of PMP patients treated with CRS and HIPEC between January 2013 and June 2023 at Affiliated Cancer Hospital and Institute of Guangzhou Medical University. The inclusion criteria were as follows: (1) Aged 18 to 75 years and nonpregnant women. (2) Histologically confirmed diagnosis of pseudomyxoma peritonei. (3) Karnofsky Performance Scale (KPS)>70. (4) The functions of major organs such as the heart, liver, lungs, and kidneys can tolerate major surgery for long periods of time. (5) No evidence of extra-abdominal metastasis. Patients with extensive intra-abdominal adhesions or severe infectious diseases were excluded. The main outcomes were overall survival (OS) and postoperative major complications. The postoperative major complications were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (version 5.0). We used the peritoneal cancer index (PCI) score to quantitatively assess the peritoneal metastases and the completeness of cytoreduction (CCR) score at the end of surgery (CCR-0 and CCR-1 considered to be complete CRS). Results: A total of the 186 PMP patients with a median age of 56 (interquartile range extremes (IQRE), 48-64) years were included, 65 (34.9%) males and 121 (65.1%) females. The median peritoneal cancer index (PCI) score was 28 (20-34). Appendiceal origin accounted for 91.4%. Histological types were low grade in 99 patients (53.2%), high grade in 57 patients (30.6%), and 55 patients (29.6%) received complete cytoreduction (CCR-0/1). The median operative duration was 300 (211-430) minutes for all patients. Treatment-related 30-day mortality was 2.7%; 90-day mortality 4.3%; reoperation 1.6%; and severe morbidity 43.0%. Within the entire series, anemia(27.4%), electrolyte disturbance(11.6%), and hypoalbuminemia(7.5%) were the most frequent major complications (grade 3-4). The incidences of gastrointestinal anastomotic leakage, abdominal bleeding, and abdominal infection were 2.2%, 2.2%, and 4.3%, respectively. After a median follow-up of 38.1 (95%CI:31.2-45.1) months, the 5-year OS was 50.3% (95%CI: 40.7%-59.9%) with a median survival time of 66.1 (95%CI: 43.1-89.1) months. The survival analysis showed that patients with pathological low grade, low PCI, and low CCR score had better survival with statistically significant differences (all P<0.05). Further stratified into complete and incomplete CRS subgroups, the 5-year OS of the CCR-0 and CCR-1 subgroups was 88.9% (95%CI: 68.3%-100.0%) and 77.6% (95%CI: 62.7%-92.5%), respectively; and 42.0% (95%CI: 29.5%-54.5%) in the CCR-2/3 subgroup. Conclusions: CRS and HIPEC may result in a long-term survival benefit for PMP patients with acceptable perioperative morbidity and mortality. This strategy, when complete CRS is possible, could significantly prolong survival for strictly selected patients at experienced centers.

The peritoneal cancer index as a predictor of complete cytoreduction at primary and interval cytoreductive surgery in advanced ovarian cancer

ObjectiveThe peritoneal cancer index quantitatively assesses cancer distribution and tumor burden in the peritoneal cavity. The aim of this study is to evaluate the association between the peritoneal cancer index...