Peritoneal Surface Disease Severity Score Research Articles

External validation of prognostic scores and comparison of predictive accuracy for patients with colorectal cancer with peritoneal metastases considered for cytoreductive surgery and intraperitoneal chemotherapy.

Prognostic scores are developed to facilitate the selection of patients with colorectal cancer peritoneal metastases (CRPM) for treatment with cytoreductive surgery (CRS) ± intraperitoneal chemotherapy (IPC). Three prominent prognostic scores are the Peritoneal Surface Disease Severity Score (PSDSS), the Colorectal Peritoneal Metastases Prognostic Surgical Score (COMPASS), and the modified COloREctal-Pc (mCOREP). We externally validate these scores and compare their predictive accuracy. Data from consecutive CRPM patients who underwent CRS/IPC from 1996 to 2018 was used to externally validate COMPASS, PSDSS, and mCOREP. Analysis evaluated the efficacy of each score in predicting (1) open-close laparotomy-those found at laparotomy to not be eligible for curative intent CRS/IPC, (2) surgical futility-those who underwent open-close laparotomy, palliative debulking surgery, or had an overall survival of less than 12 months, and (3) overall and recurrence-free survival (OS, RFS). Prognostic scores were calculated for the 174-patient external validation cohort. COMPASS was most accurate in predicting open-close laparotomy, futile surgery, and survival (OS and RFS). Area under the curve (AUC) for open-close prediction was 0.78 (95% confidence interval,CI: 0.68-0.87), representing useful discrimination. However, AUC for futility prediction was 0.62 (95%CI: 0.52-0.71), and C-statistic for OS was 0.65 indicating only possibly helpful discrimination. C-statistic for RFS was 0.59 indicating poor discrimination. While COMPASS showed the best statistical behavior, accuracy for several clinically relevant outcomes remains low, and thus applicability to clinical practice limited.

Meeting actual benchmarks for short- and long-term outcomes after cytoreductive surgery for peritoneal surface malignancy at a newly established academic treatment center

BackgroundCytoreductive surgery with hyperthermic intraperitoneal chemotherapy is a curative treatment for selected patients with peritoneal surface malignancy. Reaching actual outcomes benchmarks is challenging given the complex nature of peritoneal surface malignancy surgery. The aim of this study was to assess how the benchmarks for morbidity and oncologic outcome can be reached at a newly established program for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. MethodsBuilding on existing institutional experience in complex abdominal surgery and interdisciplinary ovarian cancer treatment, a peritoneal surface malignancy center for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy was established at the Medical University of Vienna using a structured mentoring process. This is a retrospective analysis of the first 100 consecutive patients. Morbidity and mortality were assessed using the Clavien-Dindo classification, and oncologic outcomes using overall survival. ResultsMajor morbidity and mortality were 26% and 3%, and median overall survival was 49.0 months. In patients with colorectal peritoneal metastases, the median overall survival was 35.1 months (all colorectal peritoneal metastases patients) and 48.8 months in the subgroup with Peritoneal Surface Disease Severity Score ≤3. No median overall survival could be calculated in patients with low-grade appendiceal mucinous neoplasms, appendiceal adenocarcinoma, or peritoneal mesothelioma due to >50% of patients being alive at the end of follow-up. ConclusionWe show that the current morbidity and oncological outcomes benchmarks can be reached within the first 100 cases of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at a newly established peritoneal surface malignancy center. Previous institutional experience in complex abdominal surgery and a structured mentoring process are key factors in achieving this goal.

Consensus statement and clinical pathway for the management of colon cancer with peritoneal metastases in the state of Delaware

BackgroundIncreasing data suggests that the combination of modern systemic therapies and Cytoreductive surgery with or without Hyperthermic Intraperitoneal Chemotherapy (HIPEC) may improve the outcome of patients with colon cancer with peritoneal metastases. Patient selection and sequence of treatments remains ill-defined. Materials and methodsA working group, the State of Delaware Peritoneal Surface Malignancies Task Force (DE-PSM-TF), was created including representatives from medical and surgical oncology from the acute care hospitals in Delaware. An extensive review of all available literature was carried out. Virtual meetings were held, and interpretation and discussion of the data was conducted. ResultsA clinical pathway that includes a multidisciplinary evaluation at the time of diagnosis of colon cancer with peritoneal metastases and reflects a consensus from the Task Force on 7 key points that suggest the management of these patients based on the severity of their peritoneal metastases and incorporates all currently available therapies was created. The sequence of therapies of this multimodality treatment was determined by the Peritoneal Surface Disease Severity Score (PSDSS) (Fig. 1). ConclusionThe current pathway represents a comprehensive, team effort that should improve the outcome of patients with Colon Cancer with peritoneal metastases in the state of Delaware by having multidisciplinary discussions at the time of diagnosis, selecting the best order of sequence of currently available therapies in order to maximize benefits and minimize morbidity.

Incorporation of the 8<sup>th</sup> Edition AJCC/TNM Staging of Carcinoma of the Appendix into the Esquivel Peritoneal Surface Disease Severity Score (E-PSDSS) in 229 Patients with Mucinous Appendiceal Neoplasms

Introduction: A practical staging classification that has prognostic significance in mucinous appendiceal neoplasms represents an unmet need in oncology. The purpose of this study is to present a second edition of the PSDSS in mucinous appendiceal neoplasms with or without peritoneal dissemination based on the AJCC/TNM 8th edition. Materials and Methods: We analyzed 229 patients based on the AJCC/TNM 8th edition incorporating G (grade) and E (extent of disease). The impact of these 5 clinicopathological variables (T, N, M, G, E) is scored as stages 0 to IV and is reported as the Esquivel Peritoneal Surface Disease Severity Score (E-PSDSS). Results: One hundred and seventy-three patients underwent cytoreductive surgery (CRS) and HIPEC. There were 30 (13.1%), 56 (24.4%), 48 (20.9%), 20 (8.7%) and 75 (32.7%) patients with E-PSDSS 0, I, II, III, and IV, respectively. Five-year overall survival was 100%, 100%, 84.46%, 52.29% and 12.92% for E-PSDSS 0, I, II, III and IV, respectively (p < 0.0001). On multivariate analysis, sex (p = 0.0462) and E-PSDSS stage [0, I, II, III, IV] (HR 0 vs IV NR, HR 1 vs IV NR, HR II vs IV 0.072 [95% CI 0.028, 0.189], HR III vs IV 0.353 [95% CI 0.158, 0.791]; p < 0.0001) were identified as independent predictors of survival. Conclusion: The E-PSDSS combines specimen examination and reporting according to the College of American Pathologists with the pTNM requirements from the AJCC staging manual. It represents an important prognostic indicator in patients with mucinous appendiceal neoplasms.

Evaluation of the peritoneal surface disease severity score (PSDSS) in ovarian cancer patients undergoing cytoreductive surgery and HIPEC: Two pathogenetic types based study

Background: Clinical experience suggests that cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) play an important role in the management of ovarian cancer. In order to improve patient selection, the peritoneal surface disease severity score (PSDSS) was previously introduced for use in colorectal cancer patients. However, almost no data exist regarding the utility of the PSDSS index in ovarian cancer patients.

Colorectal peritoneal metastases treated by perioperative systemic chemotherapy and cytoreductive surgery with or without HIPEC. A comparative study using the Peritoneal Surface Disease Severity Score (PSDSS)

Colorectal peritoneal metastases treated by perioperative systemic chemotherapy and cytoreductive surgery with or without HIPEC. A comparative study using the Peritoneal Surface Disease Severity Score (PSDSS)

Colorectal Peritoneal Metastases Treated by Perioperative Systemic Chemotherapy and Cytoreductive Surgery With or Without Mitomycin C-Based HIPEC: A Comparative Study Using the Peritoneal Surface Disease Severity Score (PSDSS).

The Prodige-7 trial has questioned the role of hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal metastases from colorectal cancer (CRC-PM). We compared a prospectively collected group of 48 patients undergoing oxaliplatin/irinotecan-based perioperative systemic chemotherapy (s-CT) with targeted agents, and cytoreductive surgery (CRS) (no-HIPEC group) with 48 controls undergoing the same perioperative s-CT and CRS/HIPEC (HIPEC group). Patients were matched (1:1) according to the Peritoneal Surface Disease Severity Score, completeness of cytoreduction, history of extraperitoneal disease (EPD), and Peritoneal Cancer Index. The groups were comparable, except for a higher number of patients in the HIPEC group with World Health Organization performance status 0, pN2 stage primary tumor, and treated with preoperative s-CT. Forty-one patients in the no-HIPEC group and 43 patients in the HIPEC group had optimal comprehensive treatment (P = 0.759), defined as complete cytoreduction of PM and margin-negative EPD resection. Median follow-up was 31.6months in the no-HIPEC group and 39.9months in the HIPEC group. Median overall survival was 39.3months in the no-HIPEC group and 34.8months in the HIPEC group (P = 0.702). In the two groups, severe morbidity occurred in 14 (29.2%) and 13 (27.1%) patients, respectively (P = 1.000), with no operative deaths. On multivariate analysis, left-sided primary and curative treatment independently correlated with better survival while HIPEC did not (hazard ratio 0.73; 95% confidence interval 0.47-1.15; P = 0.178). Our results confirmed that, in selected patients, perioperative s-CT and surgical treatment of CRC-PM resulted in unexpectedly high survival rates. Mitomycin C-based HIPEC did not increase morbidity but did not impact prognosis.

Peritoneal Surface Disease Severity Score (PSDSS), AGO-score and TIAN model in patients with platinum-sensitive recurrent ovarian cancer treated by cytoreductive surgery plus HIPEC.

In patients with platinum sensitive recurrent ovarian cancer selected for a secondary cytoreduction, the use of prognostic scores allows predicting the possibilities of a new complete cytoreduction. The aim of this work is to evaluate the usefulness of PSDSSov, the AGO-score and the TIAN-model as prognostic tools in these patients. Sixty four patients with recurrent platinum sensitive ovarian cancer treated by cytoreduction and HIPEC were analyzed between January 2008 and December 2016. Since 2012, the data needed to calculate the PSDSS, AGO-score and TIAN model were collected prospectively. Fifty patients (78%) received systemic chemotherapy before cytoreduction and HIPEC. In 57 patients (89%) a CC-0 was achieved. Patients with PSDSSov I-II and TIAN model of "low risk" had a DFS at 1 and 5years of 71% and 57%, respectively, without reaching the median of DFS. PSDSSov is a useful prognostic tool and can be used in decision making in patients with peritoneal carcinomatosis due to recurrent platinum-sensitive ovarian cancer. Its combination with the Tian model makes it possible to identify patients with an especially favorable prognosis.

Diagnostic Nodes of Patient Selection for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Among Colorectal Cancer Patients: A Swiss National Multicenter Survey

BackgroundThe management of patients with colorectal cancer (CRC) with peritoneal metastases is challenging, and the roles of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are unclear and debated among experts. Materials and MethodsThe experts of the Swiss Peritoneal Cancer Group were contacted and agreed to participate in this analysis. Experts from 9 centers in Switzerland provided their decision algorithms for CRS/HIPEC for patients with or at high risk for peritoneal metastases from CRC. Their responses were converted into decision trees on the basis of objective consensus methodology. The decision trees were used as a basis to identify consensus and discrepancies. ResultsThe final treatment algorithms included a total of 5 decision criteria (age, Peritoneal Cancer Index [PCI], extraperitoneal metastases, Peritoneal Surface Disease Severity Score, and various risk factors [RF]) and 2 treatment options (HIPEC, yes or no). HIPEC was never recommended for patients without peritoneal metastases in the absence of RF for peritoneal metastases. For patients with a PCI ≤15 without organ metastases, all centers recommended CRS/HIPEC. There was also a consensus not to perform CRS/HIPEC in elderly patients (80 years and older), those with a PCI >20, and those with unresectable metastases. For patients with a PCI = 16 to 20, there was no consensus. ConclusionMultiple decision criteria relevant to all participating centers were identified. Because patient selection for CRS/HIPEC remains difficult, uniform criteria for the term “high risk” for peritoneal metastases and systemic metastases are helpful. Future trials and guidelines should take these criteria into account.

RAS Mutation Decreases Overall Survival After Optimal Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy of Colorectal Peritoneal Metastasis: A Modification Proposal of the Peritoneal Surface Disease Severity Score.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are currently the most accepted treatment for peritoneal metastases from colorectal cancer. Restrictive selection criteria are essential to obtain the best survival benefits for this complex procedure. The most widespread score for patient selection, the peritoneal surface disease severity score (PSDSS), does not include current biological factors that are known to influence on prognosis. We investigated the impact of including RAS mutational status in the selection criteria for these patients. We studied the risk factors for survival by multivariate analysis using a prospective database of consecutive patients with carcinomatosis from colorectal origin treated by CRS and HIPEC in our unit from 2009 to 2017. The risk factors obtained were validated in a multicentre, international cohort, including a total of 520 patients from 15 different reference units. A total of 77 patients were selected for local análisis. Only RAS mutational status (HR: 2.024; p = 0.045) and PSDSS stage (HR: 2.90; p = 0.009) were shown to be independent factors for overall survival. Early PSDSS stages I and II associated to RAS mutations impaired their overall survival with no significant differences with PSDSS stage III overall survival (p > 0.05). These results were supported by the international multicentre validation. By including RAS mutational status, we propose an updated RAS-PSDSS score that outperforms PSDSS alone providing a quick and feasible preoperative assessment of the expected overall survival for patients with carcinomatosis from colorectal origin undergone to CRS + HIPEC.

A Simplified Peritoneal Sarcomatosis Score for patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

With the introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), long-term survival can be achieved in selected patients with peritoneal surface malignancy. In patients with peritoneal sarcomatosis (PS), CRS/HIPEC remains a topic of debate. It is important that patient selection and outcome be improved with a tool that better predicts survival in such patients. To this end, we devised a Simplified Peritoneal Sarcomatosis Score (SPSS) adopted from the previously-described peritoneal surface disease severity score (PSDSS). Patients were included if they were diagnosed with PS and underwent CRS/HIPEC with intended complete cytoreduction between 2007 and 2017. To calculate SPSS, we recorded symptoms (none =0, present =1), peritoneal carcinomatosis index (PCI) (≤10=0, >10=1), and grade of tumor (low =0, high =1). Thus, SPSS ranged from 0 to 3. SPSS-L (low) included patients with score of 0-1; SPSS-H (high) included patients with scores 2-3. Survival curves were generated using Kaplan-Meier method according to the two tiers of SPSS. Twenty-five patients were included. Mean age was 51.84±10.75 years. Median follow-up was 18 months. Compared to SPSS-H, SPSS-L patients had a longer median overall survival (OS) (36±16 vs. 16±6 months, respectively; P=0.021) and a longer median disease-free survival (DFS) (36±16 vs. 16±6 months, respectively; P<0.001). On multivariate analysis, advanced disease (SPSS-H) was an independent predictor of OS (P=0.020) and DFS (P=0.018). SPSS can be used as a tool for patient selection for surgery, prognosis prediction, and stratification into clinical trials of PS patients.

Evaluation of the peritoneal surface disease severity score (PSDSS) in ovarian cancer patients undergoing cytoreductive surgery and HIPEC: Two pathogenetic types based study.

Clinical experience suggests that cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) play an important role in the management of ovarian cancer. In order to improve patient selection, the peritoneal surface disease severity score (PSDSS) was previously introduced for use in colorectal cancer patients. However, almost no data exist regarding the utility of the PSDSS index in ovarian cancer patients. A retrospective study of the effectiveness of CRS and HIPEC was carried out in 59 patients with ovarian cancer. The PSDSS was based on three criteria: symptoms, extent of peritoneal dissemination, and primary tumor structure as assessed by histology and biomarker expression. The overall survival time for patients with ovarian cancer in PSDSS Stage I was 48 ± 25.3 months. For PSDSS Stage II, the survival time was 26.5 ± 4.7 months. For PSDSS Stage III, it was 15.5 ± 4 months, and for PSDSS Stage IV, it was 6 ± 4.3 months. A multivariate analysis showed that the PSDSS stage was the only independent survival predictor. These data demonstrate that a PSDSS based on two pathogenetic types may be useful for predicting survival outcomes in ovarian cancer patients treated with CRS/HIPEC.

Prognostic scores for colorectal cancer with peritoneal metastases treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Background: Selecting colorectal patients for HIPEC-surgery needs improvement. The study aim was to improve the colorectal peritoneal score (COREP) and to compare it with three other scores: peritoneal-surface disease-severity score (PSDS), colorectal-peritoneal metastases prognostic-surgical-score (COMPASS), and the CEA/PCI ratio.Method: Twelve preoperative factors were chosen to evaluate for COREP score modification. Criteria from logistical analyses were set to qualify for the modified COREP score (mCOREP). Odds ratios were used to assign score points for the eligible factors with open/close laparotomy prediction as endpoint. mCOREP was applied internally and compared with the original COREP, PSDS, COMPASS, and CEA/PCI ratio. Odds ratios, hazard ratios, and Kaplan–Meier curves were used for comparison.Results: Seven factors qualified for mCOREP: CEA, CA 19-9, CA-125, C-reactive protein, albumin, platelet count and signet-cell histology. mCOREP was superior to the original COREP. mCOREP and COMPASS scores were the only scores with independent prognostic value. The mCOREP had the best discriminatory ability between its prognostic groupings. mCOREP 11 + had 9 months survival with half of patients being open/close surgery.Conclusion: The mCOREP has successfully been simplified while still improving its prognostic ability. The mCOREP and COMPASS scores have independent prognostic value. Patients with mCOREP 11 + may not benefit from treatment.

External Validation of the Prognostic Nomogram (COMPASS) for Patients with Peritoneal Carcinomatosis of Colorectal Cancer.

To optimize outcome, selection of patients for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is critical. Recently, Simkens et al.7 evaluated the peritoneal surface disease severity score (PSDSS) and suggested a new prognostic nomogram, the colorectal peritoneal metastases prognostic surgical score (COMPASS) based on age, peritoneal carcinomatosis index score, locoregional lymph node status, and signet ring cell histology. This COMPASS nomogram had better discriminative ability according to the Harrell c-index than PSDSS (c=0.72 vs. 0.62). This study aimed to validate the COMPASS nomogram externally. Data were retrieved from a prospectively maintained database, and all patients who underwent surgery between May 2005 and May 2016 were included in the study. For each patient, the PSDSS and COMPASS were calculated and then divided into subgroups. The discriminative ability of both scores for overall survival were quantified using Harrell c indices. A total of 153 patients underwent CRS+HIPEC for peritoneal carcinomatosis (PC) of colorectal cancer. The median overall survival (OS) was 46months, and the mean PSDSS was 7.8±3.7. When the PSDSS was divided into subgroups, the c index was 0.67. The mean COMPASS was 55.5±25.6. When the patients were divided into four groups according to cutpoints of Simkens et al.7 a c index of 0.72 was obtained, showing its significant superiority over the discriminative ability of the PSDSS (p=0.016). External validation of the COMPASS confirms its moderate to good discriminative ability and its superiority over the PSDSS. Nevertheless, discrimination with the COMPASS score remains suboptimal, and further research on prognostic variables is essential for optimal patient selection.

Development of a Prognostic Nomogram for Patients with Peritoneally Metastasized Colorectal Cancer Treated with Cytoreductive Surgery and HIPEC.

With the introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), long-term survival can be achieved in selected patients with colorectal peritoneal metastases (PM). Patient selection and outcome may be improved significantly with a tool that adequately predicts survival in these patients. This study was designed to validate the peritoneal surface disease severity score (PSDSS) in patients with colorectal PM treated with CRS+HIPEC. If performance of the PSDSS was suboptimal (c<0.7), we aimed to develop a new prognostic model. Patients were included if they had colorectal PM and underwent CRS+HIPEC with intended complete cytoreduction in a Dutch tertiary hospital between 2007 and 2015. Statistical analyses were performed with R-software. A total of 200 patients underwent CRS+HIPEC. External validation of the PSDSS showed a Harrell's c statistic of 0.62. After analysis, four parameters appeared prognostically relevant factors for overall survival: age, PCIscore, locoregional lymph node status, and signet ring cell histology. The weighted relevance of these parameters was turned into a prognostic nomogram that we termed colorectal peritoneal metastases prognostic surgical score (COMPASS). The COMPASS differentiated well and showed a Harrell's c statistic of 0.72 with a calibration plot showing good agreement. This study externally validated the PSDSS and developed a new prognostic score, the COMPASS. This pre-cytoreduction nomogram was more accurate than PSDSS in predicting survival of patients undergoing CRS+HIPEC. It can be used as tool to assist in the decision about continuing cytoreduction and HIPEC and can provide valuable information in the follow-up period after CRS+HIPEC.

Multidisciplinary Treatment for Colorectal Peritoneal Metastases: Review of the Literature

Peritoneum is one of the common sites of metastasis in advanced stage colorectal cancer patients. Colorectal cancer patients with peritoneal metastases (PM) are traditionally believed to have poor prognosis, which indicates it is of no value to adopt surgical treatment. With the advancement of surgical techniques, hyperthermic intraperitoneal chemotherapy (HIPEC), and multidisciplinary treatment in recent years, the cognition and treatment strategies of colorectal peritoneal metastases (CPM) have changed dramatically. In terms of prognosis, CPM under the palliative systemic treatment shows an inferior outcome compared with nonperitoneal metastasis. Nevertheless, some CPM patients amenable to the complete peritoneal cytoreductive surgery (CRS) combined with HIPEC may achieve long-term survival. The prognostic factors of CPM comprise peritoneal carcinomatosis index (PCI), completeness of cytoreduction score (CC score), the presence of extraperitoneal metastasis (liver, etc.), Peritoneal Surface Disease Severity Score (PSDSS), Japanese peritoneal staging, and so forth. Taken together, literature data suggest that a multimodality approach combining complete peritoneal CRS plus HIPEC, systemic chemotherapy, and targeted therapy may be the best treatment option for PM from colorectal cancer.

Evaluation of a new staging classification and a Peritoneal Surface Disease Severity Score (PSDSS) in 229 patients with mucinous appendiceal neoplasms with or without peritoneal dissemination.

Most classifications of mucinous appendiceal neoplasms (MAN) do not take into consideration the type of primary tumor or the burden of peritoneal disease. We conducted a retrospective evaluation of 229 patients with MAN. The severity of their disease was analyzed with the Peritoneal Surface Disease Severity Score (PSDSS) on a five-point scale that included: (1) the primary appendiceal tumor, (2) the type of peritoneal dissemination, and (3) the burden of disease. Overall survival was analyzed according to five tiers of estimated disease severity based on the above parameters. There were 19, 67, 59, 43, and 41 patients with PSDSS 0, I, II, III, and IV, respectively. One hundred seventy-three patients underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Overall survival was 80.0 months in this group with 5-year survival of 100%, 79.2%, 23.3%, and 6.9% in patients with PSDSS I, II, III, and IV, respectively (P < 0.001). On multivariate analysis, sex and PSDSS stage were identified as independent predictors of survival. The PSDSS appears to be an important prognostic indicator in patients with MANs with or without peritoneal dissemination and may improve selection of patients for appropriate therapy from the time of diagnosis.

Peritoneal Surface Disease Severity Score as a predictor of resectability in the treatment of peritoneal surface malignancies

BackgroundWe evaluated the clinical utility of the Peritoneal Surface Disease Severity Score (PSDSS) as a preoperative predictor of resectability in the treatment of peritoneal surface malignancies. MethodsForty-nine patients were selected for cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) and were stratified according to the PSDSS retrospectively. ResultsOf 52 cytoreductive surgeries performed in 49 patients, HIPEC was performed in 33 cases (63%). We analyzed 31 cases of appendiceal and colorectal cancer patients who underwent CRS and HIPEC and 12 who underwent CRS only. 68% of the patients in whom CRS and HIPEC was performed were classified as PSDSS stage I or II. Contrastingly, all patients in whom CRS and HIPEC was unachievable were scored as PSDSS stage III or IV. ConclusionsThe outcomes of this study suggest that the PSDSS can be used as a preoperative assessment tool to predict disease resectability in the treatment of peritoneal surface malignancies.

Comparison of Prognostic Scores for Patients with Colorectal Cancer Peritoneal Metastases Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

There are three prognostic scores for the cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) treatment of colorectal cancer peritoneal metastases: the newly introduced COREP (colorectal peritoneal) score, the peritoneal surface disease severity score (PSDS), and the prognostic score (PS). The aim was to determine which prognostic score had the best prognostic value. Between 2006 and 2010, a total of 77 patients with peritoneal metastases from colorectal cancer underwent CRS/HIPEC treatment. The COREP, PSDS, and PS scores were successfully applied to 56 patients (73 %) having sufficient data. The end points were prediction of open-and-close cases (n = 9), R1 resections (n = 41), and survival of <12 months (n = 18). Area under the receiver operating characteristic curves (accuracy) was compared. Subgroup analysis was performed on patients not previously used for the development of the COREP score (n = 24). Multivariable logistic regressions of the three end points were performed as well as Cox regression for overall survival. Furthermore, COREP and peritoneal cancer index were compared. For open-and-close case prediction, accuracy for the whole group (n = 56) and subgroup (n = 24) was 87 and 88 %, respectively for COREP; 66 and 77 % for PSDS; and 68 and 78 % for PS. For R1 resection prediction, accuracy was 81 and 81 %, 76 and 78 %, and 75 and 77 %, respectively. For prediction of survival of <12 months, accuracy was 83 and 84, 54 and 67 %, and 55 and 56 %, respectively. The COREP score was the only independent prognostic factor in all four multivariable analyses. A COREP score of ≥6 identified patients with poor survival more accurately than a PCI of >20. The COREP score predicted open-and-close cases, R1 resections, and poor survival better than PSDS and PS. COREP better identifies patients with poor survival than intraoperative PCI.

Assessment of clinical benefit and quality of life in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for management of peritoneal carcinomatosis.

Peritoneal carcinomatosis (PC) is a challenging problem with poor prognosis. Survival even with the current standard chemotherapy is dismal. Cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC) in appropriately selected patients may offer significant survival benefit. In the review article entitled “Assessment of Clinical benefit and quality of life in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for management of peritoneal carcinomatosis” authors provide a comprehensive review of the available data related to the morbidity, mortality, survival and quality of life with CRS and HIPEC for the management of peritoneal carcinomatosis (1). Several retrospective studies have shown the feasibility and benefit of CRS and HIPEC in the management of various peritoneal surface malignancies (2,3). Although clinical utility of CRS and HIPEC in the management of mesothelioma and peritoneal dissemination of appendiceal malignancies is widely accepted, its role in colorectal cancer peritoneal carcinomatosis has been heavily debated. Randomized controlled trial by Veerwal et al. demonstrated a survival benefit of 9 months for patients with colorectal peritoneal carcinomatosis treated with CRS and HIPEC followed by 5-FU chemotherapy compared to palliative surgery and 5-FU chemotherapy (4). Furthermore, patients who underwent complete cytoreduction had a 5-year survival rate of 45%, which favorably compares to the reported survival for colorectal hepatic metastasectomy. Despite these promising results skepticism still exists, as the patients in the control arm of the trial did not receive current standard chemotherapy. However, recent studies utilizing current standard chemotherapy with or without biologic agents have reported a median overall survival of 10-15 months in patients with colorectal peritoneal carcinomatosis (5,6). These results underscore the decreased efficacy of systemic treatment in the setting of PC, when feasible CRS and HIPEC should be considered as the standard treatment for patients with colorectal cancer peritoneal carcinomatosis. As described in the review article cytoreductive surgery is a major surgical procedure with significant morbidity. However, in appropriately selected patients the risk-benefit ratio favors an aggressive treatment approach. Extent of peritoneal dissemination, measured as peritoneal cancer index (PCI) and the completeness of cytoreduction have been indisputably shown to be major predictors of outcome (7). Patient selection is a challenging task, as the risk-benefit ratio is influenced by multiple factors. In addition, the ability to accurately estimate the extent of peritoneal dissemination and predicting the chances of complete cytoreduction is far from perfect. Esquivel and Pelz have proposed a peritoneal surface disease severity (PSDS) scoring system based on symptoms, extent of disease and histology to stratify patients with colon cancer peritoneal carcinomatosis into different prognostic groups that may aid in patient selection for different treatment (8). The risk-benefit ratio for CRS and HIPEC not only depends on the ability to achieve complete cytoreduction but on the biologic aggressiveness of the tumor, which is heavily weighed into the PSDS score. Multi-institutional prospective validation studies are required to assess the clinical utility of the PSDS scoring system. Finally, the importance of measurement of health related quality of life (HRQoL) cannot be overemphasized in patients undergoing CRS and HIPEC. The authors have provided a comprehensive review of the available scoring systems and the data for QoL. Most studies report a decrease in the quality of life up to six months after CRS and HIPEC, with improvement in majority of patients at one year. This should be taken into consideration while counseling patients about the outcomes of CRS and HIPEC. In summary, management of patients with peritoneal carcinomatosis is complex and requires a multidisciplinary approach. Proper patient selection for CRS and HIPEC based on favorable risk-benefit ratio is of utmost importance. Management should focus on both cancer-specific outcomes and quality of life.