Resection Of Peritoneal Metastases Research Articles

Clinical Impact of Radical Resection of Synchronous and Metachronous Peritoneal Metastases from Colorectal Cancer.

According to some case series, patients with colorectal cancer (CRC) who underwent radical resection of synchronous peritoneal metastases (PM) with the primary tumor had better survival than patients who underwent non-surgical treatment. However, little evidence exists regarding the significance of radical resection for metachronous PM. This study aimed to evaluate the clinical significance of surgical intervention for isolated PM from CRC, with a particular focus on time to PM. A total of 74 consecutive patients with isolated PM from CRC, including 40 and 34 patients with synchronous and metachronous PM, respectively, treated between 2007 and 2018 were retrospectively analyzed. The primary outcome measure was overall survival (OS) from diagnosis, and the OS was compared between radical resection and palliative chemotherapy. Five-year OS was 39.7% for all patients. Patients with radical resection had significantly better 5-year OS compared with those with palliative chemotherapy (62.8% vs. 11.0%; p<0.0001). According to time to PM, patients with radical resection had significantly better 5-year OS compared with those with palliative chemotherapy for both synchronous PM (47.6% vs. 0%; p=0.019) and metachronous PM (77.2% vs. 15.2%; p<0.0001). Multivariable analysis stratified by time to PM revealed that surgical intervention is a significant favorable prognostic factor only in patients with metachronous PM (hazard ratio 0.117, 95% confidence interval 0.020-0.678; p=0.017). Patients with radical resection of PM had good survival compared with those with chemotherapy alone, especially for metachronous PM. Surgical intervention should be considered for isolated metachronous PM when radical resection is feasible.

Defining optimal selection criteria to improve prognosis and avoid futility in surgical resection of colorectal peritoneal metastases.

36 Background: Surgical resection of peritoneal metastases of colorectal cancer (CRC PM) may benefit some patients similar to hepatic metastases. This approach remains controversial in part due to inconsistent selection criteria and reported outcomes. The impact of preoperative clinical characteristics and tumor molecular profiles on survival among surgically treated patients is incompletely understood. The aim of this study was to investigate the relationship between possible predictive variables and survival in a large cohort of patients treated on a standardized clinical pathway and to develop a clinically useful patient selection tool. Methods: This retrospective cohort study utilized the database of the Catalonian peritoneal metastases regional program, established in 2006. The program provides treatment for all PM patients within an autonomous region with a population of 7.5 million and includes a single dedicated high volume surgical unit. We included all adult patients with surgically resected CRC PM. The clinical pathway includes the administration of perioperative (neoadjuvant and adjuvant) systemic chemotherapy and has historically included a dose of heated intraoperative intraperitoneal chemotherapy (HIPEC) at the time of surgery. Demographic and clinical data was analyzed with descriptive statistics. Survival and the associated predictors were analyzed with the Cox proportional hazard model with HRs used to create a predictive nomogram. Results: A total of 538 patients (mean age 59) have been treated with surgery and a complete resection (CC0) was achieved in 94% of cases. Planned preoperative systemic chemotherapy was delivered in 95% of cases, consistent with the clinical pathway. Surgical morbidity was low (urgent reoperation 6.1%, postoperative return to the ICU 2.4%, 30-day readmission 4.3%) as was 30-day mortality (0.4%). After a median follow up of 27.5 months, the median overall survival (OS) was 43.1 months. It varied considerably by subgroup: patients with low peritoneal tumor burden had the highest OS (median 49 months) and those with signet ring cell subtype the lowest (median 19 months). Factors independently associated with survival were: N stage at diagnosis, histological subtype, quantified peritoneal tumor burden (PCI score) and presence of visceral involvement. A selection tool and predictive nomogram were designed incorporating the results of the multivariable analysis. Conclusions: A set of clinical variables can be identified that independently influences patient survival after surgical resection of CRC PM that should be used as selection criteria when considering surgery. With optimized patient selection and treatment within a specialized center, excellent survival and low morbidity can be anticipated following surgery for CRC PM.

Results of a phase II randomized study evaluating the potential benefit of a postoperative intraperitoneal immunotherapy after resection of peritoneal metastases from gastric carcinoma metastases (IIPOP- NCT01784900).

4064 Background: Prognosis of patients with peritoneal extension from gastric carcinoma remains poor. The aim of this multicentre, open-label, phase 2 randomized study was to analyze the potential survival benefit of an immediate postoperative intraperitoneal immunotherapy using a bi-specific (anti-EpCAM, anti-CD3), trifonctional agent named catumaxomab. Methods: Patients with limited synchronous carcinomatosis from gastric carcinoma (Peritoneal cancer index (PCI) ≤ 12), were treated after complete resection (gastrectomy plus all peritoneal deposits), by an intraperitoneal infusion of catumaxomab during 5 days. Patients were randomized between 2 arms according to the total doses administered of catumaxomab (100µg vs 140µg). The first end-point was the 2-year overall survival (OS). Forty randomized patients were required (20 in each arm), considering that a 2-year OS rate ≤ 30% would be considered as unacceptable, and ≥ 55%, a promising survival rate. The study was stopped prematurely due to the manufacturing stop of the catumaxomab. Results: Between March 2013 and September 2014, 26 patients were included in the study; among them, 11 were randomized, with a median PCI of 9 [1-12]. Seven patients received the whole planned treatment of catumaxomab; in the remaining 4 patients, interruptions were related to postoperative complications. One patient died postoperatively of multiorgan failure and grade 3-5 complications occurred in all the patients, without difference between the 2 groups. At the end of the follow-up, 3 were alive (25, 30, 36 months). The median OS was 19 months, and the 1 and 2- year OS rates were 63.6% and 36.4% respectively. Conclusions: This study has to be stopped prematurely; however, encouraging results regarding overall survival were observed. Intraperitoneal immunotherapy represents an innovative and promising treatment in patients with peritoneal metastases, considering the poor response to systemic chemotherapy and the “immunocompetence” of the peritoneum. The evaluation of a potential benefit of a local immunotherapy has to be pursued. Clinical trial information: NCT01784900.

Resection of peritoneal metastases in patients with hepatocellular carcinoma

Peritoneal metastases from hepatocellular carcinoma are common; they are found in as many as 18% of autopsy cases. Effective treatment for peritoneal metastases, however, has not yet been established. We resected peritoneal metastases 12 times in 9 patients with hepatocellular carcinoma. We assessed the clinical course and outcome of these patients to determine the effectiveness of resecting peritoneal metastases and the factors related to survival. The 1-, 3-, and 5-year survival rates were 58%, 52%, and 42%, respectively. Four patients survived for longer than 2 years without recurrence or with controlled recurrence confined to the liver. Three patients receiving palliative resection had a poor prognosis, with survivals of only 4, 9, and 12 months. Operative resection should be an option for selected patients with peritoneal metastases from hepatocellular carcinoma. Resection of peritoneal metastases should be considered in patients whose primary liver neoplasm is under control and who have no metastases in other organs.

Long-term survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy compared with hepatic resection for metastatic colorectal cancer.

630 Background: Surgical resection of peritoneal metastases (PM) from colorectal cancer has been reported to yield outcomes similar to liver resection for hepatic metastases (HM). However recent data suggests PM may have a worse prognosis than other metastatic sites. Methods: A review of metastatic colorectal cancer patients obtained from prospective databases (1992-2010) comparing liver resection for HM to cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for PM. Results: 181 patients underwent hepatic resection and 182 patients underwent CS/HIPEC with a median follow-up of 55 and 106 months respectively. A margin-negative resection was obtained in 168 (93%) hepatic resections, while 89 patients (49%) with PM had complete cytorection of all gross disease (R0/R1). A comparison of these two groups demonstrated significant differences in age, pre-operative chemotherapy and performance status. Disease-free median survival was 15.2 months after hepatic resection and 9.9 months after CS/ HIPEC (p=0.02). The 5-year overall survival (OS) for HM patients was 33% with a median OS of 45.0 months; while 5-year OS was 23% and median OS was 32.3 months for PM patients (p=0.02). In a proportional hazards regression model, performance status and pre-operative chemotherapy had no significant effect on survival, while increased age (p=0.02) and PM (p=0.03) were associated with decreased OS. Postoperative morbidity was 38% versus 51% (p=0.04) and mortality was 3.0% versus 2.3% (p=0.73) in the HM and PM groups, respectively. Conclusions: Disease-free survival and OS are worse for patients who received complete cytoreduction and CS/HIPEC for PM compared to margin-negative liver resection for HM suggesting a more aggressive tumor biology in PM.

Laparoscopic nephroureterectomy for Wilms' tumor: Oncologic considerations

Wilms' tumor is the most common malignant renal tumor of childhood. Surgical resection is an important aspect of therapy and is traditionally performed through an open transabdominal approach. The advent of advanced laparoscopic techniques for benign renal lesions has led to interest in applying a minimally invasive approach to Wilms' tumors in children. We describe a 2-year-old girl who presented with a right renal mass measuring 18 × 13 cm with peritoneal seeding and pulmonary metastatic disease. Wilms' tumor was confirmed on open biopsy. After neoadjuvant chemotherapy, a laparoscopic resection of the tumor with right radical nephroureterectomy, retroperitoneal lymph node dissection, and resection of peritoneal metastases was achieved using one 12-mm and four 5-mm ports. The specimens were removed in an endoscopic retrieval bag through a small Pfannenstiel incision by extending the 12-mm port site. The patient had an uncomplicated recovery and was discharged on the fifth post-operative day. She remains disease free at 19 months postoperatively. Minimally invasive techniques may be considered for resection of Wilms' tumor provided oncologic principles are carefully followed.