Simplified Peritoneal Cancer Index Research Articles

The effect of metastasis location on outcome after cytoreductive surgery and heated intraperitoneal chemotherapy.

ObjectivesThis study aims to evaluate how metastases in the seven topographical regions of the simplified peritoneal cancer index (sPCI) affect the survival of patients treated with cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC) from colorectal (CRC) or appendiceal cancers.MethodsData was collected retrospectively from patient records. Abdominal regions affected by PC were identified using the histological verification of surgically removed tumours found in the electronic pathology report. Verified tumours were grouped according to the sPCI topography.ResultsOne hundred and eighty-three patients treated with CRS and HIPEC were included. Metastases in the small bowel had a negative impact on survival with a hazard ratio of 1.89 (p=0.005). A significantly impaired survival was also detected for patients affected by metastases in the ileocolic region (p=0.01) and in the omentum and spleen (p=0.04).ConclusionsWhen selecting patients for CRS and HIPEC a more cautious approach may be applied by considering the regions affected.

A new internet tool to report peritoneal malignancy extent. PeRitOneal MalIgnancy Stage Evaluation (PROMISE) application

Based on the importance of assessing the true extent of peritoneal disease, PeRitOneal MalIgnancy Stage Evaluation (PROMISE) internet application (www.e-promise.org) has been developed to facilitate tabulation and automatically calculate surgically validated peritoneal cancer index (PCI), and other surgically validated scores as Gilly score, simplified peritoneal cancer index (SPCI), Fagotti and Fagotti-modified scores. This application offers computer-assistance to produce simple, quick but precise and standardized pre, intra and postoperative reports of the extent of peritoneal metastases and may help specialized and non-specialized institutions in their current practice but also facilitate research and multicentre studies on peritoneal surface malignancies.

Outcomes of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion in Patients with High-Grade, High-Volume Disseminated Mucinous Appendiceal Neoplasms.

High-grade (HG) mucinous appendiceal neoplasms (MAN) have a worse prognosis than low-grade histology. Our objective was to assess the safety and efficacy of cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (CRS/HIPEC) in patients with high-grade, high-volume (HG-HV) peritoneal metastases in whom the utility of this aggressive approach is controversial. Prospectively collected perioperative data were compared between patients with peritoneal metastases from HG-HV MAN, defined as simplified peritoneal cancer index (SPCI) ≥12, and those with high-grade, low-volume (HG-LV; SPCI <12) disease. Kaplan-Meier curves and multivariate Cox regression models identified prognostic factors affecting oncologic outcomes. Overall, 54 patients with HG-HV and 43 with HG-LV peritoneal metastases underwent CRS/HIPEC. The HG-HV group had longer operative time, increased blood loss/transfusion, and increased intensive care unit length of stay (p < 0.05). Incomplete macroscopic cytoreduction (CC-1/2/3) was higher in the HG-HV group compared with the HG-LV group (68.5 vs. 32.6 %; p = 0.005). Patients with HG-HV disease demonstrated worse survival than those with HG-LV disease (overall survival [OS] 17 vs. 42 m, p = 0.009; time to progression (TTP) 10 vs. 14 m, p = 0.024). However, when complete macroscopic resection (CC-0) was achieved, the OS and progression-free survival of patients with HG-HV disease were comparable with HG-LV disease (OS 56 vs. 52 m, p = 0.728; TTP 20 vs. 19 m, p = 0.393). In a multivariate Cox proportional hazard regression model, CC-0 resection was the only significant predictor of improved survival for patients with HG-HV disease. Although patients with HG-HV peritoneal metastases from MAN have worse prognosis compared with patients with HG-LV disease, their survival is comparable when complete macroscopic cytoreduction is achieved.

Institutional learning curve of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for peritoneal malignancies.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemoperfusion (HIPEC) is routinely used to treat certain peritoneal carcinomatoses (PC), but it can be associated with relatively high complication rates, prolonged hospital length of stay, and potential mortality. Our objective was to determine the learning curve (LC) of CRS/HIPEC in our high-volume institution. A total of 370 patients with PC from mucinous appendiceal neoplasms (MAN=282), malignant peritoneal mesothelioma (MPM=60), and gastric cancer (GC=24) were studied. Outcomes analyzed included incomplete cytoreduction (IC), severe morbidity (SM), 60-day mortality, progression-free survival (PFS), and overall survival (OS). Risk-adjusted sequential probability ratio test (RA-SPRT) was employed to assess the LC of CRS/HIPEC for IC and SM using prespecified odds ratio (OR) boundaries derived from previously published data. Risk adjusted-cumulative average probability (RA-CAP) was used to analyze 1-year PFS and 2-year OS. Complete cytoreduction, severe morbidity, and 60-day mortality were84.2, 30, and 1.9% respectively. Higher simplified peritoneal cancer index was the major independent risk factor for IC, whereas high-grade histology, IC, and diagnosis of MPM and GC (compared with MAN) were predictors of SM after CRS/HIPEC (p<0.05). RA-SPRT showed that approximately 180 cases are needed to achieve the lowest risk of IC and SM. Ninety cases were needed to achieve a steady 1-year PFS and 2-year OS in RA-CAP plots. The completeness of cytoreduction, morbidity, and mortality rates for CRS/HIPEC at our institution are comparable to previously reported data. Approximately 180 and 90 procedures are required to improve operative and oncologic outcomes respectively.

Malignant Peritoneal Mesothelioma: Prognostic Factors and Oncologic Outcome Analysis

Most patients with malignant peritoneal mesothelioma (MPM) present with late-stage, unresectable disease that responds poorly to systemic chemotherapy while, at the same time, effective targeted therapies are lacking. We assessed the efficacy of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) in MPM. We prospectively analyzed 65 patients with MPM undergoing CRS/HIPEC between 2001 and 2010. Kaplan-Meier survival curves and multivariate Cox-regression models identified prognostic factors affecting oncologic outcomes. Adequate CRS was achieved in 56 patients (CC-0 = 35; CC-1 = 21), and median simplified peritoneal cancer index (SPCI) was 12. Pathologic assessment revealed predominantly epithelioid histology (81 %) and biphasic histology (8 %), while lymph node involvement was uncommon (8 %). Major postoperative morbidity (grade III/IV) occurred in 23 patients (35 %), and 60-day mortality rate was 6 %. With median follow-up of 37 months, median overall survival was 46.2 months, with 1-, 2-, and 5-year overall survival probability of 77, 57, and 39 %, respectively. Median progression-free survival was 13.9 months, with 1-, 2-, and 5-year disease failure probability of 47, 68, and 83 %, respectively. In a multivariate Cox-regression model, age at surgery, SPCI >15, incomplete cytoreduction (CC-2/3), aggressive histology (epithelioid, biphasic), and postoperative sepsis were joint significant predictors of poor survival (chi square = 42.8; p = 0.00001), while age at surgery, SPCI >15, incomplete cytoreduction (CC-2/3), and aggressive histology (epithelioid, biphasic) were joint significant predictors of disease progression (Chi square = 30.6; p = 0.00001). Tumor histology, disease burden, and the ability to achieve adequate surgical cytoreduction are essential prognostic factors in MPM patients undergoing CRS/HIPEC.

Influence of blood neutrophil to lymphocyte ratio on oncologic outcomes in peritoneal carcinomatosis of appendiceal origin.

e14184 Background: The Neutrophil to lymphocyte ratio (NLR), a marker of systemic inflammatory response, is associated with prognosis in various cancers. The aim of this study is to evaluate the association of pre-operative NLR with oncologic outcomes in patients with appendiceal carcinomatosis. Methods: Clinico-pathological data were obtained from a prospectively maintained database of patients with appendiceal carcinomatosis who underwent cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemoperfusion (HIPEC) between 2001 and 2010. Pre-operative absolute neutrophil and lymphocyte counts were used to compute NLR, with elevated NLR defined a priori as &gt;5. Logistic regression modeling and Kaplan-Meier analyses were performed on the available data. Results: 195 patients, with a median age of 54.5 years, underwent CRS and HIPEC. The median follow up time was 1.96 years. There were 41 patients (21%) who had elevated NLR preoperatively. Factors associated with overall survival (OS) were grade (p=0.01), simplified peritoneal cancer index (SPCI) (p=0.013), and age (p=0.02). In patients who did not undergo splenectomy at the time of CRS, elevated NLR, lymph node involvement, SPCI, age and pre-operative albumin were statistically significant predictors of OS on multivariable analysis. None of these factors were significant in patients who underwent splenectomy at the time of CRS. The 5-year overall survival was 57% vs. 31% in patients with NLR&lt;5 compared to NLR&gt;5 respectively (p&lt;0.0001). Time to progression was 30 months compared to 14 months in patients with NLR&lt;5 vs. &gt;5 (p=0.001). Strikingly, the 5-year OS in patients with NLR&lt;5 with or without splenectomy was 63% and 50% compared to patients with NLR&gt;5 with or without splenectomy 37.5% vs. 23%, respectively (p=0.0001). Conclusions: In patients with appendiceal carcinomatosis, pre-operative NLR is a potential systemic inflammatory marker that independently predicts oncologic outcomes. The impact of NLR appears to be influenced by the performance of splenectomy at the time of CRS. Further studies will be required to prospectively validate this systemic inflammatory marker and its interaction with splenectomy.

Aggressive Management of Peritoneal Carcinomatosis from Mucinous Appendiceal Neoplasms

Peritoneal carcinomatosis (PC) in the setting of mucinous appendiceal neoplasms is characterized by the intraperitoneal accumulation of mucinous ascites and mucin-secreting epithelial cells that leads to progressive compression of intra-abdominal organs, morbidity, and eventual death. We assessed postoperative and oncologic outcomes after aggressive surgical management by experienced surgeons. We analyzed clinicopathologic, perioperative, and oncologic outcome data in 282 patients with PC from appendiceal adenocarcinomas between 2001 and 2010 from a prospective database. Kaplan–Meier survival curves and multivariate Cox-regression models were used to identify prognostic factors affecting oncologic outcomes. Adequate cytoreduction was achieved in 82% of patients (completeness of cytoreduction score (CC)-0: 49%; CC-1: 33%). Median simplified peritoneal cancer index (SPCI), operative time, and estimated blood loss were 14 (range, 0–21), 483.5 min (range, 46–1,402), and 800 ml (range, 0–14,000), respectively. Pathology assessment demonstrated high-grade tumors in 36% of patients and lymph node involvement in 23% of patients. Major postoperative morbidity occurred in 70 (25%) patients. Median overall survival was 6.72 years (95% confidence interval (CI), 4.17 years not reached), with 5 year overall survival probability of 52.7% (95% CI, 42.4, 62%). In a multivariate Cox-regression model, tumor grade, age, preoperative SPCI and chemo-naïve status at surgery were joint significant predictors of overall survival. Tumor grade, postoperative CC-score, prior chemotherapy, and preoperative SPCI were joint significant predictors of time to progression. Aggressive management of PC from mucinous appendiceal neoplasms, by experienced surgeons, to achieve complete cytoreduction provides long-term survival with low major morbidity.

Quantitative intra-operative assessment of peritoneal carcinomatosis – A comparison of three prognostic tools

Aims Selecting patients for cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (HIPEC) remains challenging. We compared the predictive power of three intra-operative assessment tools of peritoneal involvement of colorectal cancer. Methods Ninety-two procedures (1999–2005) were prospectively scored using the Simplified Peritoneal Cancer Index (SPCI) and 7 Region Count. The Peritoneal Cancer Index (PCI) was retrospectively scored using the SPCI tool, operative notes and pathological reports. Endpoints were completeness of cytoreduction and overall survival. Logistic regression and Receiver Operating Characteristic (ROC) curves were applied to compare the predictive value of the three scoring systems on completeness of cytoreduction. Results After a median follow-up of 31 months, the median overall survival was 25.6 months. It decreased to 7.3 months, when cytoreduction was incomplete ( p = 0.001). An increased PCI, SPCI or number of regions were all associated with a decrease in probability of complete cytoreduction ( p < 0.05). With complete cytoreduction as outcome, the ROC areas for the PCI, SPCI and 7 Region Count were 0.92, 0.94 and 0.90, respectively ( p = 0.14). Using a cut-off value of 16 in the PCI system ( p = 0.03), 13 in the SPCI system ( p = 0.04) and 6 regions in the 7 Region Count ( p = 0.0002) the probability of complete cytoreduction decreased significantly. Conclusion The PCI, SPCI and 7 Region Count are useful and equally effective prognostic tools predicting completeness of cytoreduction and associated improved survival. The 7 Region Count may be preferred due to its practical simplicity.

Learning curve of combined modality treatment in peritoneal surface disease

Cytoreductive surgery with intraperitoneal chemotherapy has emerged as a new standard approach for peritoneal surface disease. This study investigated the learning curve of this combined modality treatment at a single institute. Variables analysed over three consecutive treatment periods (1996-1998, 1999-2002 and 2003-2006) included number of abdominal regions affected, Simplified Peritoneal Cancer Index (SPCI) score, result of cytoreduction, morbidity, duration of hospital stay and survival. A total of 323 procedures were performed between January 1996 and June 2006, 184 for peritoneal carcinomatosis of colorectal cancer origin and 139 for pseudomyxoma peritonei (PMP), including second procedures in 11 patients with PMP. The mean SPCI score decreased significantly over the study period (P < 0.001), but the number of regions affected did not. The rate of complete cytoreductions increased from 35.6 to 65.1 per cent (P = 0.012). The postoperative morbidity rate decreased from 71.2 to 34.1 per cent (P < 0.001). The median duration of hospital stay decreased from 24 to 17 days. The peak of the learning curve, graded by the percentage of complete cytoreductions, was reached after approximately 130 procedures. The learning curve of combined modality treatment for peritoneal surface disease is long, and reflects patient selection and treatment expertise.

Preoperative computed tomography and selection of patients with colorectal peritoneal carcinomatosis for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Aim A survival benefit has been observed for colorectal cancer patients with peritoneal carcinomatosis treated by cytoreductive surgery with intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). However, this treatment modality is associated with a considerable morbidity and mortality and in a significant number of patients survival is not improved. We studied whether poor survivors could be identified on preoperative computed tomography (CT), in order to avoid unnecessary surgery. Patients and methods Films of abdominopelvic CT scans from 25 such patients treated by cytoreductive surgery and HIPEC were retrospectively analysed by two radiologists separately. A simplified peritoneal cancer index (SPCI) was used to determine the extent of peritoneal involvement. Correlation between the on preoperative CT based SPCI-scores as well as number of involved abdominopelvic areas ( N) and survival was examined with the log-rank test. The relation between each affected region and survival was evaluated with Cox regression analysis. Results The preoperative SPCI- and N-scores of one of the radiologists had no statistically significant prognostic value, while for the second radiologist SPCI≥7 and N≥4 were associated with particularly poor outcome. Additionally, the presence of ileocaecal region involvement and, depending on the radiologist, the occurrence of tumour deposits in the left subdiaphragmatic area on CT appeared to be unfavourable prognostic signs. Conclusions The prognostic value of preoperative conventional CT appeared to be radiologist dependent and may, therefore, be of limited value in selecting colorectal cancer patients with peritoneal carcinomatosis who will not benefit from extensive cytoreductive surgery followed by HIPEC.

Prognostic indicators in peritoneal carcinomatosis from gastrointestinal cancer

Peritoneal carcinomatosis from gastrointestinal cancer has new treatment options for surgical management. The approach uses cytoreductive surgery which combines peritonectomy and visceral resection in an effort to remove all visible cancer within the abdomen and pelvis. Then the peritoneal cavity is flooded with chemotherapy solution in an attempt to eradicate residual disease. In order to select patients for this approach the quantitative prognostic indicators for carcinomatosis were reviewed, compared and contrasted. Prognostic indicators to be used to select patients for this aggressive approach at the initiation of surgery and after completion of cytoreduction were studied. Four quantitative assessments to be used at the time of abdominal exploration were the Gilly staging, Japanese gastric cancer P score, peritoneal cancer index (PCI), and the simplified peritoneal cancer index (SPCI). All have value with the PCI being the most validated and most precise. Preoperative assessments include the tumor histopathology and the prior surgical score. The completeness of cytoreduction score is an assessment of residual disease after a maximal surgical effort. An opportunity for long-term survival following treatment for carcinomatosis requires a complete cytoreduction in all reports for gastrointestinal cancer. Quantitative prognostic indicators need to be knowledgeably employed when patients with carcinomatosis are being treated. Improved patient selection with greater benefit and reduced morbidity and mortality should result.