Surgical Cytoreduction In Patients Research Articles

ASO Visual Abstract: Value of Surgical Cytoreduction in Patients with Small Intestinal Neuroendocrine Tumors Metastatic to the Liver and Peritoneum.

ASO Visual Abstract: Value of Surgical Cytoreduction in Patients with Small Intestinal Neuroendocrine Tumors Metastatic to the Liver and Peritoneum.

Value of Surgical Cytoreduction in Patients with Small Intestinal Neuroendocrine Tumors Metastatic to the Liver and Peritoneum.

Cytoreductive hepatectomy can improve survival and symptoms of hormonal excess in patients with small intestinal neuroendocrine tumor (siNET) liver metastases, but whether to proceed when peritoneal metastases are encountered at the time of planned cytoreductive hepatectomy is controversial. This was a retrospective review of patients who underwent surgical management of metastatic siNETs at Mayo Clinic between 2000 and 2020. Patients who underwent cytoreductive operation for isolated liver metastases or both liver and peritoneal metastases were compared. Of 261 patients who underwent cytoreductive operation for siNETs, 211 had isolated liver metastases and 50 had liver and peritoneal metastases. Complete cytoreduction was achieved in 78% of patients with isolated liver metastases and 56% of those with liver and peritoneal metastases (p = 0.002). After complete cytoreduction, median overall survival (OS) was 11.5 years for isolated liver metastases and 11.2 years for liver and peritoneal metastases (p = 0.10), and relief of carcinoid syndrome was ≥ 97% in both groups. After incomplete cytoreduction with debulking of > 90% of hepatic disease and/or closing Lyon score of 1-2, median OS was 6.4 years for isolated liver metastases and 7.1years for liver and peritoneal metastases (p = 0.12). Patients with siNETs metastatic to both the liver and peritoneum have favorable outcomes after aggressive surgical cytoreduction, with the best outcomes observed after complete cytoreduction. Therefore, the presence of peritoneal metastases should not by itself preclude surgical cytoreduction in this population.

GECOP-MMC: phase IV randomized clinical trial to evaluate the efficacy of hyperthermic intraperitoneal chemotherapy (HIPEC) with mytomicin-C after complete surgical cytoreduction in patients with colon cancer peritoneal metastases

BackgroundThe French PRODIGE 7 trial, published on January 2021, has raised doubts about the specific survival benefit provided by HIPEC with oxaliplatin 460 mg/m2 (30 minutes) for the treatment of peritoneal metastases from colorectal cancer. However, several methodological flaws have been identified in PRODIGE 7, specially the HIPEC protocol or the choice of overall survival as the main endpoint, so its results have not been assumed as definitive, emphasizing the need for further research on HIPEC. It seems that the HIPEC protocol with high-dose mytomicin-C (35 mg/m2) is the preferred regime to evaluate in future clinical studies.MethodsGECOP-MMC is a prospective, open-label, randomized, multicenter phase IV clinical trial that aims to evaluate the effectiveness of HIPEC with high-dose mytomicin-C in preventing the development of peritoneal recurrence in patients with limited peritoneal metastasis from colon cancer (not rectal), after complete surgical cytoreduction. This study will be performed in 31 Spanish HIPEC centres, starting in March 2022. Additional international recruiting centres are under consideration. Two hundred sixteen patients with PCI ≤ 20, in which complete cytoreduction (CCS 0) has been obtained, will be randomized intraoperatively to arm 1 (with HIPEC) or arm 2 (without HIPEC). We will stratified randomization by surgical PCI (1–10; 11–15; 16–20). Patients in both arms will be treated with personalized systemic chemotherapy. Primary endpoint is peritoneal recurrence-free survival at 3 years. An ancillary study will evaluate the correlation between surgical and pathological PCI, comparing their respective prognostic values.DiscussionHIPEC with high-dose mytomicin-C, in patients with limited (PCI ≤ 20) and completely resected (CCS 0) peritoneal metastases, is assumed to reduce the expected risk of peritoneal recurrence from 50 to 30% at 3 years.Trial registrationEudraCT number: 2019–004679-37; Clinicaltrials.gov: NCT05250648 (registration date 02/22/2022, ).

The correlation between BRCA status and surgical cytoreduction in high-grade serous ovarian carcinoma

<h3>Objectives:</h3> BRCA-associated ovarian cancers are biologically unique, as evident by differential molecular and clinical behaviour of these tumor as compared to sporadic ovarian cancers. It is unclear if these biological differences translate to favorable outcomes at the time of primary cytoreduction. The aim of this study is to compare the amount of residual disease after primary cytoreduction in <i>BRCA</i> mutated and wildtype populations, and to assess whether <i>BRCA</i> status is an independent predictor of optimal cytoreduction. <h3>Methods:</h3> We conducted a retrospective analysis of patients with high-grade serous (HGSC) ovarian cancers with known germline and somatic <i>BRCA</i> mutation status, treated with primary cytoreductive surgery from 2000 to 2017. Post-operative <i>BRCA</i> germline and somatic testing was conducted in all cases. We compared the complete, optimal and suboptimal cytoreduction rates between the <i>BRCA</i> positive and the <i>BRCA</i> negative cohorts and built a predictive model to assess whether the <i>BRCA</i> status was associated with the amount of residual disease after controlling for confounding variables. <h3>Results:</h3> Of 355 women with HGSC ovarian cancers treated with primary cytoreduction, 144 harbored germline or somatic <i>BRCA</i> mutations (41%) and 211 were <i>BRCA</i> wildtype (59%). <i>BRCA</i> positive women tended to be younger (54 vs 59; p<0.001), but there were no differences between the two groups in preoperative CA-125 levels, disease burden (measured by disease score), surgical complexity score, stage distributions, length of surgery, intraoperative or postoperative complications. Comparing residual disease burden at the end of primary cytoreduction, the <i>BRCA</i> positive group had a higher rate of complete cytoreduction to no residual disease (0mm) [75% vs 54%], and a lower rate of optimal cytoreduction (1-9mm) [16% vs 34%] or suboptimal cytoreduction (≥10mm) [9% vs. 12%] (p<0.001). In our predictive model, after accounting for length of surgery, CA-125 level, stage distributions, disease scores and surgical complexity scores, <i>BRCA</i> positive status was predictive of complete cytoreduction to 0mm residual disease with odds ratio (OR) of 4.78 (95% CI 2.32-9.85; p<0.001). Subgroup analysis restricted to patients with stage III/IV HGSC showed similar results, with <i>BRCA</i> positive status having OR of 5.2 (95% CI 2.44-11.09; p<0.001) for complete primary cytoreduction. <h3>Conclusions:</h3> <i>BRCA</i> status is predictive of complete and optimal cytoreduction at the time of primary surgical cytoreduction in patients presenting with newly diagnosed ovarian cancer. This positive correlation should be taken into consideration when deciding between primary cytoreductive surgery or neoadjuvant chemotherapy in women with this disease.

Rezidiviertes Ovarialkarzinom: „Minimal Access Surgery“ vs. Laparotomie

Eriksson AGZ et al. Minimal access surgery compared to laparotomy for secondary surgical cytoreduction in patients with recurrent ovarian carcinoma: Perioperative and oncologic outcomes. Gynecol Oncol 2017; 146: 263 – 267

Minimal access surgery compared to laparotomy for secondary surgical cytoreduction in patients with recurrent ovarian carcinoma: Perioperative and oncologic outcomes

ObjectivesTo assess the perioperative outcomes of minimal access surgery (MAS) in secondary surgical cytoreduction (SSCR) for recurrent epithelial ovarian cancer (ROC); to compare oncologic outcomes with laparotomy (LAP). MethodsUsing an institutional database, we identified all patients with ROC undergoing SSCR from 1/5/09–6/14/14. Selection for MAS or LAP was based on surgeon preference. To minimize selection bias, preoperative imaging was reviewed for all LAP cases. In this manner, we identified potential MAS candidates, who were used in the comparison. Intent-to-treat analyses were undertaken using statistical testing. Results170 cases were identified (131 LAP, 8 LSC, 31 RBT). 68/131 (52%) LAP cases were deemed potential candidates for MAS. Feasibility analyses included 68 LAP and 39 MAS cases. Six (15%) MAS cases were converted to LAP. Median age, BMI, operative time did not differ significantly between the groups. Complete gross resection was achieved in 37/39 (95%) MAS, 63/68 (93%) LAP (P=1.0). Median estimated blood loss was 50cm3 (range, 5–500) MAS, 150cm3 (range, 0–1500) LAP (P=0.001). Median length of stay was 1day (range, 0–23) MAS, 5days (range, 1–21) LAP (P<0.001). Complications occurred in 3/39 (8%) MAS, 15/68 (22%) LAP (P=0.06). The 2-year progression-free survival was 56.1% (SE 9%) MAS, 63.5% (SE 6%) LAP (P=1.0). The 2-year overall survival was 92.2% (SE 5.4%) MAS, 81.4% (SE 5.5%) LAP (P=0.7). ConclusionsMAS for SSCR is feasible in properly selected cases. MAS is associated with favorable perioperative outcomes and similar oncologic outcomes, compared to LAP.

Aggressive Surgical Approach to the Management of Neuroendocrine Tumors: A Report of 1,000 Surgical Cytoreductions by a Single Institution

Neuroendocrine tumors (NETs) are rare neoplasms. Our group has treated more than 2,000 NET patients and has performed more than 1,000 surgical cytoreductive procedures. Records of 834 NET patients who underwent surgical cytoreduction at our institution were reviewed. Demographic information, intraoperative findings, extent of disease, complications, and survival rates were calculated. Eight hundred patients underwent 1,001 cytoreductive operations. Sixty-five percent had small bowel primaries. One hundred and thirty-eight patients presented with an unknown primary site, which was localized intraoperatively in 89% of these cases. The intraoperative complication rate was 9%. The incidence of intraoperative carcinoid crisis was 1%. Mean ± SD operative time was 368 ± 146 minutes. Mean ± SD hospital stay was 9 ± 10 days. Minor postoperative complications occurred after 43% of procedures and major postoperative complications were noted after 19% of procedures. The 30-day postoperative mortality rate was 2%. Median overall survival (OS) for patients with pancreatic NETs was 124 months. The 5-, 10-, and 20-year OS rates for patients with pancreatic NETs were 67%, 51%, and 36%, respectively. The life expectancy difference (between OS and actuarial survival) after surgical cytoreduction for patients with pancreatic NETs was 16.6 years. Median OS for patients with small bowel NETs was 161 months. The 5-, 10-, and 20-year OS rates for patients with small bowel NETs were 84%, 67% and 31%, respectively. The life expectancy difference after surgical cytoreduction for patients with small bowel NETs was 11.7 years. Surgical cytoreduction in NET patients has low morbidity and mortality rates and results in prolonged survival. We believe that surgical cytoreduction should play a major role in the care of patients with NETs.

Cytoreduction surgery with hyperthermic intraperitoneal chemotherapy in recurrent ovarian cancer improves progression-free survival, especially in BRCA-positive patients- a case-control study.

Approximately 70% of women diagnosed with advanced-stage ovarian cancer experience disease recurrence. Survival data were compared between a group of recurrent epithelial ovarian cancer (rEOC) patients treated by cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) and a matched group of rEOC patients treated by systemic chemotherapy only (without surgery). Treatment outcome in relation to the patients' BRCA status was compared. Twenty-seven rEOC patients treated by cytoreduction and HIPEC were selected from our database and matched (1:3) with 84 rEOC patients treated with chemotherapy only. Progression-free survival (PFS) and overall survival (OS) in the two groups were analyzed and compared. The estimated median PFS was 15 months in the HIPEC group and 6 months in the systemic chemotherapy group (P = 0.001). The median OS following HIPEC treatment has not been reached, since more than 70% of the women were alive at the time of analysis. The 5-year survival rate was significantly higher in the HIPEC treated patients compared to that of the controls (79% vs. 45%, P = 0.016). BRCA status did not affect PFS. HIPEC after surgical cytoreduction in patients with rEOC appears beneficial compared to systemic chemotherapy treatment alone. The benefit is even greater in BRCA mutation carriers.

Perioperative Morbidity and Mortality in Octogenarians With Ovarian Cancer

The decision to choose surgical cytoreduction in patients with newly diagnosed ovarian cancer may be influenced by their age. We compared perioperative morbidity and mortality of octogenarians compared with younger patients undergoing surgical cytoreduction. A retrospective chart review identified patients who underwent primary surgical cytoreduction for ovarian cancer between January 2005 and December 2009. Patients were divided into 2 cohorts: younger than 80 years and 80 years or older (octogenarian). Patient demographics, surgical procedures, 30-day readmission, length of stay, 30-day mortality rates, and chemotherapy administration were examined. Student t test and χ test were used to evaluate statistical significance. Three hundred eighty-four patients who underwent surgical cytoreduction for ovarian cancer were identified. Three hundred fifty-two patients (91.7%) were younger than 80 years, whereas 32 patients (8.3%) were 80 years or older. Two hundred thirty-six women (67.0%) in the younger cohort had optimal cytoreduction (<1 cm) compared with 17 women (53.1%) in the older cohort (P = 0.12). Thirty-day readmission rates and postoperative complications were similar. More patients in the older cohort required preoperative admission for medical clearance (P < 0.01). Mean length of stay was significantly longer in the older cohort (10.0 vs 7.5; P = 0.02). The number of patients who received adjuvant chemotherapy was significantly lower in the older cohort (71.9% vs 93.8%; P < 0.01). The 30-day mortality rate was significantly higher in the older cohort (18.8% vs 4.0%; P < 0.01). Although octogenarians with ovarian cancer have similar surgical complication rates as their younger counterparts, they require more medical clearance and have a longer hospital stay. Older patients are less likely to undergo chemotherapy and have a higher 30-day mortality rate than are younger patients.

Secondary Cytoreduction Versus Chemotherapy Alone in the Treatment of Patients with Recurrent Ovarian Cancer: Is a Randomized Trial Worthwhile?

The review by Harter et al. [1] entitled “Surgery for relapsed ovarian cancer: when should it be offered?” appropriately analyzes major concerns related to surgery for recurrent ovarian cancer. Despite underlining published reports from various series on secondary cytoreduction in platinum-sensitive patients, seeking a satisfactory answer to the question what should be considered standard care in these patients, they present two ongoing randomized trials (AGO-OVAR DESKTOP III and GOG 213) evaluating cytoreductive surgery versus chemotherapy alone in patients with platinum-sensitive recurrent ovarian cancer. Even though we agree that these studies are needed to obtain level 1 evidence for choosing the optimal treatment in similar clinical scenarios, we feel obliged to express and draw to the scientific community’s attention certain doubts. From currently available data, no one can deny that in selected cases such as the categories identified by the inclusion criteria for the AGO-OVARDESKTOP III trial, the results obtained after secondary surgical cytoreduction in patients with recurrent ovarian cancer are better than those after chemotherapy alone [2, 3]. This consideration raises ethical and practical concerns. As physicians engaged in scientific research, it is our duty to suggest to our patients the therapeutic option likely to guarantee the best outcome. Equally important, when asking patients to take part in a randomized trial, we have the duty to inform them about the reasons for the trial and the results that the two alternative procedures proposed can guarantee. Giving correct information could presumably lead to an accrual dropout. No less important in this context are the latest developments from cytogenetic studies on ovarian carcinoma. In their critical review published on the pathogenesis of ovarian cancer, Kurman and Shih [4] divide epithelial ovarian carcinoma into two groups designated type I and type II that distinctly differ in phenotype, genotype, and clinical behavior. These new concepts on ovarian carcinogenesis inescapably imply that a “blanket approach” to the treatment of ovarian carcinoma no longer suffices. The overriding need now is to develop targeted therapies adapted to the molecular and genetic features shown by the two main tumor types. Randomized trials that fail to take these differences into account can hardly provide reliable results.

A proteomic analysis of surgical cytoreduction in patients with advanced ovarian cancer.

e15560 Background: Optimal surgical cytoreduction (&lt;1 cm residual tumor) has been shown to improve overall survival compared to suboptimal (&gt;1cm) debulking as primary treatment for advanced stage epithelial ovarian cancer (EOC). Molecular descriptions of optimally and suboptimally debulked ovarian tumors are lacking. We have performed a global, quantitative proteomic analysis of optimally and suboptimally debulked EOC tumor samples. Methods: A cohort of 16 optimally (8) and suboptimally (8) debulked patients with archival formalin-fixed, paraffin-embedded tumor specimens was identified. Homogenous tumor cell populations were collected and protein digests were prepared and analyzed by high resolution mass spectrometry for identification and quantification by spectral counting. Immunohistochemistry (IHC) was performed and slides were scored using a semi-quantitative method (H-score). Results: An average of 1,110 proteins were identified within each cohort, of which 21 possessed significant (p&lt;0.05) differential abundances. Specifically, three proteins (annexin A1, S100-A11, and synuclein-gamma, or SNCG) which have significant roles in cell migration and cancer biology were identified. Although no H-score was statistically significant, comparison of positively-staining cells for SNCG showed a trend toward increased expression in suboptimally debulked patients, p=0.08. Conclusions: Overexpression of SNCG has been shown to be predictive of worse prognosis in papillary serous uterine cancer cell lines, and increased expression of SNCG in breast cancer correlates with advanced stage and aggressiveness of disease. Our data suggest SNCG may have similar predictive value in EOC, as tumors with elevated levels of this protein may be less amenable to optimal cytoreduction.

Outcomes of primary surgical cytoreduction in patients with BRCA-associated high-grade serous ovarian carcinoma

ObjectiveBRCA-associated and sporadic ovarian cancers have different pathologic and clinical features. Our goal was to determine if BRCA mutation status is an independent predictor of residual tumor volume following primary surgical cytoreduction. MethodsWe conducted a retrospective analysis of patients with FIGO stage IIIC-IV high-grade serous ovarian cancer classified for the presence or absence of germline BRCA mutations. The primary outcome was tumor-debulking status categorized as complete gross resection (0mm), optimal but visible disease (1–10mm), or suboptimal debulking (>10mm) following primary surgical cytoreduction. Overall survival by residual tumor size and BRCA status was also assessed as a secondary endpoint. ResultsData from 367 patients (69 BRCA mutated, 298 BRCA wild-type) were analyzed. Rate of optimal tumor debulking (0–10mm) in BRCA wild-type and BRCA-mutated patients were 70.1% and 84.1%, respectively (P=0.02). On univariate analysis, increasing age (10-year OR, 1.33; 95% CI, 1.07–1.65; P=0.01) and wild-type BRCA status (OR, 0.47; 95% CI, 0.23–0.94, P=0.03) were both significantly associated with suboptimal surgical outcome. On multivariate analysis, BRCA mutation status was no longer associated with residual tumor volume (OR, 0.63; 95% CI, 0.31–1.29; P=0.21) while age remained a borderline significant predictor (10-year OR, 1.25; 95% CI, 1.01–1.56; P=0.05). Both smaller residual tumor volume and mutant BRCA status were significantly associated with improved overall survival. ConclusionBRCA mutation status is not associated with the rate of optimal tumor debulking at primary surgery after accounting for differences in patient age. Improved survival of BRCA carriers is unlikely the result of better surgical outcomes but instead intrinsic tumor biology.

Surgical cytoreduction in patients with metastatic uterine leiomyosarcoma at the time of initial diagnosis

ObjectiveTo determine whether cytoreduction is associated with improved outcome in patients newly diagnosed with metastatic uterine leiomyosarcoma (LMS). MethodsWe retrospectively identified all patients treated at our institution for high-grade uterine LMS with extrauterine disease at the time of initial diagnosis from 7/1/82 to 7/31/07. Pattern of disease spread was classified as intraperitoneal (IP) or extraperitoneal (EP). Progression-free survival (PFS) and overall survival (OS) were determined from date of initial surgery using Kaplan–Meier estimates. ResultsWe identified 96 cases. Median age was 54years (range, 23–81). IP disease was seen in 48 (50%) and EP in 48 (50%). A complete gross resection of all tumor was achieved in 41/84 (49%). Recurrence or progression was noted in 93 (97%); 81 (84%) have died. Median PFS and OS for the entire cohort was 9.7months (range, 6.7–10.9) and 20.2months (range, 15.5–24.8), respectively. All 8 non-surgical cases died within 30months of diagnosis. Median PFS was 14.2months (range, 11.4–16.9) for those with a complete gross resection versus 6.8months (range, 4.1–9.5) for those with any residual disease (P=0.002). Median OS was 31.9months (range, 3.3–60.4) versus 20.2months (range, 11.8–28.6), respectively (P=0.04). On multivariate analysis, no residual disease was independently associated with PFS when adjusting for disease distribution (IP vs EP) and the use of chemotherapy but not OS. ConclusionsSurgical cytoreduction of metastatic uterine LMS was independently associated with PFS but not OS in cases selected for surgery. The improvement in PFS must be weighed against the morbidity of surgery.

Clinical Outcome of Tertiary Surgical Cytoreduction in Patients with Recurrent Epithelial Ovarian Cancer

Clinical Outcome of Tertiary Surgical Cytoreduction in Patients with Recurrent Epithelial Ovarian Cancer

Clinical Outcome of Tertiary Surgical Cytoreduction in Patients with Recurrent Epithelial Ovarian Cancer

The value of tertiary cytoreductive surgery (TCS) on overall survival (OS) of patients with relapsed epithelial ovarian cancer (ROC) is not well defined. Aim of the present study was to evaluate the operative and clinical outcome after TCS. We systematically evaluated all consecutive patients undergoing TCS. Tumor dissemination pattern, operative morbidity, residual tumor, and survival are described based on a validated intraoperative documentation tool. Predictors of survival and complete tumor resection are analyzed with Cox regression or logistic regression models. Between October 2000 and December 2008, 135 patients (median age, 51 years; range, 22-80 years) of mainly initial FIGO stage ≥ III (106 patients, 78.5%) were evaluated. In 53 patients (39.3%) a complete tumor-resection was obtained. The 1-month operative mortality was 6%. During a median follow-up period of 9.6 months (range, 0.1-75 months), 78 patients (57.8%) died, while 52 patients (38.5%) experienced a further relapse. Median OS was 19.1 months for the total collective (95% confidence interval [95% CI], 14.84-23.35). Median OS was 37.8 months (95% CI, 12.7-62.7) for patients without residual tumor; versus 19.0 months (95% CI, 9.8-28.2) for residual tumor ≤ 1 cm and 6.9 months (95% CI, 3.05-10.7) for residual tumor > 1 cm (P < .001). The presence of peritoneal carcinomatosis did not seem to significantly affect OS. Complete tumor resection was identified as the strongest predictor of OS. Other independent predictors of OS were interval to primary diagnosis ≥ 3 years (hazard ratio [HR], 0.28; 95% CI, 0.14-0.59) and serous papillary histology (HR, 0.23; 95% CI, 0.09-0.56). A total of 42 patients (31.1%) presented at least 1 major complication. Multivariate analysis identified tumor involvement of the middle abdomen and peritoneal carcinomatosis as independent predictors of complete tumor resection. Postoperative tumor residual disease remains the strongest predictor of survival even in TCS setting. To identify the optimal candidates for TCS, the predictive value of ascites and peritoneal carcinomatosis should be confirmed by future prospective trials.

Surgical cytoreduction in patients with colorectal peritoneal carcinomatosis treated with contemporary chemotherapy.

3546 Background: In the setting of contemporary chemotherapy (CH) regimens there are limited data evaluating cytoreductive surgery (CRS) and outcomes of patients with colorectal adenocarcinoma (CRC) and isolated peritoneal surface disease (PSD). Methods: A retrospective review of a single-cancer center experience in the management of CRC and PSD was performed. Cases with PSD diagnosed between 1998 and 2007 were identified from an institutional database and medical records were reviewed. Patients with appendiceal carcinoma, concurrent metastasis to other sites (e.g., liver, retroperitoneum), or second malignancies were excluded. The role of CRS to microscopic disease only (CC0), used selectively, was analyzed with overall survival (OS) as the primary endpoint. Results: Of 8,052 patients with CRC, 686 (8.5%) were found to have PSD and 214 (2.7%) had isolated PSD. Of these 151 received FOLFOX or FOLFIRI with or without a biologic agent for metastatic CRC. Of these, 35 (23.2%) had a CC0 resection. Of the remaining 116 (76.8%) patients, surgical procedures were used selectively for palliation. The median follow up at the institution was 21.2 months. 93.8% of treatment was delivered at the cancer center. There was no difference between the CC0 and non-CC0 patients with respect to gender, age, comorbidities, performance status, previous exposure to CH, histology, stage at presentation, and burden of PSD. Ascites was less frequent in the CC0 group (11.4% vs. 33.3% p = 0.02). During the follow up period 76.2% of patients were admitted to an inpatient service and 38.4% had a bowel obstruction (BO). CC0 patients had delayed presentation with BO (median time to BO 53.1 vs. 31.5 months, p = 0.02). CC0 was associated with longer OS (median 31.6 vs. 20.3 months, p = 0.003). Index PSD CEA, index PSD albumin, stage IV presentation, burden of PSD, achievement of CC0, and having received biological agents in any combination were independently associated with OS. Conclusions: CRC with isolated PSD is rare and major morbidity related to it is high. Among patients treated with contemporary CH, patients in whom CC0 resection was achieved had a median OS of 31.6 months compared to 20.3 months in whom CC0 resection was not achieved. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Alchemia, Biothera, Delcath, ImClone Systems, Merck, Novartis, Roche Pfizer Amgen, Biothera, Bristol-Myers Squibb, Curetech, Genentech, ImClone Systems, Lilly, Merck, Pfizer, Roche, Tercica

Extensive Retroperitoneal Carcinoid Involving the Mesenteric Vasculature Does Not Preclude Effective Cytoreduction

Summary Background Data: Traditionally, carcinoid tumors and their associated fibrosis have usually been considered unresectable when they encase the mesenteric vasculature. We hypothesized that carcinoid tumors with mesenteric vascular involvement (MVI) could be successfully and safely resected in an effort to maximize surgical cytoreduction in patients with locally advanced disease. Methods: We reviewed the medical records of carcinoid patients who underwent cytoreductive surgery from January 2001 to June 2008 by our group. Results: Forty five patients underwent surgical decompression of MVI and their outcomes were compared to 35 surgical patients who underwent cytoreduction but did not demonstrate MVI (control). The majority of patients (83-100%) in the control and MVI group experienced significant symptom relief following operation. A greater percentage of control patients vs. MVI patients had previous tumor explorations (60% versus 35.6%; p = 0.0296). No significant differences in the two groups were found with respect to post operative weight change, narcotic usage, surgical complications, or length of hospital stay. The survival curve of the MVI group did not differ significantly from the control group (median survival times = 392 and 484 days, respectively; p = 0.9437). Surgeons are often reluctant to explore patients with MVI. Conclusions: Resection of metastatic carcinoid in patients with MVI effectively alleviates symptoms with no appreciable increase in morbidity or mortality rates. Tumor-derived MVI should be resected when encountered in patients with carcinoid, and the presence of MVI alone should not preclude carcinoid patients from undergoing cytoreductive surgery.

Beyond tertiary cytoreduction in patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer

Background Primary, secondary, and possibly tertiary surgical cytoreduction in patients with recurrent epithelial ovarian (EOC), fallopian tube (FTC), or primary peritoneal (PPC) cancer appears to be associated with a survival benefit. The objective of this study was to assess if cytoreduction of recurrences after tertiary cytoreduction offers any potential benefit in these patients. Methods We performed a retrospective chart review of all patients with recurrent EOC, FTC, or PPC who underwent additional cytoreductive procedures after a prior tertiary cytoreduction (quaternary cytoreduction) at our institution between 1991 and 2008. Disease-specific survival (DSS) was calculated from the time of quaternary cytoreduction to last follow-up. Univariate analyses were used to analyze outcomes and to identify potential prognostic factors. Results A total of 15 patients were identified, of which 7 (47%) have died of disease. All patients had undergone prior optimal secondary and tertiary surgical cytoreductive procedures. The size of residual disease varied from 0 (in 10 cases/67%) to > 1 cm (in 2 cases, 13%). Residual disease (≤ 1 cm vs > 1 cm) and number of recurrence sites (single vs multiple) were found to be significant prognostic factors on univariate analysis. Conclusions Cytoreductive surgery beyond tertiary cytoreduction may be a reasonable option in highly select patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer, especially in the setting of a single site of recurrent disease.

A phase II clinical trial utilizing maximum medical and surgical cytoredutive treatments for patients with metastatic colorectal cancer to the liver

e15130 Background: The median overall survival (‘OS‘) for patients with mCRC treated with chemotherapy is about 20.4 months. Combination chemotherapy with surgical cytoreduction for patients with liver metastases are evaluated in a phase II clinical trial. Methods: Patients with newly diagnosed mCRC to the liver or recurrent CRC after 5FU failure were consented to receive further chemotherapy with at least irinotecan-based chemotherapy, oxaliplatin-based chemotherapy, and with the intention to treat the liver metastases with either RFA and/or liver resection between chemotherapy regimens whenever possible. Bevacizamab and cetuximab were considered options for treatment after their respective FDA approvals. Chemotherapy was given until there was treatment failure. The primary endpoint was OS. Results: Between 2001 and 2004 thirty-seven patients aged 41 to 79 were consented. One remained alive by December 2008. Only patients with an ECOG performance status of 0–1 were consented. Twenty had been treated with 5FU for a stage III CRC befored developing mCRC. All patients received irinotecan in the form of FOLFIRI, IFL, or as a single agent. Thirty-six also received oxaliplatin in the form of either FOLFOX4 or 6. Twenty-two patients received cetuximab as a single agent. Some regimens were augmented with bevacizumab. Fourteen patients could not undergo resection or RFA because of performance status or progression. Three required radiation to the CNS or distant bone. There were eleven patients who underwent RFA of at least one liver metastasis. There were ten patients who underwent liver resection. One patient underwent both RFA and liver resection at two different times. Another patient underwent RFA, adrenalectomy and wedge resection of the lung at three different times. He remained alive at 78 months at the time of submission. Median OS was 34.5+ months at the time of submission. Patient survival ranged from 15 to 86 months. There were no deaths associated with any surgical intervention. Conclusions: OS was improved in mCRC patients or recurrent CRC patients who had potentially ablatable or resectable liver lesions at the time of their diagnosis and who were treated with available aggressive medical and surgical therapies. [Table: see text]

Role of salvage cytoreductive surgery in the treatment of patients with recurrent ovarian cancer after platinum‐based chemotherapy

The role of cytoreductive surgery, which is well established in the primary treatment for epithelial ovarian cancer, is controversial in recurrent disease. The aim of this study was to assess the clinical benefit of salvage surgical cytoreduction in patients with recurrent ovarian cancer after platinum-based chemotherapy. We conducted a retrospective analysis of 46 patients with recurrent epithelial ovarian cancer treated at our department between 1988 and 2003. Twenty-three patients underwent salvage cytoreductive surgery (cytoreductive group), and the other 23 patients were treated without surgery (control group). Patients in cytoreductive group had a median survival of 41.7 months after recurrence, which was significantly longer than control group (18.8 months; P < 0.01). The duration of stay at home and the period oral intake was preserved were significantly longer in the cytoreductive group. In the cytoreductive group, survival was influenced by the residual disease after surgery (residual tumor diameter, <2 cm vs >2 cm; median survival, 50 months vs 35.2 months; P < 0.05). However, the number of recurrent sites (solitary vs multiple) and the lengths of treatment-free intervals after primary treatment (<6 months vs >6 months) showed no significant influence on survival. The application of cytoreductive surgery might improve the prognosis of patients with recurrent ovarian cancer if the tumor was resectable. Preserved prognoses of platinum-resistant disease with short treatment-free interval demonstrated in this study suggest that the concept of maximum cytoreduction might be introduced in the treatment of recurrent disease in the future.