Surgical Cytoreduction Research Articles

The natural history and role of surgical cytoreduction and systemic chemotherapy in high-grade mucinous adenocarcinomas of the appendix.

199 Background: The natural history, clinical presentation, and impact of cytoreductive surgery (CRS) or systemic chemotherapy for high grade MAA has been poorly studied. Methods: A retrospective chart review of patients (pts) with moderate or poorly differentiated AA was completed from 1994-2010. Radiographic response was assessed semi-quantitatively form physician records and complete cytoreductive surgery (CRS) was defined as a completeness of cytoreduction score of 0 or 1. For CRS and chemotherapy subgroups efficacy endpoints were calculated from date of CRS or first chemotherapy dose, respectively. Results: 288 (136 moderate and 152 poor grade) pts were identified with a median age of 52 years (range: 25-82). Mucinous histology was present in 110 pts (38%) and differed by grade: 55% of moderate and 23% of poor. Stage IV presentation (n=163) occurred in 76% of poor grade but only 35% of moderate grade. Both median OS (4.5 vs. 2.7 yrs, P=0.04) and median OS for the stage IV subgroup (3 vs 1.9yrs, P=0.005) were improved for MAA vs. non-MAA. Moderate compared to poor grade had improved median OS (3.7 vs 1.9 yrs, P=0.002) for Stage IV disease, but this differed by mucinous histology (moderate mucinous 6.2yr vs. poor mucinous 1.6yr, P=0.001; moderate nonmucinous 1.4yr, poor nonmucinous 2yr). 39 MAA pts underwent a complete CRS (30 moderate and 9 poor) with a median time to recurrence of 1.5yrs and median OS of 9.2yrs. Improved OS was seen for pts with a complete CRS compared to pts with an incomplete CRS, P<0.001. 55 MAA pts received systemic chemotherapy (fluoropyrimidine/oxaliplatin in 30, irinotecan-based in 8, fluoropyrimidine-based in 16, and other in 1): median OS of 2.1yr, median TTP of 7.2 months, and radiographic response of 36%. No statistical differences were seen between chemotherapy groups. Conclusions: High-grade MAA represents a heterogenous disease with a statistically worse OS for poor as opposed to moderate histological differentiation. This data does not support the AJCC 7th edition use of a single mucinous high-grade category. The use of systemic chemotherapy appears to be a viable treatment option for these pts and a complete CRS is associated with improved OS.

Diaphragmatic surgery during cytoreduction for primary or recurrent epithelial ovarian cancer: a review of the literature

Surgical cytoreduction remains a cornerstone in the management of patients with advanced and recurrent epithelial ovarian cancer (EOC). Diaphragm involvement is a common site of metastases and represents a major limit in the achievement of an optimal cytoreduction. The purpose of this manuscript is to discuss the rationale of diaphragmatic surgery and the morbidity related to this procedure in advanced and recurrent EOC. A search of the National Library of Medicine's MEDLINE/PubMed database until August 2012 was performed using the keywords: 'diaphragmatic surgery' and 'ovarian cancer'. Surgical treatment of diaphragmatic disease in advanced stage and recurrent EOC patients leads to high rates of optimal cytoreduction. It also correlates with an improved survival in advanced-stage EOC. The most common post-operative complication is a pleural effusion with rates ranging from 10 to 60 %. Pleural effusions are more common after diaphragmatic resections as compared to diaphragmatic stripping or coagulation. The need for post-operative thoracentesis or chest tube placement is low. The routine use of intraoperative trans-diaphragmatic decompression of pneumothorax reduces these rates. Diaphragmatic lesions at the time of interval debulking are less frequent and smaller in size. The morbidity of diaphragmatic surgery in this setting is lower as compared to a primary debulking; this is probably related to the fewer multivisceral radical procedures performed. Diaphragmatic surgery at the time of cytoreduction increases rates of optimal cytoreduction and improves survival in advanced-stage and recurrent EOC patients. Gynecologic oncologists should be confident with its indication, technique and morbidity.

Narrow-Band Imaging in Laparoscopic Management of Recurrent Platinum Sensitive Ovarian Cancer

The recurrence risk for advanced ovarian cancer managed using surgical cytoreduction and adjuvant chemotherapy is 60% to 70% [1]. The standard treatment of recurrent disease is still under debate and depends on patient history and characteristics of the tumor [1,2]. Recently, the role of cytoreductive surgery for platinum-sensitive cancer has been reassessed, and findings indicate that residual tumor is the most valuable determining factor for survival, even in recurrent disease [3]. Preliminary data seem to demonstrate that the addition of hyperthermic intraperitoneal intraoperative chemotherapy (HIPEC) could improve overall survival in these patients [4,5].

Ovarian Carcinosarcoma: Effects of Cytoreductive Status and Platinum-Based Chemotherapy on Survival

Objective. To define survival patterns of women with ovarian carcinosarcoma based on patient, tumor, and treatment characteristics. Methods/Materials. A single-institution, retrospective analysis of women diagnosed with ovarian carcinosarcoma from February 1993 to May 2009 was performed. Survival was analyzed with Cox proportional hazards ratios and Kaplan Meier tests. Results. Forty-seven cases of primary ovarian carcinosarcoma were identified. Age conveyed an HR 3.28 (95% CI 1.51–7.11, P = 0.003) for death. Compared to Stages I-II, Stage III carried an HR for death of 4.75 (95% CI 1.16–19.4, P = 0.03) and Stage IV disease an HR of 9.13 (95% CI 1.76–47.45, P = 0.009). Compared to those with microscopic residual, women with >1 cm diameter of residual disease after primary cytoreductive surgery had an HR for death of 4.71 (95% CI 1.84–12.09, P = 0.001). At analysis, 59.1% of those who received platinum-based chemotherapy were alive, compared to 23.1% of those who received nonplatinum-based chemotherapy (P = 0.08). Conclusions. Age, stage, and cytoreduction to no gross residual disease are associated with improved survival in women with ovarian carcinosarcoma. Complete surgical cytoreduction should be the goal of surgical management when possible, but the ideal adjuvant treatment regimen remains unclear.

Cytoreductive surgery in primary advanced epithelial ovarian cancer

Epithelial ovarian cancer is one of the most common malignancy and one of the principal causes of death among gynaecological neoplasm. The majority of patients(about 70%) present with an advanced International Federation of Gynaecology and Obstetrics stage disease. The current standard treatment for these patients consists of complete cytoreduction and combined systemic chemotherapy(CT). An increasing proportion of patients undergoing complete cytoreduction to no gross residual disease(RD) is associated with progressively longer overall survival. As a counterpart, some authors hypothesized the improving in survival could be due more to a less diffused initial disease than to an increase in surgical cytoreduction rate. Moreover the biology of the tumor plays an important role in survival benefi t of surgery. It's still undefi ned how the intrinsic features of the tumor make intra-abdominal implants easier to remove.Adjuvant and hyperthermic intraperitoneal CT could play a decisive role in the coming years as the completeness of macroscopic disease removal increases with advances in surgical techniques and technology. The introduction of neo-adjuvant CT moreover will play a decisive role in the next years Anyway cytoreduction with no macroscopic residual of disease should always be attempted. However the defi nition of RD is not universal. A unique and defi nitive defi nition is needed.

Carcinosarcoma (malignant mixed mesodermal tumor) of the uterus: clinicoimmunohistochemical and histogenetic characteristics

Aims: To search for favorable prognostic factors in CS on the basis of clinical, morphological and immunocytochemical data, while simultaneously considering histogenesis of this neoplasm. Methods and Results: Thirty two uterine CS patients were analyzed based on clinical and morphological data. In addition, each specimen was immunohistochemically stained with appropriately selected antibodies characterizing relevant types of cells and tissues. The presence of both carcinomatous and sarcomatous patterns was observed in all tumors. Among carcinomatous patterns, endometrioid carcinoma was most common, while serous, clear cell, and undifferentiated were less common. Among sarcomatous patterns, endometrioid sarcomas represented the largest group, while leiomyosarcomas, chondrosarcomas, fibrosarcomas, osteosarcomas, rhabdosarcomas were rarely observed. Mitotic activity was evidently higher in carcinomas. Among seven neoplasms the expression of both cytokeratin and vimentin was noted in cells of carcinomatous patterns. Conclusions: This study shows that an early diagnosis (stage I-II) and an initial aggressive surgical cytoreduction are favorable prognostic factors in CS. Furthermore, cytokeratin-vimentin positive cells in carcinomatous patterns suggest sarcomatous metaplasia of adenocarcinoma. Unfortunately, the study did not identify histological structures of prognostic value.

Carcinosarcoma (malignant mixed mesodermal tumor) of the uterus: clinicoimmunohistochemical and histogenetic characteristics

To search for favourable prognostic factors in carcinosarcoma (CS) on the basis of clinical, morphological and immunocytochemical data, while simultaneously considering the histogenesis of this neoplasm. Thirty two uterine CS patients were analysed based on clinical and morphological data. In addition, each specimen was examined by immunohistochemistry with antibodies characteristic for relevant types of cells and tissues. The presence of both carcinomatous and sarcomatous patterns was observed in all tumours. Among carcinomatous patterns, endometrioid carcinoma was the commonest, while serous, clear cell, and undifferentiated carcinomas were less common. Among sarcomatous patterns, endometrioid sarcomas represented the largest group, while leiomyosarcomas, chondrosarcomas, fibrosarcomas, osteosarcomas, and rhabdosarcomas were rarely observed. Mitotic activity was evidently higher in carcinomas. In seven cases, the expression of both cytokeratin and vimentin was noted in cells of carcinomatous patterns. We found that an early diagnosis (stage I-II) and an initially aggressive surgical cytoreduction were favourable prognostic factors in CS. Furthermore, the presence of cytokeratin-vimentin positive cells in carcinomatous patterns suggests sarcomatous metaplasia of adenocarcinoma. However, the prognostic value of various histological structures of carcinosarcomas could not be identified.

Acute neurological disorders following intraperitoneal administration of cisplatin

Posterior reversible encephalopathy syndrome (PRES) is a rare syndrome that can be caused by a variety of clinical conditions (e.g. severe hypertension) or the administration of immunosuppressive drugs or cytotoxic agents [1,2]. Symptoms can include headache, confusion, nausea, hearing loss, seizures, and visual disturbances. The pathophysiology of PRES is poorly understood, but reversible alterations in the cerebrovascular autoregulatory control mechanism and blood–brain integrity are thought to play an important role. In general, PRES has a good prognosis resulting in full recovery after removal of the causative agent, although cases with a fatal outcome have been described [1,2]. A 51-year-old womanwas diagnosed with ovarian cancer, classified as FIGO Stage IIIC. Initial treatment consisted of 3 cycles of carboplatin (600 mg) and taxol. Treatment was uneventful and resulted in a partial response. The patient provided informed consent for inclusion in a randomized multicenter clinical trial comparing optimal surgical cytoreduction versus optimal cytoreduction followed by hyperthermic intraperitoneal chemotherapy (HIPEC) currently being conducted in the Netherlands [3]. The patient was randomized to undergo an adjuvant HIPEC procedure. Heated cisplatin (41 °C, 100 mg/m) was administered into the peritoneal cavity for 90 minutes after complete cytoreduction had been achieved. The patient's body temperature increased to a maximum of 38.7 °C during the procedure, normalizing 2 hours after the procedure. On the first postoperative day the patient complained of severe headache, nausea, and hearing loss in her left ear, and became progressively confused. Neurological examination showed a slightly decreased level of consciousness (eyes 3, motor 6, vocal 4) on the Glasgow Coma Scale, but without focal symptoms. Physical examination and laboratory tests were normal with the exception of a mild increase in serum creatinine levels from 57 to 83 μmol/L on the first postoperative day. CT scan of the brain showed generalized edema and a subsequent MRI of the cerebrum revealed symmetrical bilateral occipital white matter lesions. This radiological image is typical for PRES [1]. Supportive carewas initiated and all symptoms resolved completely over the following 72 hours. The patient was treated with an additional 3 cycles of chemotherapy, during which no recurrence of the neurological symptoms occurred. Intraperitoneal administration of heated cisplatin following cytoreduction was thought to be the causative agent. Indeed, several case reports have previously described PRES following intravenous administration of cisplatin [4]. HIPEC procedures are increasingly being applied to treat a variety of malignancies confined to the peritoneal cavity, including ovarian cancer [3]. In such cases, the development of PRES should be considered when a patient develops neurological symptoms in the early postoperative period.

Metformin intake is associated with better survival in ovarian cancer

The objective of this case-control study was to identify any association of metformin intake with the survival of patients with ovarian cancer. In this retrospective case-control study, women with ovarian cancer who received metformin (cases) were compared with women with ovarian cancer who did not receive metformin (controls). A 2-layered analysis was conducted. In preliminary analysis, all cases (the OC cohort) were compared with controls at a 1:2 ratio. Subsequently, in definitive analysis, only patients who had epithelial ovarian cancer (the EOC cohort) were compared with controls at a 1:3 ratio. In the EOC cohort, cases were matched with controls for age (±5 years), International Federation of Gynecology and Obstetrics stage, and residual disease. Prognostic variables and disease specific survival were compared using chi-square tests, the Kaplan-Meier (log-rank) method, and Cox proportional hazards analysis. In a preliminary analysis of the OC cohort (72 cases and 143 controls), cases had better survival (5-year disease-specific survival for cases vs controls, 73% vs 44%; P = .0002). In the definitive analysis of the EOC cohort (61 cases and 178 controls), the distribution of age, disease stage, optimal cytoreduction, serous histology, and platinum chemotherapy remained similar between cases and controls (P > .05). Despite these similarities, cases had significantly better survival (5-year disease-specific survival for cases vs controls, 67% vs 47%; P = .007). On multivariate analysis, metformin remained an independent predictor of survival (hazard ratio, 2.2; 95% confidence interval, 1.2-3.8; P = .007) after controlling for disease stage, grade, histology, chemotherapy, body mass index, and surgical cytoreduction. The results of this study indicated an association of metformin intake with survival in patients with ovarian cancer. The receipt of metformin was associated with better survival, and the authors concluded that metformin is worthy of clinical trials in ovarian cancer.

Considerations in the Surgical Management of Ovarian Cancer in the Elderly

Elderly patients with advanced epithelial ovarian cancer present a complex treatment dilemma. On the one hand, patients can be treated with primary debulking surgery to achieve the ideal oncologic outcomes but at the expense of risk of surgical morbidity and mortality. On the other hand, they can be treated with alternative, less morbid approaches, reducing toxicity, but sacrificing the survival benefits of low residual disease by surgical cytoreduction. Retrospective studies have attempted to identify risk factors for poor surgical outcome. Although there is no consensus to define "elderly" or "frail," current evidence identifies age, performance status, nutritional status, and surgical complexity as major risk factors for surgical morbidity. Accepting the shortcomings of these retrospective data, candidates for primary debulking surgery can be assessed for risk of surgical morbidity. Age is likely a contributor to morbidity, particularly in the face of comorbid conditions. Clinicians should strive to treat elderly patients with a standard approach of primary debulking surgery and adjuvant chemotherapy when healthy and in the absence of other risk factors. Elderly patients with the following are poor surgical candidates and an alternative treatment approach should be considered: poor nutritional status (characterized by serum albumin <3.0 g/dL), or poor performance status (ASA ≥3), and stage IV disease. Several of these factors are modifiable by treating the underlying cancer. These patients should be treated with two to three cycles of neoadjuvant chemotherapy and reassessed for surgical debulking. Patients with improvement in their nutritional or performance status can undergo interval debulking with the goal to resect all visible disease.

Image guidance in malignant gliomas: a focused strategy.

The standard of care for malignant gliomas is maximal surgical cytoreduction followed by concurrent chemoradiation and adjuvant chemotherapy with temozolomide. Chemotherapy adds a modest improvement in overall survival. Unfortunately, tumor recurrence is the rule and typically occurs at the initial site of disease. Salvage reirradiation may be a useful approach in selected patients with recurrent glioblastoma. Image-guided technology coupled with highly conformal treatment planning techniques have allowed the safe delivery of high-dose radiotherapy in the setting of tumor recurrence. Defining the optimal combination of hypofractionated stereotactic radiotherapy with chemotherapy is under investigation. In this perspective, we examine the role of image guidance in malignant gliomas.

Cytoreductive Surgery and Intraoperative Administration of Paclitaxel-loaded Expansile Nanoparticles Delay Tumor Recurrence in Ovarian Carcinoma

Locoregional recurrence significantly impacts survival and quality of life in patients with ovarian carcinoma. We hypothesize that local administration of paclitaxel-loaded expansile nanoparticles (pax-eNP) at the time of cytoreductive surgery decreases local tumor recurrence. In vitro cytotoxicity of pax-eNP was assessed against both the OVCAR-3 human ovarian cancer cell line and tumor cells isolated from a malignant pleural effusion from a patient with multidrug-resistant ovarian cancer. A murine xenogenic model involving surgical cytoreduction of established OVCAR-3 intra-abdominal tumor was used to evaluate in vivo efficacy of intraoperative intraperitoneal (IP) injection of 10 mg/kg of paclitaxel either as pax-eNP or paclitaxel in Cremophor EL/ethanol solution (pax-C/E) versus empty eNP controls. Cytoreductive surgery and intraoperative treatment were performed 4 weeks after established tumor. All animals were sacrificed when empty eNP controls displayed extensive evidence of disease progression. Labeled-eNP entered tumor cells in vitro within 4 h and specifically accumulated at sites of tumor in vivo. Pax-eNP exhibited dose-dependent cytotoxicity in both OVCAR-3 and patient tumor cells isolated from a malignant pleural effusion and effectively prevented tumor recurrence following debulking (p = 0.003 vs. empty eNP). Furthermore, pax-eNP-treated animals did not develop severe recurrent carcinomatosis compared with 43 % of the pax-C/E-treated cohort, suggesting that single-dose intracavitary pax-eNP is more effective than an equivalent dose of pax-C/E. Expansile nanoparticles readily enter human ovarian tumor cells and localize to sites of tumor in vivo with pax-eNP cytotoxicity resulting in superior inhibition of locoregional tumor recurrence following cytoreductive surgery.

Assessment of clinical benefit and quality of life in patients undergoing cytoreduction and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for management of peritoneal metastases.

Peritoneal metastasis is a significant clinical challenge; life expectancy following diagnosis is usually very short. Surgical cytoreduction with HIPEC is being used with increasing frequency in selected patients; most outcome data have shown that prolonged median survivals can be observed in selected patients. This review summarizes the published data related to outcome and quality of life after cytoreduction and HIPEC to provide insights into its use in patients with peritoneal carcinomatosis.

Phase II study of interval debulking surgery followed by intraperitoneal chemotherapy for advanced ovarian cancer: A Kansai Clinical Oncology Group study (KCOG9812)

ObjectiveIntraperitoneal chemotherapy (IP) is known to be effective after optimal primary debulking surgery (PDS) for ovarian cancer (OC). Here, we conducted a phase II study to investigate its effectiveness after interval debulking surgery (IDS). MethodsThirty-seven patients with FIGO stage IIIB-IV and suboptimal (≥1cm diameter) residual disease after PDS were enrolled. Carboplatin (AUC 4 IV, Day 1) and cisplatin (50mg/m2 IV, Day 3) were given q21d for 3cycles. After IDS, paclitaxel (175mg/m2 IV Day 1 or 60mg/m2 IV Days 1, 8, and 15, since 2000) and cisplatin (75mg/m2 IP Day 2) were given q21d for 4cycles. The primary endpoint was progression-free survival (PFS), and secondary endpoints were overall survival (OS) and adverse events (CTCAE ver. 2.0). Clinical manifestations at first recurrence and subsequent treatment were also surveyed. ResultsOf the 37 patients, high-grade, serous adenocarcinoma was found in 33. Stages IIIB, IIIC, and IV were found in 2, 24, and 11 patients, respectively. After IDS, 23 patients had no macroscopic residual tumor. No patients had permanent enterostomy, febrile neutropenia, or platelet transfusion. The treatment protocol was completed in 22 patients, and discontinued in 5 due to IP catheter-related complications. Median PFS and OS were 22 and 57months, respectively. Among the 28 patients with recurrence, 10 had no intraperitoneal disease at first recurrence. Among the 8 patients who underwent surgical cytoreduction, 6 had no residual tumor, while 2 had a <1-cm-diameter residual tumor. ConclusionIP after IDS for patients with initially suboptimally debulked OC was effective.

Emerging Concerns When Evidence-Based Medicine Is Translated into Real Life: The Case of Neoadjuvant Chemotherapy in Ovarian Cancer

Keywords Ovariancancer .Neoadjuvantchemotherapy .Optimalcytoreduction .SurgeryMore than 70 % of patients with epithelial ovarian cancerare diagnosed with an advance stage of disease. For deca-des, the therapeutic approach to these patients has consistedof cytoreductive surgery followed by a platinum-based che-motherapy regimen. Although there are no randomized clin-ical trials confirming that cytoreductive surgery improvessurvival, several retrospective studies as well as one meta-analysis have shown that the most important prognosticfactor for patients with advanced epithelial ovarian canceris the amount of residual disease after surgical cytoreduction[1, 2]. Constantly in the literature, the absence of macro-scopic residual disease after debulking surgery has beenassociated with better overall survival [3–5]. Recently, thefourth Ovarian Cancer Consensus Conference stated that theexpression “optimally debulked patients” should be re-served for those patients without residual macroscopic dis-ease after debulking surgery [6].However, the likelihood of achieving the objective of“optimal cytoreduction” is highly dependent on the skillsand experience of the surgical team operating on the patient.There are several data in the literature showing that that therate of optimal cytoreduction increases when the surgeonwho operates on an ovarian cancer patient is a well-trainedsubspecialist in gynecologic oncology [7, 8]. The mainreason for this is probably the necessity of sometimesperforming very complex procedures during the surgery inorder to obtain the goal of absence of residual disease. Suchprocedures might include, for instance, bowel resections,radical retroperitoneal lymphadenectomies, splenectomies,partial pancreatectomies, or resection of diaphragmaticimplants. Unfortunately, the training of the surgical teamsoperating on ovarian cancer patients around the world is nothomogeneous and, unlike in countries in which there is anofficial accreditation or specialization, we cannot expect thesame results from different teams in different parts of theworld or even in the same country. This heterogeneity canalso stimulate a further debate, beyond the scope of thisarticle, about the validity of performing clinical trials inwhich the main intervention is a complex surgical procedureas well as about the quality control in such as trials.Eisenkop and Spirtos [9], in an illustrative survey amongAmerican gynecologic oncologists, found that the main limi-tation for obtaining complete cytoreduction was the approachtotheupperabdomen,reinforcingtheneedforspecialtrainingfor the optimal surgery in this disease. Additionally, we havedatashowingthatthebetterthetrainingofthesurgicalteamincomplex procedures, including the approach to the upperabdomen, the higher is the rate of optimal cytoreductionamong these patients [10, 11].Neoadjuvant chemotherapy consists in the administrationof some courses of chemotherapy before surgery. This strat-egy has been used when the surgical team has considered itimpossible to achieve adequate cytoreduction in an individ-ual patient. Despite the absence of consensus on the criteriafor considering a patient to not be a candidate for upfrontsurgery, there are some patient circumstances that are uni-versally accepted, for instance, bad clinical condition of the

The role of high‐dose‐rate and pulsed‐dose‐rate brachytherapy in the management of recurrent or residual stomal tumor after total laryngectomy

The main purpose of the study was to assess the role and efficacy of high-dose-rate (HDRBT) and pulsed-dose-rate (PDRBT) brachytherapy in the palliative treatment of recurrent or residual stomal tumor after total laryngectomy. We aimed at presenting a series of 22 consecutive patients treated in the Department of Otolaryngology, Head and Neck Surgery of Poznań University of Medical Sciences, and in the Brachytherapy Department of Greater Poland Cancer Center. In 16 patients PDRBT was used and in six patients HDRBT was used. In three patients, BT procedures were performed in combination with simultaneous chemotherapy. Two patients were additionally treated with interstitial hyperthermia. In 16 patients, surgical cytoreduction of the tumor preceded the catheters placement. In six patients, a second course of BT was performed due to neck metastases. All patients were regularly followed up within 6 months. Local control, complications, and survival were assessed. Complete and partial remissions 6 months after finishing the treatment were achieved in four (20%) patients, while survival rates 24 months after BT were estimated for 22%. Severe late complications occurred in two (9%) patients. The results of our study show that HDRBT and PDRBT are feasible in previously irradiated patients with recurrent or residual stomal tumor after total laryngectomy. They provide acceptable toxicity and good palliative effect.

How to approach patients in relapse

How to approach patients in relapse

661 - Tumors of the Appendix: the Experience of Ipo-Porto

ABSTRACT Introduction Malignant neoplasms of ileocecal appendix are rare, an clinical features are unspecific, often mimicking acute appendicitis. They are diagnosed in about 1% of appendicectomy specimens. The most common histologic types are mucinous adenocarcinoma, intestinal-type adenocarcinoma and carcinoid tumor. Methods The authors reviewed the primary appendix carcinomas treated in Instituto Portugues de Oncologia Francisco Gentil-Porto (IPOFG-Porto) between January 2000 and June 2011. Results Fourty two patients were treated during this period: 30 women (71%) and 12 men, aged between 20 and 90 years old (median age 58). Mucinous adenocarcinoma was the most common histologic subtype, with 27 cases (64%), followed by adenocarcinoma NOS (10 cases - 24%); carcinoids were 5 cases (12%). Fifteen percent presented as stage IV, 7% stage III, 24% stage II and 19% stage I. The primary treatment was surgery: 16 patients were submitted to appendicectomy, 6 patients to appendicectomy, ooforectomy and hysterectomy, 12 to hemicolectomy. Of patients submitted to appendicectomy, 11 (50%) had a second laparotomy in order to perform hemicolectomy. Five percent of the patients received adjuvant chemotherapy (mFOLFOX6). Hyperthermic Intraoperative Peritoneal Chemotherapy (HIPEC) was performed in 18 patients with stage IV disease (peritoneal carcinomatosis). The median follow-up was 35 months. Thirty three percent of the patients (n = 14) died because of disease progression and 62% (n = 26) were alive with no evidence of disease. Conclusion Appendiceal carcinomas are rare tumours and there is limited evidence on the indications for right hemicolectomy. The role of adjuvant chemotherapy for adenocarcinoma of the appendix is unknown. Optimal treatment of patients with intraperitoneal dissemination of appendiceal adenocarcinoma (mucinous peritoneal carcinomatosis) is unclear. Selected patients treated with aggressive surgical cytoreduction and HIPEC may have a favorable outcome in long term, but patient selection and the experience of the treating team are critical. The benefit of systemic chemotherapy for advanced disease is unknown. Disclosure All authors have declared no conflicts of interest.

Retrospective analysis evaluating ovarian cancer cases presented at the clinical oncology department, Alexandria University

Ovarian cancer is the most common cause of death among women with gynecologic malignancies. The standard management is maximal surgical cytoreduction followed by systemic chemotherapy.The aim of this retrospective study is to evaluate ovarian cancer cases presented at Alexandria Clinical Oncology Department (ACOD) during the years 2008–2010. Methods and materialsWe reviewed the files of all patients presented at or referred to ACOD from January 2008 till December 2010 with the diagnosis of ovarian cancer, ovarian epithelial tumor, ovarian sex cord tumors, border line ovarian tumor and ovarian germ cell tumors. ResultsThe study included 116 patients, representing 1.4% of all cancer cases; the mean age for all patients was 47.9±13.9years. Only 13.7% of the patients had positive family history. Stages III and IV were seen in 79.2% of the cases. Epithelial ovarian cancer (EOC) constituted 75% of the cases, border line tumors 12.9%, granulosa cell tumor 6%, and germ cell tumors 4.3%. Among EOC, serous cystadenocarcinoma was seen in 58%. For EOC, surgery was the initial step in 80.4% of the cases. Paclitaxel-carboplatin was the most commonly used regimen as first line chemotherapy. Response rate to first line chemotherapy reached 87.3% (44.8% complete response). The mean follow up period was 15months. The progression free survival for EOC after first line chemotherapy was 10.8months. ConclusionThe age incidence of ovarian cancer in our patients is 10years younger than that seen in Western countries. EOC constitutes the majority among all ovarian cancer cases, followed by border line tumors. Papillary serous cystadenocarcinoma predominates other types of EOC. The response rate of EOC to first line chemotherapy was high but the progression free survival was lower than that seen in the literature.

Identification of a Subgroup of Patients at Highest Risk for Complications After Surgical Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy

To assess the influence of parietal and visceral peritonectomy procedures on moderate/severe morbidity in patients undergoing surgical cytoreducion and hyperthermic intraperitoneal chemotherapy (HIPEC) and to identify subgroups of patients at highest operative risk. Cytoreducion with HIPEC is an effective but potentially morbid treatment option for peritoneal surface malignancies. Although complication rates have recently decreased with increasing experience, risk-factors for adverse operative outcome are still poorly understood. A prospective database of 426 combined procedures was reviewed. Multivariate analysis tested the correlation between major morbidity and 6 peritonectomies (greater and lesser omentectomy, pelvic, parietal anterior, left and right diaphragmatic peritonectomy), 14 visceral resections, 5 other operative factors, and 12 clinical variables. The extent of peritoneal involvement was quantified by peritoneal cancer index (PCI). Mortality and major morbidity were 2.6% and 28.2%. PCI, number of visceral resections, poor performance status, and cisplatin dose more than 240 mg independently correlated to morbidity. The type and number of parietal peritonectomies and the type of visceral resections did not correlated to complications. Major morbidity rate was 65.7% in 35 (8.2%) patients with at least 2 of the following factors: PCI greater than 30, more than 5 visceral resections, poor performance status. Morbidity was 100% in 9 patients presenting all the risk factors. Acceptable morbidity and low mortality may be achieved in high-volume centers. Operative outcome is mainly affected by a complex interplay of tumor, patient, and treatment-related factors. Preoperative and early intraoperative assessment of operative risk may identify a subset of patients unlikely to tolerate aggressive management.