Synchronous Peritoneal Carcinomatosis Research Articles

Gene Expression Profile-Guided Personalized Intraperitoneal Chemotherapy for Gastric Cancer Peritoneal Carcinomatosis.

Peritoneal carcinomatosis (PC) is one of the most unfavorable sites of metastasis for malignant tumors of various localizations, especially gastric cancer (GC). According to the literature, synchronous PC in GC is common in 15-52% of patients. The purpose of this study was to examine the long-term results using personalized systemic and intraperitoneal chemotherapy as part of the combined treatment of stomach cancer presenting with synchronous PC. Cytoreductive surgical treatment was performed for 70 patients at the first stage. The control group (n = 35) received standard postoperative chemotherapy according to the FOLFOX scheme. Personalized postoperative systemic and intraperitoneal chemotherapy was administered in the basic group (n = 35), based on the expression levels of the eight genes in the primary tumor, lymph node, and peritoneal metastases. The median progression-free survival was 14.9 months in the basic group, and in the control group it was 11.2 months (P < 0.001). The median life expectancy in the basic group was 16.8 (13.7 - 18.8) months, in the control group it was 12.5 (11.3 - 13.1) months (P < 0.001). Developing algorithms of personalized systemic and intraperitoneal chemotherapy in patients with GC with synchronous carcinomatosis, based on the analysis of molecular genetic characteristics of the tumor and metastases, allows to improve the long-term results of combined treatment.

Impact of Body Mass Index on Postoperative Pain and Opioid Administration After Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC).

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new surgical technique, developed for the treatment of peritoneal carcinomatosis (PC). In this retrospective observational study we assessed the impact of body mass index (BMI) on postoperative pain and opioid consumption. We analyzed pain scores after 100 PIPAC procedures using either oxaliplatin or doxorubicin-cisplatin performed in 49 patients with PC between July 2016 and September 2020. The patients were divided into 3 groups (BMI <18.5, 18.5 ≥ BMI < 25, BMI≥25). Pain was self-rated on a visual analogue scale (VAS) from 0 to 10. Univariate logistic regression analysis identified oxaliplatin and PCI score to be associated with moderate to severe pain (VAS 4-10 at 8 am D1) after adjustment on BMI (OR [95% CI]; 3.26[1.00 - 10.65] p=0.050) and (OR [95% CI]; 1.09[1.01 - 1.17] p=0.019). The level of pain appeared significantly different between the treatment groups (median 2.5[0; 5] vs 0[0; 2.5] p=0.0017) irrespective of BMI (p =0.705 and p=0.118). Multivariate logistic regression analysis identified moderate to severe pain and synchronous PC to be associated with greater use of opioids (OR [95% CI]: 3.91 [1.24 - 12.32]) and (OR [95% CI]: 5.16 [1.71 - 15.58]; respectively. Opioids were administered after 45 procedures (45%) and was comparable between the treatment groups. Opioid administration and length-of-stay were similar among BMI bands. BMI is not related to postoperative pain or opioid use, howevermoderate to severe pain and synchronous PC are factors associated with requiring opioids.

Unusual Clinical Experience in BRAF Exon 15 p.K601E-Mutated Lung Cancer: A Case Report and Brief Review of the Literature

Molecular profiling has revolutionized the treatment of metastatic NSCLC. Uncommon mutations have been reported primarily in EGFR and BRAF genes and are frequently associated with atypical clinical presentations. Here, we present a rare case of a patient affected by BRAF exon 15 p.K601E-mutated lung cancer with synchronous peritoneal carcinomatosis. First line treatment with chemo-immunotherapy combinations provided a PFS of 8–9 months, whereas a second line treatment with BRAF and MEK inhibitors elicited a dissociated response. The latter clinical outcome suggests that these inhibitors have only partial activity against this rare mutation.

Delineating the intra-patient heterogeneity of molecular alterations in treatment-naïve colorectal cancer with peritoneal carcinomatosis

AbstractIn a non-negligible number of patients with metastatic colorectal cancer (mCRC), the peritoneum is the predominant site of dissemination. Cure can be achieved by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), but this procedure is associated with long-term morbidity and high relapse rates. Thus, there is a pressing need for improved therapeutic strategies and complementary biomarkers. The present study explored the molecular heterogeneity in mCRC with peritoneal carcinomatosis (PC), and the potential clinical implications thereof. Multi-region immunohistochemical profiling and deep targeted DNA-sequencing was performed on chemotherapy-naïve tumours from seven patients with synchronous colorectal PC who underwent CRS and HIPEC. In total, 88 samples (5-19 per patient) were analysed, representing primary tumour, lymph node metastases, tumour deposits, PC and liver metastases. Expression of special AT-rich sequence-binding protein 2 (SATB2), a marker of colorectal lineage, was lacking in the majority of cases, and a conspicuous intra-patient heterogeneity was denoted for expression of the proposed prognostic and predictive biomarker RNA-binding motif protein 3 (RBM3). Loss of mismatch repair proteins MLH1 and PSM2, observed in one case, was concordant with microsatellite instability and the highest tumour mutational burden. When present in a patient, mutations in key CRC driver genes, i.e., KRAS, APC and TP53, were homogenously distributed across all samples, while less common mutations were more heterogenous. On the same note, copy number variations showed intra-patient as well inter-patient heterogeneity. In two out of seven cases, hierarchical clustering revealed that samples from the PC and lymph node metastases were more similar to each other than to the primary tumour. In summary, these findings should encourage additional studies addressing the potential distinctiveness of mCRC with PC, which might pave the way for improved personalized treatment of these patients.

Preoperative prognostic factors for obstructive colorectal cancer.

The aim of the study was to determine the preoperative predictive factors of overall survival, relapse-free survival, and peritoneal carcinomatosis in obstructive colorectal cancer. Data from patients undergoing emergency surgery for obstructive colorectal cancer at our center between 2004 and 2016 were extracted retrospectively from our health records. Several preoperative parameters were used to predict survival and peritoneal carcinomatosis using univariate and multivariate analysis, and ROC curves. A total of 107 patients with obstructive colorectal cancer were included. Five-year relapse-free and overall survival rates were 14% and 28%, respectively, with 15% peritoneal carcinomatosis. Univariate analysis showed that age ≥ 83years old, preoperative ASA score ≥ 3, initial hemodynamic instability, and CRP > 18.3mg/L was significantly associated with worse relapse-free and overall survival. In a multivariate analysis, only age > 83years (HR = 1.75; HR = 2.16, for relapse-free and overall survival status, respectively) and hemodynamic instability (HR = 7.29; HR = 6.55) were confirmed in the multivariate model. Global peritoneal carcinomatosis was significantly associated with synchronous liver metastases in the multivariate model (OR = 4.56), and synchronous peritoneal carcinomatosis only was significantly associated with platelet to lymphocyte ratio (PLR) > 269 and synchronous liver metastases in the multivariate model (OR = 0.003; OR = 7.26). Synchronous liver metastases are prognostic risk factor for global and synchronous peritoneal carcinomatosis whereas PLR > 269 was a significant protective factor for synchronous peritoneal carcinomatosis only for obstructive colorectal cancer. Age > 83years and initial hemodynamic instability were key preoperative prognostic risk factors for worse relapse-free and overall survival. Prognostic usefulness of blood cell ratios for mortality and peritoneal carcinomatosis warrants further investigation.

Results of systemic chemotherapy in combination with pressurized intraperitoneal aerosol chemotherapy in patients with gastric cancer and synchronous peritoneal carcinomatosis

<h3></h3> Перитонеальный карциноматоз (ПК) является одним из наиболее частых проявлений распространенного рака желудка (РЖ). Результаты паллиативного лекарственного лечения РЖ остаются малоудовлетворительными. Внутрибрюшная аэрозольная химиотерапия под давлением (ВАХД) (<i>англ.</i> — PIPAC) — новый метод паллиативного лечения больных ПК, представляющий собой малоинвазивное введение цитостатиков в брюшную полость в виде мелкодисперсного аэрозоля под давлением. <h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Изучить результаты применения системной и внутрибрюшной аэрозольной химиотерапии под давлением у больных раком желудка с синхронным перитонеальным карциноматозом. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> Протокол сочетанной системной и внутрибрюшной аэрозольной химиотерапии под давлением при первичном РЖ с синхронным ПК в качестве первой линии терапии был разработан и реализован в рамках клинического исследования второй фазы на базе МНИОИ им. П.А. Герцена ФГБУ «НМИЦ радиологии». Лечение начинали с 4 курсов системной полихимиотерапии (XELOX, FOLFOX, FLOT). Следующим этапом проводили сеанс ВАХД, который выполняли в условиях лапароскопии с интервалом 6—8 нед, при этом продолжали курсы системной полихимиотерапии между сеансами. Лечение, сочетающее курсы системной химиотерапии с сеансами ВАХД, продолжали до момента выявления прогрессирования. <h3>РЕЗУЛЬТАТЫ</h3> Метод применен у 226 больных (127 женщин и 99 мужчин, средний возраст 49 лет) РЖ с синхронным ПК. В общей сложности проведено 552 сеанса ВАХД. По 1 сеансу получили 69 (30,5%) больных, по 2—4 сеанса — 139 (61,5%), 5 и более сеансов — 18 (7,9%). Средний показатель PCI (peritoneal cancer index) на старте лечения составил 10,3. Более 90% больных имели диффузный тип первичной опухоли желудка по Lauren. Наиболее частыми побочными явлениями после ВАХД были болевой синдром и лихорадка. Послеоперационная летальность составила 0,036% (перфорация тонкой кишки). Лечебный патоморфоз в перитонеальных очагах (Peritoneal Regression Grading Score) оценен у 128 больных, получивших 2 сеанса ВАХД и более. Полный и выраженный морфологический ответ (PRGS 1 и 2) зафиксирован у 67% больных. Медиана общей выживаемости для всех больных составила 15 мес, 1-годичная выживаемость — 66,2%. <h3>ЗАКЛЮЧЕНИЕ</h3> Таким образом, сочетанная системная и внутрибрюшная аэрозольная химиотерапия под давлением является безопасным и эффективным методом паллиативного лечения больных с первичным диссеминированным РЖ. Неблагоприятными факторами прогноза при проведении сочетанной системной и внутрибрюшной химиотерапии являются молодой возраст (моложе 40 лет), высокий PCI на старте лечения (более 18), наличие асцита, а также прогрессирование на фоне предшествующей системной химиотерапии. Данный метод индуцирует выраженный лечебный патоморфоз в перитонеальных очагах у 67% больных и демонстрирует обнадеживающие показатели выживаемости.

The Impact of Multidisciplinary Team Approach on Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis.

Background: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS–HIPEC) is a therapeutic approach used to achieve curative treatment in intra-abdominal malignancy with peritoneal carcinomatosis (PC). However, it is a complicated procedure with high post-operative complication rates. Thus, we analyzed our preliminary data to establish whether multidisciplinary teamwork (MDT) implementation is beneficial for CRS–HIPEC outcomes. Method: A series of 132 consecutive patients with synchronous or recurrent PC secondary to gastrointestinal or gynecologic cancer who received CRS–HIPEC operation between May 2015 and September 2017 were included. Ninety-nine patients were categorized into the MDT group, with the 33 other patients into the non-MDT group. Results: The mean PCI score was 16.3 ± 8.8. Patients in the MDT group more often presented a higher PCI score (p value = 0.038). Regarding CRS completeness (CCR 0–1), it was distributed 81.8% and 57.6% in the MDT and the non-MDT group, respectively (p value = 0.005). Although post-operative complications were common (n = 62, 47.0%), post-operative complication rates did not differ between the two groups. The cumulative OS survival rate at the first year was 75.5%. Older age (p = 0.030, HR = 4.58, 95% CI = 1.16–18.10), ECOG 2 (p = 0.030, HR = 6.41, 95% CI = 1.20–34.14), and incomplete cytoreduction (p = 0.048, HR = 2.79, 95% CI = 1.04–8.27) were independent prognostic factors for survival. Conclusions: Our experience suggests that the CRS–HIPEC performed under MDT cooperation may result in higher complete cytoreduction rates without increasing post-operative complications and hospital mortalities.

INFLUENCE OF SOMATIC MUTATIONS OF KRAS, NRAS, BRAF AND MICROSATELLITE INSTABILITY STATUS ON SURVIVAL OF COLORECTAL CANCER PATIENTS WITH PERITONAL CARCINO

Purpose: to evaluate the effect of somatic mutations of the KRAS, NRAS, BRAF genes and the status of microsatellite instability on the overall and disease-free survival of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.Material and Methods. From 2012 to 2018, the study included 45 patients who underwent surgery for synchronous peritoneal carcinomatosis with colorectal cancer. In all patients, mutations of the KRAS, NRAS, BRAF genes and MSI status of the tumor and peritoneum metastases were determined using Sanger sequencing, fragment analysis and digital droplet polymerase chain reaction. The effect of mutations on patient survival was evaluated.Results. The prevalence of somatic mutations was 69 % of patients. The discordance between the tumor and peritoneum metastases was 9 %. All tumors and peritoneum metastases were microsatellite stable. KRAS, NRAS, BRAF mutations did not affect the overall and disease-free survival (p=0.87 and p=0.85, respectively).Conclusion. Somatic mutations in the KRAS, NRAS, or BRAF genes are not a prognostic factor affecting the overall and relapse-free survival of colorectal cancer patients with peritoneal carcinomatosis. The molecular status of primary tumor may differ from the status of peritoneal metastasis. It should be taken into account when prescribing targeted drugs.

Development and Validation of an Image-based Deep Learning Algorithm for Detection of Synchronous Peritoneal Carcinomatosis in Colorectal Cancer.

The aim of this study was to build a SVM classifier using ResNet-3D algorithm by artificial intelligence for prediction of synchronous PC. Adequate detection and staging of PC from CRC remain difficult. The primary tumors in synchronous PC were delineated on preoperative contrast-enhanced computed tomography (CT) images. The features of adjacent peritoneum were extracted to build a ResNet3D + SVM classifier. The performance of ResNet3D + SVM classifier was evaluated in the test set and was compared to routine CT which was evaluated by radiologists. The training set consisted of 19,814 images from 54 patients with PC and 76 patients without PC. The test set consisted of 7837 images from 40 test patients. The ResNet-3D spent only 34 seconds to analyze the test images. To increase the accuracy of PC detection, we have built a SVM classifier by integrating ResNet-3D features with twelve PC-specific features (P < 0.05). The ResNet3D + SVM classifier showed accuracy of 94.11% with AUC of 0.922 (0.912-0.944), sensitivity of 93.75%, specificity of 94.44%, positive predictive value (PPV) of 93.75%, and negative predictive value (NPV) of 94.44% in the test set. The performance was superior to routine contrast-enhanced CT (AUC: 0.791). The ResNet3D + SVM classifier based on deep learning algorithm using ResNet-3D framework has shown great potential in prediction of synchronous PC in CRC.

Routine baseline serum carcinoembryonic antigen as a negative predictor of peritoneal metastasis in colorectal malignancies: a cost-effective tool in South India

Background: Colorectal cancer, a formidable health problem worldwide has upto 8% synchronous peritoneal carcinomatosis. As only diagnostic laparoscopy can identify them, in countries with economic burden, selection of patients for laparoscopy is ideal. Our aim is to evaluate whether the baseline Carcinoembryonic antigen (CEA) is a good selection tool.Methods: A retrospective study of 125 patients, who were diagnosed to have colorectal malignancy (any stage) and underwent elective surgery at our institution from 2012 till 2019 were included. The baseline serum CEA was compared with the intraoperative findings. The threshold levels of serum CEA compared were 6.5 and 100 ng/dl. The sensitivity, specificity, positive predictive value and negative predictive value for both thresholds were compared in 3 categories of patients, namely peritoneal metastasis (9 cases), metastasis to other organs (36 cases) and cases with no metastasis either in peritoneum or other organs (85 cases). The results were analysed using SPSS software.Results: The mean age was 65, sex ratio (male:female) was 72:53. The sensitivity, specificity, positive predictive value, negative predictive value (NPV) for CEA threshold of 6.5 ng/dl was 44.44%, 60.34%, 8% and 93.33% for category 1. For CEA threshold of 100 ng/dl, it was 33.33%, 97.41%, 50% and 94.95% for category 1. NPV was 96.55% for category 3 (the highest value).Conclusions: If the baseline CEA levels are less than 100 ng/dl, 96.55% of cases will not require a diagnostic laparoscopy. This hopefully will cut down the cost of unnecessary diagnostic laparoscopies, and reduce the morbidity of unnecessary laparotomies.

A computed tomography-based nomogram for preoperative prediction of synchronous peritoneal carcinomatosis in colorectal cancer.

14 Background: Peritoneal carcinomatosis (PC) of colorectal cancer remain poor and is considered to be the terminal stage. Early detection of PC can bring survival benefit for chances of complete cytoreductive surgery. In this study, we have developed and validated a CT-based nomogram for preoperative prediction of synchronous PC in CRC. Methods: The CT-based nomogram optimized for image classification of PC was developed and validated in a large cohort. The specific features of synchronous PC were extracted from preoperative CT arterial stage scans by radiologists. A CT-based model was constructed by Boruta algorithm and multivariate logistic regression in the training set and validated in the test set. A CT-based nomogram was then built to predict the risk value of PC. The performance and efficacy of this nomogram to discriminate PC were assessed. Results: A total of 170 eligible CRC patients with synchronous PC were randomly divided into a training set (n = 92) and a validation set (n = 78). After processing and partition, five items of PC-related features including tumor location, cT stage, distant metastasis, thickened greater omentum and pelvic nodules were enrolled into this CT-based model. In the training set, the ROC shows AUC of CT-based model was 0.929(95% CI: 0.764-0.946). The sensitivity was 73.2% and the specificity was 98.3%. The positive predictive value (PPV) was 82.26%, while the negative predictive value (NPV) was 100%. In the test set, AUC by the ROC was 0.855(95% CI: 0.764-0.946). The sensitivity of CT-based model was 72.7% and the specificity was 93.3%. The PPV was 82.35%, while the NPV was 88.89%. These results show high predicted accuracy of CT-based model in diagnosis of synchronous PC both in the training set and test set. A nomogram based on these five preoperative predictors of PC was created. This CT-based nomogram showed good diagnostic performance by calibration curve. The decision curves analysis revealed high benefit of this CT-based nomogram in clinical decision. Conclusions: The CT-based nomogram has shown great potential in the detection and diagnosis of synchronous peritoneal metastasis in colorectal cancer.

Clinical outcomes of curative treatment for colorectal liver metastases combined with cytoreductive surgery and intraperitoneal chemotherapy for peritoneal metastases: a systematic review and meta-analysis of current evidence

Background The optimal treatment for colorectal cancer (CRC) with synchronous peritoneal carcinomatosis (PC) and liver metastases (LM) remains controversial. We aimed to investigate clinical outcomes in patients with CRC and concomitant PC and LM who had undergone curative surgery, including resections at both metastatic sites and synchronous intraabdominal chemotherapy. Methods We searched PubMed, EMBASE, and Web of Science databases for eligible studies. Studies focusing on the clinical effects of curative surgery and synchronous intraabdominal chemotherapy for patients with CRC and concomitant PC and LM were included. Meta-analysis results were recorded as hazard ratios (HRs), risk ratios (RRs) and mean differences. Results We included 9 of 998 identified studies in the meta-analysis, involving 746 patients (221 patients with PC + LM, 525 patients with PC). Overall survival (pooled HR 1.68, 95% confidence interval [CI] 1.33–2.13, p < 0.01) and disease-free survival (pooled HR 1.82, 95% CI 1.51–2.20, p < 0.01) were both lower in patients with PC + LM. A higher recurrence rate (RR 1.22, 95% CI 1.04–1.44, p = 0.02) and major postoperative morbidity (RR 1.47, 95% CI 1.19–1.82, p < 0.01) were also observed in patients with PC + LM. Conclusion Liver resection in combination with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for patients with CRC and synchronous hepatic and peritoneal metastases may be associated with worse survival and higher morbidity compared with patients with isolated PC. More restricted patient inclusion criteria should be established to facilitate an optimal prognosis for this patient group.

Prophylactic HIPEC in pT4 Colon Tumors: Proactive Approach or Overtreatment?

BackgroundThe peritoneum is the second most common site for metastasis in patients with colorectal cancer. Various factors have been studied to identify patients at risk of developing peritoneal carcinomatosis (PC), including T4 tumors. The objectives were to assess the incidence of synchronous and metachronous PC, explore potential risk factors for developing PC as the only site of metastasis, and identify which patients might be candidates for prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsWe conducted a retrospective analysis of 125 patients with pT4 colon cancer who underwent surgery in a single center between January 2010 and December 2014.ResultsOf the 947 colon cancer patients who underwent surgery, 125 (13.2%) were diagnosed with pT4a or b colon carcinoma. The median follow-up was 3.7 years. The overall rate of PC was 34.3%, being synchronous in 12% and metachronous in 22.3% of cases. The 8% and 6% of synchronous and metachronous cases of PC respectively were isolated (single site) metastasis. The incidence of PC was 6.1% at 1 year and 14.5% at 3 years after surgery. pT4 was not found to be an independent risk factor for the development of PC (p = 0.231). Nonetheless, the rate of metachronous PC as a single site of metastasis was higher in patients with pT4 tumors and peritoneal nodules around the primary tumor and/or tumor perforation (p = 0.027) and/or who underwent emergency surgery (p = 0.043) than other patients.ConclusionsConsidering pT4 tumor stage as the only risk factor for the development of PC in deciding whether to administer prophylactic HIPEC would lead to unjustified overtreatment.

The status analysis of diagnosis and treatment of synchronous peritoneal carcinomatosis from colorectal cancer in China: a report of 1 003 cases in 16 domestic medical centers

Objective: To analyze the status of domestic surgical treatment of synchronous peritoneal carcinomatosis from colorectal cancer in China. Methods: Clinicopathological data of patients who underwent surgery from October 2003 to October 2018 in 16 domestic medical centers was retrospectively analyzed. Excel database was created which covered 77 fields of 7 parts: baseline information of patients, laboratory tests, imaging tests, chemoradiotherapy information, intra-operative findings, postoperative pathology and follow-up data. The Wilcoxon rank-sum test was used for comparison of the measurement data between groups. The χ(2) test was used for comparison of the categorical data between groups. The survival curve was calculated by the Kaplan-Meier method. Results: Of the 1 003 patients, there were 575 male and 428 female patients with the age of (58.5±14.1) years (range: 18 to 92 years). In a total of 920 patients, the carcinoma of sigmoid colon was performed in 292 cases (31.8%) with the highest ratio. The proportion of patients with liver metastasis and lung metastasis were 27.9% (219/784) and 8.3% (64/769). Preoperative detection of carcino-embryonic antigen level was the most common method in China (87.74%, 880/1 003), and the positive rate was 64.5% (568/880). The correct rate of preoperative imaging tests was 40.7% (280/688). The ratio of peritoneal carcinomatosis index (PCI) scores between 0 and 10 was the highest (59.6%, 170/285). Two hundred and sixty-two (27.0%) patients were performed by totally laparoscopic operation in 971 patients. The resection of primary tumor was performed in 588 of the 817 patients (72.0%). In a total of 457 cases, 253 (55.4%) patients were performed cytoreduction which group scored completeness of cytoreduction (CCR) 0. The postoperative hyperthermic intraperitoneal chemotherapy was implemented in 70 of the 334 cases (21.0%). Among 1 003 cases, 562 cases (56.03%) had complete follow-up data and the median overall survival was 15 months. The primary tumor resection and the CCR scores were affected by the PCI scores. The patients underwent primary tumor resection (187/205 vs. 26/80, χ(2)=105.085, P=0.000) and the patients were performed cytoreduction which scored CCR 0 or CCR 1 (162/204 vs. 8/78, Z=-10.465, P=0.000) had significant difference between the groups of PCI<20 and ≥20. There was a close correlation between the surgical method and the CCR scores (Z=-3.246,P=0.001).When the maximum degree of tumor reduction was planned, most surgeons would choose laparotomy. The overall survival time was longer in patients with primary tumor resection (P=0.000). The median survival time was 18.6 months in the group of primary tumor resection. Conclusions: It is difficult to diagnose the synchronous peritoneal carcinomatosis from colorectal cancer before the operation. Primary tumor resection has an obvious effect to prolong the survival time. It is necessary to standardize the treatment of peritoneal metastasis.

Peritoneal carcinomatosis in non-small-cell lung cancer: retrospective multicentric analysis and literature review.

We investigated outcomes in patients with advanced non-small-cell lung cancer (NSCLC) and peritoneal involvement. NSCLC patients with peritoneal carcinomatosis (PC) were included. We evaluated mOS1 (overall survival [OS] from NSCLC diagnosis) and mOS2 (OS from diagnosis of PC). In total, 60 NSCLC patients were diagnosed with PC, 12 (20%) patients had a diagnosis of NSCLC and synchronous PC with a median OS of 9months. Smokers had a shorter mOS1 and mOS2 compared with never-smokers; EGFR-mutated patients on tyrosine kinase inhibitors had longer mOS1 and mOS2 than EGFR wild-type patients. Metachronous PC is correlated to a short survival, irrespective of treatment line. Never-smokers and EGFR-mutated patients had improved mOS1 and mOS2 when compared with smokers and EGFR wild-type population.

Should Liver Metastases and Synchronous Peritoneal Carcinomatosis of Colorectal Origin Be Treated Simultaneously ?

Should Liver Metastases and Synchronous Peritoneal Carcinomatosis of Colorectal Origin Be Treated Simultaneously ?

Cirugía de second look más HIPEC en pacientes sin evidencia de recidiva con alto riesgo de desarrollar carcinomatosis tras resección de cáncer colorrectal

IntroductionTo analyze the impact of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) performed 1 year after resection of the primary tumor, in asymptomatic patients at high risk of developing peritoneal carcinomatosis (PC). MethodsBetween 2012-2016, 33 patients without any sign of peritoneal recurrence on imaging studies were prospectively included in the study and underwent second-look surgery aimed at treating limited PC earlier and were prospectively recorded. They were selected based on 5 primary tumor-associated criteria: resected minimal synchronous macroscopic PC (n = 10), synchronous ovarian metastases (n = 2), positive peritoneal cytology (n = 2), pT4 primary tumors (n = 15) and perforation (n = 4). ResultsPC was found and treated by cytoreduction plus HIPEC in 10 of the 33 (30.3%) patients, although it was detected in only 2/15 patients of the pT4 subgroup (13.3%). The patients without PC underwent complete abdominal exploration plus HIPEC. Median follow-up was 14.5 months. One patient died postoperatively at day 55. Severe morbidity rate (Clavien-Dindo III-V) was low (15.2%). The 3-year overall survival rate was 93% and the 3-year disease-free survival rate was 33%. Peritoneal recurrences occurred in 4 patients (12.1%), 2 of whom had macroscopic PC discovered at the second-look (20%), while the other 2 patients had no macroscopic PC (8.7%) (P = .04). ConclusionsThe second look + HIPEC strategy in our series of patients at high risk of developing PC, allows its early detection and its treatment in 30.3% of cases, with a very low rate of peritoneal recurrence. It is important to continue evaluating the results to increase the accuracy of the inclusion criteria, especially the pT4 criterion that in this series has a low predictive power for the occurrence of PC.

Systematic Second-look Surgery Plus HIPEC in Patients Without Evidence of Recurrence, at High Risk of Carcinomatosis After Colorectal Cancer Resection

IntroductionTo analyze the impact of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) performed 1 year after resection of the primary tumor, in asymptomatic patients at high risk of developing peritoneal carcinomatosis (PC). MethodsBetween 2012 and 2016, 33 patients without any sign of peritoneal recurrence on imaging studies were prospectively included in the study and underwent second-look surgery aimed at treating limited PC earlier and were prospectively recorded. They were selected based on 5 primary tumor-associated criteria: resected minimal synchronous macroscopic PC (n=10), synchronous ovarian metastases (n=2), positive peritoneal cytology (n=2), pT4 primary tumors (n=15) and perforation (n=4). ResultsPC was found and treated by cytoreduction plus HIPEC in 10 of the 33 (30.3%) patients, although it was detected in only 2/15 patients of the pT4 subgroup (13.3%). The patients without PC underwent complete abdominal exploration plus HIPEC. Median follow-up was 14.5 months. One patient died postoperatively at day 55. Severe morbidity rate (Clavien–Dindo III–V) was low (15.2%). The 3-year overall survival rate was 93% and the 3-year disease-free survival rate was 33%. Peritoneal recurrences occurred in 4 patients (12.1%), 2 of whom had macroscopic PC discovered at the second-look (20%), while the other 2 patients had no macroscopic PC (8.7%) (P=.04). ConclusionsThe second look+HIPEC strategy in our series of patients at high risk of developing PC, allows its early detection and its treatment in 30.3% of cases, with a very low rate of peritoneal recurrence. It is important to continue evaluating the results to increase the accuracy of the inclusion criteria, especially the pT4 criterion that in this series has a low predictive power for the occurrence of PC.

Establishment of nomogram model to predict peritoneal metastasis in colon cancer patients without distant metastasis by preoperative imaging examination

To establish a nomogram model to predict the peritoneal metastasis in colon cancer patients without distant metastasis by preoperative imaging examination. Clinicopathological data of colon cancer patients without distant metastasis by preoperative imaging examination who underwent surgery in our department between January 2000 and December 2014 were retrospectively analyzed. Predictors of peritoneal carcinomatosis were analyzed by univariate and Logistic multivariate analyses. Base on the independent predictors by multivariable analysis results, a nomogram model was formulated with further use of R software. The total score was calculated by the addition of each predictor score, indicating the corresponding risk of peritoneal metastasis. The score was greater in the nomogram, and the risk was higher in peritoneal implantation metastasis. A receiver operating characteristic(ROC) curve was then constructed to evaluate the predictive abilities of the various preoperative factors and nomogram. A total of 1 417 patients were defined as above and enrolled in the study. The median age was (60.5±13.3) years, 835 cases (58.9%) were male, and 132 cases (9.3%, 132/1417) were diagnosed with synchronous peritoneal carcinomatosis during operation. Univariate analysis showed that peritoneal metastasis was associated with age, incidence of abdominal pain, incidence of mucous bloody stool, CEA level, traversible rate, tumor diameter, ratio of infiltrating type cancer, differentiation, histological type, cT staging and cN staging (all P<0.05). Logistic multivariate analysis revealed that younger age (OR:0.974, 95%CI: 0.958 to 0.990, P=0.001), later clinical T stage (OR: 2.949, 95%CI: 1.588 to 5.476, P=0.001), lesion not traversible(OR: 0.519, 95%CI: 0.314 to 0.858, P=0.011), infiltrative gross type (OR: 1.812, 95%CI: 1.099 to 2.987, P=0.020), larger tumor (OR: 1.044, 95%CI: 0.998 to 1.093, P=0.061), higher preoperative serum CEA level(OR:1.004,95%CI: 1.001 to 1.007, P=0.007) and histopathologic type of mucinous or signet ring cell adenocarcinoma (OR:1.642, 95%CI: 1.009 to 2.673, P=0.046) were independent risk factors. The nomogram model was further established based on above 7 independent risk factors, whose total score was 350 and area under the ROC curve was 0.753(P=0.000). The nomogram model can be helpful to screen the colon cancer patients with high risk of peritoneal metastasis and to avoid unnecessary laparotomy for colon cancer patients without distant metastasis by preoperative imaging examination.

Overall and disease-free survival in patients treated with CRS + HIPEC with cisplatin and paclitaxel for gastric cancer with peritoneal carcinomatosis

Our experience regarding cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) was reviewed in terms of overall survival (OS) and disease-free survival (DFS) in patients with synchronous peritoneal carcinomatosis (SPC) and metachronous peritoneal carcinomatosis (MPC) from gastric cancer (GC). An analysis of prospectively collected data about patients who underwent CRS and HIPEC from July 2011 to July 2016 was carried out. Patients and tumor characteristics were taken into consideration together with pre and post-operative data. The outcomes concerned OS and DFS in both groups. A total of 17 cases were reported. All patients of SPC group underwent neoadjuvant chemotherapy, while all patients of MPC group underwent adjuvant chemotherapy subsequently to surgery of the primary tumor. The mean follow up period was 9 months (SD±9.5). Thirteen patients (76.5%) had SPC and four (23.5%) had MPC. The mean total Peritoneal Cancer Index (PCI) was 8.5 (SD±8.4). The mean PCI was 3.75 (SD±4.9) for SPC group and 16 (SD±9.5) for MPC (P=0.003). HIPEC regimen was cisplatin plus paclitaxel for fourteen patients (82.4%) and cisplatin plus mitomycin-C (MMC) for three patients (17.6%). OS was 16 months and 6 months respectively in patients with SPC and MPC (P=0.189). DFS was 11 months and 2 months respectively in the two groups (P=0.156). Patients with SPC patients and PCI ≥12 were significantly different in terms of DFS from SPC with PCI <12 (P=0.001). Overall, twelve patients had postoperative major complications (CTCAE>2), in particular eight (61%) in SPC group while four (100%) in MPC group. Our study showed significantly better DFS for patients aged >60 years (P=0.016). HIPEC and CRS with cisplatin and paclitaxel in patients with PC from GC showed promising results in improving the DFS and the OS, particularly for patients with PCI <12 and for those aged >60. Although a high incidence of complications was revealed, especially in MPC group.