Phase II Study of Single Intraperitoneal Chemotherapy Followed by Systemic Chemotherapy for Gastric Cancer with Peritoneal Metastasis

Background

We conducted a phase II study involving a single administration of intraperitoneal chemotherapy with paclitaxel followed by sequential systemic chemotherapy with S-1+ paclitaxel for advanced gastric cancer patients with peritoneal metastasis.

Methods

Gastric cancer patients with peritoneal metastasis were enrolled. Paclitaxel (80?mg/m²) was administered intraperitoneally at staging laparoscopy. Within 7?days, patients received systemic chemotherapy with S-1 (80?mg/m²/day on days 1?C14) plus paclitaxel (50?mg/m² on days 1 and 8), followed by 7-days rest. The responders to this chemotherapy underwent second-look laparoscopy, and gastrectomy with D2 lymph node dissection was performed in patients when the disappearance of peritoneal metastasis had been confirmed. The primary endpoint of the study was overall survival rate.

Results

Thirty-five patients were enrolled. All patients were confirmed as having localized peritoneal metastasis by staging laparoscopy. Eventually, gastrectomy was performed in 22 patients. The median survival time of the total patient population and those patients in which gastrectomy was performed was 21.3 and 29.8?months, respectively. The overall response rate was 65.7?% for all patients. The frequent grade 3/4 toxic effects included neutropenia and leukopenia.

Conclusions

Sequential intraperitoneal and intravenous paclitaxel plus S-1 was well tolerated in gastric cancer patients with peritoneal metastasis.     

Prognostic Significance of Non-curative Gastrectomy for Incurable Gastric Carcinoma

Background

To date, there is no convincing evidence regarding the benefits of non-curative gastrectomy for gastric carcinoma. In the present study, we reviewed the outcomes of patients who underwent surgery for incurable gastric carcinoma and evaluated the prognostic significance of non-curative gastrectomy.

Methods

Between 2004 and 2011, a total of 197 patients undergoing elective surgery for incurable gastric carcinoma were divided into the gastric resection and non-resection groups. Patient survival was compared between the two groups, and the prognostic significance of non-curative gastrectomy was investigated using multivariate analysis.

Results

Overall, 162 (82.2 %) patients underwent non-curative gastrectomy with morbidity and mortality of 21.0 and 1.2 %, respectively. The median survival of patients undergoing non-curative gastrectomy was significantly longer than that of patients without gastrectomy (12.4 vs. 7.1 months, p = 0.003). Patients who received postoperative chemotherapy also showed significantly better survival than those without chemotherapy (13.2 vs. 4.3 months, p < 0.001). Multivariate analysis revealed that non-curative gastrectomy was an independent prognostic factor (hazard ratio 0.61, 95 % CI 0.40–0.93, p = 0.023) after adjusting for postoperative chemotherapy and other clinical factors. Median survival in patients receiving non-curative gastrectomy combined with postoperative chemotherapy was 13.9 months, which was significantly longer than gastrectomy alone (5.4 months), chemotherapy alone (9.6 months), and no treatment (3.2 months) (p < 0.001).

Conclusion

Primary tumor resection and postoperative chemotherapy are the most important prognostic factors for incurable gastric carcinoma. The survival benefits of non-curative gastrectomy need to be confirmed in a large-scale, randomized trial.     

Laparoscopic cytoreductive surgery and early postoperative intraperitoneal chemotherapy for patients with colorectal cancer peritoneal carcinomatosis: initial results from a single center

Background

In recent decades, a combination of cytoreductive surgery and intraperitoneal chemotherapy has yielded improvements in the survival of patients with peritoneal carcinomatosis. Laparoscopic cytoreductive surgery and intraperitoneal chemotherapy comprise a challenging and rarely reported surgical procedure.

Methods

Between November 2004 and February 2010, 29 patients underwent cytoreductive surgery and early postoperative intraperitoneal chemotherapy for peritoneal carcinomatosis secondary to colorectal cancer. Of the 29 patients, 15 underwent laparoscopic surgery and 14 underwent open surgery.

Results

The patient characteristics did not differ significantly between the two groups. Synchronous peritoneal carcinomatosis with a primary tumor was more common in the laparoscopic group, and the Gilly stage of peritoneal carcinomatosis was found more frequently in the open group. Complication rate and hospital stay were less in the laparoscopic group. However, the outcomes for the patients undergoing the combined treatment were similar between the two groups with respect to completeness of cytoreduction, operation morbidity, and overall survival. The laparoscopic group had a cytoreduction completeness of 86.7 % and an operative morbidity of 13.3 %. Operative mortality occurred for one patient after open surgery.

Conclusions

Laparoscopic cytoreductive surgery and early postoperative intraperitoneal chemotherapy can be performed safely for selected patients with peritoneal carcinomatosis from colorectal cancer to a limited extent. Further studies with longer follow-up periods and larger numbers of patients are warranted to confirm the study findings.     

Complete Cytoreduction and HIPEC Improves Survival in Desmoplastic Small Round Cell Tumor

Background

Desmoplastic small round cell tumor (DSRCT) is a rare tumor of adolescents and young adults. Less than 100 cases per year are reported in North America. Extensive peritoneal metastases are characteristic of this disease. We performed cytoreductive surgery and hyperthermic peritoneal perfusion with chemotherapy (HIPEC) using cisplatin (CDDP) for DSRCT.

Methods

A retrospective cohort study was performed on 26 pediatric and adult patients who underwent cytoreduction/HIPEC using CDDP for DSRCT at a single cancer center. Neoadjuvant chemotherapy, adjuvant chemotherapy, and postoperative enteral nutrition were given to all patients. Postoperative radiation therapy was given to most patients. Follow-up was from 6 months to 6 years. Outcome variables were evaluated for disease-free and overall survival (OS).

Results

Five patients (19 %) were less than 12 years of age at surgery. Patients who had disease outside the abdomen at surgery had a larger risk of recurrence or death than those who did not (p = 0.0158, p = 0.0393 time from surgery to death respectively). Age, liver metastasis, and peritoneal cancer index level did not significantly predict disease-free or OS. Patients who had CR0 or CR1 and HIPEC had significantly longer median survival compared with patients who had HIPEC and CR2 cytoreduction (63.4 vs. 26.7 months).

Conclusions

HIPEC may be an effective therapy for children and young adults with DSRCT. Patients with DSRCT require complete cytoreduction before HIPEC to optimize outcome. Patients with DSRCT and disease outside the abdomen at the time of surgery do not benefit from HIPEC.     

Role of Repeat Staging Laparoscopy in Locoregionally Advanced Gastric or Gastroesophageal Cancer after Neoadjuvant Therapy

Introduction

Staging laparoscopy (SL) can identify occult, subradiographic metastatic (M1) disease in patients with gastric or gastroesophageal (G/GEJ) cancer who are unlikely to benefit from gastrectomy. The purpose of this study is to determine the yield of repeat SL following neoadjuvant therapy for G/GEJ adenocarcinoma after initial negative pretreatment SL.

Methods

Retrospective review of a prospective database identified patients with locoregionally advanced (T3–4Nany or TanyN+) G/GEJ adenocarcinoma who underwent pretreatment SL. The yield of repeat SL following neoadjuvant therapy was determined.

Results

From 1994 to 2010, 276 patients with locoregionally advanced G/GEJ adenocarcinoma were identified, of whom 244 proceeded to operation after neoadjuvant therapy, at a median time of 105 days. One hundred sixty-four patients (67 %) underwent repeat SL, and 80 patients (33 %) proceeded directly to laparotomy. Occult M1 disease was identified in 12 (7.3 %) and 6 (7.5 %) patients, respectively. In the repeat SL cohort, M1 disease was identified at laparoscopy in nine patients (5.5 %). M1 disease not identified by laparoscopy was discovered at laparotomy in three patients (1.8 %). The median follow-up for the study population was 31 months. For patients with M1 disease, median overall survival was 15 months, versus 41 months for patients resected without M1 disease (p < 0.0001).

Conclusions

Occult, subradiographic M1 disease develops in approximately 7 % of patients following neoadjuvant therapy for locoregionally advanced G/GEJ adenocarcinoma. These patients have poor prognosis, and repeat SL can be a valuable tool in selecting patients with locoregionally advanced G/GEJ tumors for potentially curative resection after neoadjuvant therapy.     

The incremental benefit of two quadrant lavage for peritoneal cytology at staging laparoscopy for oesophagogastric adenocarcinoma

Background

Patients with positive peritoneal cytology from oesophagogastric cancer have a poor prognosis. The purpose of this study was to compare lavage cytology from the pelvis alone with the pelvis and subphrenic areas at staging laparoscopy in patients with potentially resectable oesophagogastric adenocarcinoma.

Methods

Between November 2006 and November 2010, all patients with operable oesophagogastric adenocarcinoma on spiral CT considered fit for surgical resection underwent staging laparoscopy. Subphrenic and pelvic peritoneal lavage for cytology was performed followed by laparoscopic biopsy of any visible peritoneal disease. Patients were divided into groups: macroscopic peritoneal metastases (P+), no macroscopic peritoneal disease with negative cytology (P?C?), no macroscopic peritoneal disease with positive pelvic cytology (P?PC+), no macroscopic peritoneal disease with positive subphrenic cytology (P?SC+), or both (P?PSC+).

Results

A total of 316 staging laparoscopy procedures were performed; 245 patients (78 %) were P?C?, 28 (9 %) were P+, and 43 (14 %) were P?C+, of whom 29 (9 %) were P?PSC+, 10 (3 %) were P?SC+, and 4 (1 %) were P?PC+. Pelvic cytology alone had 76.7 % sensitivity for peritoneal disease, and subphrenic cytology alone had 90.7 % sensitivity.

Conclusions

Peritoneal lavage for cytology at staging laparoscopy has an incremental benefit for staging oesophagogastric adenocarcinoma in the absence of macroscopic metastatic disease. Subphrenic washings have the highest yield of positive results. Performing isolated pelvic washings for cytology will understage 23.3 % of patients with microscopic peritoneal disease. The routine use of subphrenic in combination with pelvic lavage for cytology at staging laparoscopy in patients with oesophagogastric adenocarcinoma has an incremental benefit in detecting cytology-positive disease over either pelvic or subphrenic cytology alone.     

Short-Term Outcomes of Totally Laparoscopic Total Gastrectomy: Experience With the First Consecutive 112 Cases

Introduction

Although laparoscopic distal gastrectomy has become a viable treatment option for gastric cancer, laparoscopic total gastrectomy remains in limited use.

Purpose

The present study was designed to evaluate the short-term outcomes of totally laparoscopic total gastrectomy (TLTG).

Methods

The records of 112 consecutive patients who underwent TLTG for gastric cancer between September 2006 and November 2012 were reviewed, and surgical outcomes were retrospectively investigated.

Results

Neoadjuvant chemotherapy was given to 21 patients (18.8 %). The degree of lymphadenectomy was D1+ in 83 patients (74.1 %) and D2 in 29 (25.9 %). The operation time was 359 min, median intraoperative blood loss was 85 ml, and median total number of harvested lymph nodes was 64. Grade II or higher postoperative complications developed in 25 patients (22.3 %). On univariate analysis, pathologic stages IB to IV (versus stage IA) overlapped esophagojejunostomy (versus functional end-to-end esophagojejunostomy) and operation time >360 min (versus ≤360 min) were related to postoperative morbidity. In the multivariate analysis, operative time and pathologic stage were independent risk factors for postoperative complications.

Conclusions

TLTG is feasible and can be performed with acceptable postoperative morbidity. A longer operating time and more advanced pathologic stage were significantly associated with higher postoperative morbidity.     

Peritonectomy for Peritoneal Carcinomatosis: Long-Term Outcomes from a Single Brazilian Institution

Background

The objective of this study was to evaluate the long-term outcomes of a single institution, Hospital Sírio-Libanes in São Paulo, Brazil, regarding the treatment of peritoneal carcinomatosis.

Methods

Between October 2002 and October 2006, 46 consecutive patients were treated with radical cytoreduction and hyperthermic peritoneal chemotherapy. There were 21 patients with peritoneal surface malignancy (PSM) from colorectal origin (among whom 8 had an appendiceal primary), 15 with ovarian carcinomas, 2 with primary peritoneal mesotheliomas, and 8 with other cancers. The median age was 49 years (range 18–77 years). All patients were followed for a median of 20 months. Demographic data, tumor histology, the peritoneal carcinomatosis index (PCI), operative procedures (extension of resection, lymphadenectomy), and hyperthermic intraperitoneal chemotherapy (HIPEC) characteristics (drugs, temperature, duration) were prospectively recorded. Perioperative mortality and morbidity and the long-term outcome were assessed.

Results

Complete cytoreduction was achieved in 45 patients. The median PCI was 11, and the mean operating time was 17 h. There were no procedure-related deaths, but major morbidity was observed in 52% and included fistulas, abscesses, and hematologic complications. The overall Kaplan–Meier 4-year estimated survival was 56%. Among patients with PSM from colorectal carcinoma, the estimated 3-year survival was 70%. Nine (42%) patients had a recurrence, three with peritoneal disease. The median disease-free-interval was 16 months. The ovarian cancer patients had an estimated 4-year survival rate of 75% and median disease-free survival duration of 21 months.

Conclusions

Cytoreductive surgery with HIPEC may improve survival of selected patients with peritoneal carcinomatosis, with acceptable morbidity.     

Repeat Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy May Offer Survival Benefit for Intraperitoneal Mesothelioma: A Single Institution Experience

Introduction

Cytoreduction with heated intraperitoneal chemotherapy (HIPEC) has demonstrated improved overall survival (OS) in malignant peritoneal mesothelioma (MPM). The role of repeated HIPEC for MPM is less clear.

Methods

An institutional review board-approved database of MPM patients was analyzed for clinical factors and outcomes.

Results

From June 2004 to March 2012, 29 patients underwent surgical treatment for mesothelioma. HIPEC was aborted in 3 and completed in 26; 8 underwent additional repeat HIPEC. The majority was male (62 %), median age 66 years. There was no significant difference in surgery duration, blood loss, or hospital-stay-duration between initial and repeat HIPEC. Cisplatin was the chemotherapy used. Complications occurred in 17 (65 %) initial and 6 (50 %) repeat HIPEC, with wound complications being most common. Reoperation was less common (4 % initial and 25 % repeat), and perioperative death was rare (4 % initial, 0 % repeat). Fourteen (54 %) initial and seven (58 %) repeat HIPEC patients received adjuvant chemotherapy. Median time from HIPEC to initiation of chemotherapy was not different between initial and repeat HIPEC (8.8 and 4.6 months, respectively, p = 0.68). Median treatment-free time (time from initial to repeat HIPEC or chemotherapy) also was not different between initial and repeat HIPEC (8.8 and 6.3 months, respectively, p = 0.92). Median OS for the cohort was 41.2 months. Patients who underwent repeat HIPEC had improved median OS (80 months) versus single HIPEC (27.2 months; p = 0.007). A lower peritoneal carcinoma index and complete cytoreduction were associated positively with OS.

Conclusions

Cytoreduction and HIPEC for MPM are associated with longer OS. Patients who are candidates for repeat HIPEC may derive an even greater OS advantage.     

Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy for locally advanced cervical cancer: assessment after 52 consecutive patients

Background

To report the feasibility and reproducibility of single-port extraperitoneal para-aortic (PA) lymphadenectomy exclusively using conventional instruments in locally advanced cervical cancer (LACC) and to evaluate the learning curve.

Methods

From January 2011 to January 2013, 52 a total of consecutive patients with LACC were candidates for extraperitoneal PA lymphadenectomy via an original single-port approach that we developed. All patients underwent positron emission tomography–computed tomography that indicated no PA uptake.

Results

Fifty consecutive patients underwent single-port staging surgery. Two patients had peritoneal carcinomatosis and were not submitted to PA lymphadenectomy. Median age and body mass index were, respectively 47 (range 27–68) years and 23 (range 16–37) kg/m². In one case, lymphadenectomy was unfeasible because of renal vessel anomalies (a bifurcated left renal vein crossed the aorta at the level of the inferior mesenteric artery), and two nodes were removed. Conventional instruments were used in all cases. The median operative time was 180 (range 110–270) min. The median and mean number of nodes removed were, respectively, 18 (range 2–47) and 19.4. Six (12 %) patients had metastatic PA disease. No conversion to laparotomy or conventional multiport laparoscopy was required. The median postoperative hospital stay and the interval between staging surgery and the beginning of chemoradiation were, respectively, 2 (range 1–26) days and 16.5 (range 1–60) days. The learning curve was evaluated at seven procedures with a decreased median operative time at 160 (range 110–240) min.

Conclusions

Extraperitoneal staging via a single-port left iliac approach is feasible with conventional tools, is reproducible and safe, and offers a high degree of cosmetic satisfaction.     

Body Weight Loss After Surgery is an Independent Risk Factor for Continuation of S-1 Adjuvant Chemotherapy for Gastric Cancer

Background

Compliance of S-1 adjuvant chemotherapy is not high. The aim of the present study is to clarify risk factors for continuation of S-1 after gastrectomy.

Methods

This retrospective study selected patients who underwent curative D2 surgery for gastric cancer, were diagnosed with stage 2/3 disease, creatinine clearance more than 60 ml/min, and received adjuvant S-1 at our institution between June of 2002 and December of 2011. Time to S-1 treatment failure (TTF) was calculated.

Results

A total of 103 patients were selected for the present study. When TTF curve stratified by each clinical factor was compared by the log-rank test, body weight loss (BWL) of 15 % was regarded as a critical point. Both univariate and multivariate Cox proportional hazard analyses demonstrated that BWL was the significant independent risk factor. Moreover, BWL remained a significant factor in both the univariate and multivariate analyses in the subset excluding 8 patients who discontinued S-1 because of recurrence. The 6-month continuation rate was 66.4 % in the patients with BWL < 15 and 36.4 % in patients with BWL ≥ 15 % (P = .017).

Conclusions

BWL was the most important risk factor for the compliance of adjuvant chemotherapy with S-1 in the patients with stage 2/3 gastric cancer who underwent D2 gastrectomy. To improve drug compliance that leads to survival, it is a key to maintain body weight before starting S-1 adjuvant. Our study emphasizes the requirement for adequate studies of perioperative nutritional intervention in patients who receive gastrectomy for advanced gastric cancer.     

Suitability of Sentinel Node Mapping as an Index of Metastasis in Early Gastric Cancer Following Endoscopic Resection

Background

When pathological diagnosis following endoscopic resection (ER) for early gastric cancer (EGC) suggests probable lymph node metastasis, additional surgery with lymphadenectomy should be performed. The sentinel node (SN) concept has yet to be applied to tumors following ER. The aim of this study was to evaluate the feasibility of SN navigation surgery for such tumors.

Methods

Forty patients diagnosed with EGC lesions <4 cm in diameter underwent gastrectomy with SN mapping following ER. A technetium-99 m tin colloid solution and a dye were injected into the submucosal layer around the post-ER scar in all four abdominal quadrants. We then compared the SN distribution and metastases among the patients who underwent ER and controls (n = 192).

Results

SNs were identifiable in all patients, and the mean number of SNs per case was 4.9. The location of the SN basin was similar in the patients who underwent ER and the controls. One patient (3 %) whose primary tumor had invaded the submucosal layer had a metastatic SN. The median time from ER to surgery was 73 days. No postoperative recurrence was observed in any patient over a median follow-up of 1,023 days.

Conclusions

Our findings suggest that the SN basin is not greatly affected by ER. The SN concept could be suitable for tumors following ER, but conventional gastrectomy with lymphadenectomy involving the SN basin should be used at present.     

Catheter Tract Recurrence After Percutaneous Biliary Drainage for Hilar Cholangiocarcinoma

Background

Despite its wide use, catheter tract recurrence after percutaneous biliary drainage (PBD) is rarely reported. However, one recent large-scale study reported a catheter tract recurrence rate as high as 5.2 % in patients with perihilar or distal bile duct cancer. We report on our 20 years of experience with catheter tract seeding after PBD for hilar cholangiocarcinoma.

Methods

The medical records of 441 patients who underwent operation for hilar cholangiocarcinoma between 1991 and 2011 were retrospectively analyzed.

Results

Of the 441 patients with hilar cholangiocarcinoma, PBD was performed in 315 patients, and 232 others underwent resection of hilar cholangiocarcinoma with PBD. Catheter tract recurrence developed in 6 patients (2.6 %). The median drainage duration was 30 days, and 1 patient had multiple PBDs. The median time to catheter recurrence after surgery was 10.9 months. Three patients underwent curative resection of the abdominal wall followed by chemotherapy, 1 patient underwent chemotherapy only, and 2 patients received conservative treatment. Five patients in whom the catheter tract recurrence was their first recurrence died of systemic recurrence at median 3.9 months after detection of catheter tract seeding. T1 or 2 disease (66.7 vs. 31.3 %; p = 0.086) tended to have catheter tract seeding with marginal significance. The overall survival rate was lower in patients with catheter tract seeding than in those without (median 17.5 vs. 23.0 months; p = 0.089).

Conclusions

The PBD catheter tract recurrence rate for hilar cholangiocarcinoma was 2.6 %. However, patients with catheter tract recurrence had a poor prognosis despite complete surgical metastasectomy.     

Survival Benefit of Palliative Gastrectomy in Gastric Cancer Patients with Peritoneal Metastasis

Background

The survival benefit of palliative gastrectomy in patients with peritoneal metastasis as a single incurable factor remains unclear.

Methods

A total of 148 gastric cancer patients with peritoneal metastasis underwent gastrectomy or chemotherapy at the Shizuoka Cancer Center between September 2002 and December 2008 and were included in this study. The effects of gastrectomy and chemotherapy on their long-term outcome were investigated. Multivariate analysis was also performed to identify independent prognostic factors.

Results

Gastrectomy was performed in 82 patients and subsequent chemotherapy was administered to 55. Chemotherapy was selected as an initial treatment for 66 patients. Median survival time (MST) was identical between patients with and without gastrectomy (13.1 vs. 12.0?months; P?=?0.410). Conversely, MST was significantly longer in patients who received chemotherapy (13.7?months) than those who did not (7.1?months; P?=?0.048). According to the results of multivariate analysis, chemotherapy (hazards ratio [HR]?=?0.476; 95?% CI?=?0.288–0.787) was selected as an independent prognostic factor, while gastrectomy was not.

Conclusions

The results of the present study did not show a survival benefit of palliative gastrectomy in selected patients with peritoneal metastasis. Instead, chemotherapy has to be considered as an initial treatment for these patients.     

What to Do When It Is Technically Impossible to Perform Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) is increasingly popular with surgeons because of its apparent technical ease. However, performing LSG safely is sometimes not possible during laparoscopy. The objectives of the present study were to (i) describe the context of LSG failure and (ii) suggest preoperative care options or strategies that enable secondary LSG to be performed safely.

Methods

We studied patients having undergone primary and secondary LSG between January 2008 and July 2013. The primary efficacy criterion was the LSG success rate. The secondary efficacy criteria were preoperative care procedures, the complication rate, the failure rate, and the frequency of conversion to open surgery.

Results

During the study period, 954 patients underwent first- or second-line LSG. Laparoscopic sleeve gastrectomy was technically impossible in 12 patients (1.2 %). The cause of failure was a large left liver lobe in seven cases (58.3 %) and a lack of space in five cases. Of these 12 patients, nine underwent secondary LSG. The median preoperative BMI before the first LSG was 51.5 kg/m². The median (range) time interval between the two LSG attempts was 6 months (3–37). Prior to secondary LSG, the preoperative weight reduction measure was a diet in seven cases (78 %), an intragastric balloon in one case, and no treatment in one case. The median preoperative excess weight loss (EWL) before the second LSG was 10 % (0–20). Five LSGs were successful, two required conversion to open surgery, and two failed again. There were two postoperative complications (22 %), both of which concerned the two patients with conversion to laparotomy.

Conclusions

In the event of LSG technical failure, preoperative weight loss may enable a second attempt at laparoscopic treatment. A preoperative EWL of at least 10 % appears to be required for the avoidance of conversion to laparotomy.     

Effects of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in the Treatment of Goblet Cell Carcinoma: A Prospective Cohort Study

Background

Goblet cell carcinoma (GCC) of the appendix is a rare disease. Treatment options vary according to disease staging. Cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) may improve survival in patients with peritoneal spreading.

Objective

The aim of this study was to examine the prognosis of patients with appendiceal GCC treated per protocol, and to evaluate the results of CRS+HIPEC in cases of peritoneal spreading.

Methods

From 2009 to 2016, a total of 48 GCC patients were referred to the European Neuroendocrine Tumour Center of Excellence, Aarhus University Hospital. All patients received treatment per protocol according to disease staging. In patients with localized disease, the treatment was a right hemicolectomy. Patients with peritoneal spread who met the inclusion criteria for CRS + HIPEC, as well as patients with high-risk features of developing peritoneal spread, received CRS + HIPEC. If too-extensive disease was found, palliative chemotherapy was offered.

Results

Overall survival for patients with localized disease (n = 6) or deemed at risk of peritoneal spread (n = 8) was 100% after a median follow-up of 3.5 years. In patients with peritoneal spread and eligible for CRS+HIPEC(n = 27), the median survival was 3.2 years [95% confidence interval (CI) 2.3–4.1] and the 5-year survival rate was 57%. In contrast, the median survival for patients with too-extensive intraperitoneal disease (n = 7) was 1.3 years (95% CI 0.6–2.0), with a 3-year survival rate of 20%.

Conclusions

Long-term survival can be achieved in patients with peritoneal spread treated with CRS + HIPEC. CRS+HIPEC was associated with a favorable outcome in GCC patients at high-risk of developing peritoneal spread.

     

Metallic Stent Placement in Patients with Recurrent Malignant Obstruction in the Surgically Altered Stomach

Purpose

The purpose of this study was to assess the technical feasibility and clinical effectiveness of expandable metallic stent placement in 196 patients with recurrent malignant obstruction in their surgically altered stomach.

Methods

The 196 patients were treated using five different types of gastric surgery performed for gastric cancer: total gastrectomy (type 1) in 73 patients; distal gastrectomy with gastroduodenostomy (type 2) in 39 patients; distal gastrectomy with a Roux-en-Y gastrojejunostomy (type 3) in 21 patients; distal gastrectomy with a gastrojejunostomy (type 4) in 49 patients; and palliative gastrojejunostomy for unresectable gastric cancer (type 5) in 14 patients. The technical and clinical success rates, complications, dysphagia score, and influence of chemotherapy were evaluated and the complications compared between the two stent types. The overall survival and stent patency were calculated using the Kaplan–Meier method.

Results

Stent placement was technically successful in 192 of 196 patients (97.9 %), with 184 of the 192 patients (95.8 %) showing symptomatic improvement. The mean dysphagia score improved from 3.24 ± 0.64 to 1.48 ± 0.82 (p < 0.001). The complication rate was 25 %. The incidence of stent migration was significantly higher in fully covered stents and in patients who underwent chemotherapy (p < 0.001 and p = 0.005, respectively). Chemotherapy was significantly associated with an increase of survival (p < 0.001). The median survival and stent patency were 131 and 90 days, respectively.

Conclusion

Placement of expandable metallic stents in patients with recurrent cancer after a surgically altered stomach is technically feasible and clinically effective. Chemotherapy was associated with increased stent migration and prolonged survival.     

Comparison of Prognostic Scores for Patients with Colorectal Cancer Peritoneal Metastases Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Background

There are three prognostic scores for the cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) treatment of colorectal cancer peritoneal metastases: the newly introduced COREP (colorectal peritoneal) score, the peritoneal surface disease severity score (PSDS), and the prognostic score (PS). The aim was to determine which prognostic score had the best prognostic value.

Methods

Between 2006 and 2010, a total of 77 patients with peritoneal metastases from colorectal cancer underwent CRS/HIPEC treatment. The COREP, PSDS, and PS scores were successfully applied to 56 patients (73 %) having sufficient data. The end points were prediction of open-and-close cases (n = 9), R1 resections (n = 41), and survival of <12 months (n = 18). Area under the receiver operating characteristic curves (accuracy) was compared. Subgroup analysis was performed on patients not previously used for the development of the COREP score (n = 24). Multivariable logistic regressions of the three end points were performed as well as Cox regression for overall survival. Furthermore, COREP and peritoneal cancer index were compared.

Results

For open-and-close case prediction, accuracy for the whole group (n = 56) and subgroup (n = 24) was 87 and 88 %, respectively for COREP; 66 and 77 % for PSDS; and 68 and 78 % for PS. For R1 resection prediction, accuracy was 81 and 81 %, 76 and 78 %, and 75 and 77 %, respectively. For prediction of survival of <12 months, accuracy was 83 and 84, 54 and 67 %, and 55 and 56 %, respectively. The COREP score was the only independent prognostic factor in all four multivariable analyses. A COREP score of ≥6 identified patients with poor survival more accurately than a PCI of >20.

Conclusions

The COREP score predicted open-and-close cases, R1 resections, and poor survival better than PSDS and PS. COREP better identifies patients with poor survival than intraoperative PCI.     

Outcome Data of Patients with Peritoneal Carcinomatosis from Gastric Origin Treated by a Strategy of Bidirectional Chemotherapy Prior to Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in a Single Specialized Center in Japan

Background

Management of peritoneal disseminated gastric cancer (GC) remains a challenging problem. The purpose of our study was to evaluate the outcome of bidirectional induction chemotherapy [bidirectional intraperitoneal and systemic induction chemotherapy (BIPSC)] in patients with peritoneal carcinomatosis (PC) arising from GC who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

Patients and Methods

Overall, 194 patients with PC arising from GC were treated with BIPSC comprising intraperitoneal docetaxel at a dose of 20 mg/m² and cisplatin at a dose of 30 mg/m² followed by four cycles of oral S-1 at a dose of 60 mg/m². CRS and HIPEC were performed in responders to BIPSC.

Results

Of these 194 patients, 152 (78.3 %) underwent CRS and HIPEC between January 2005 and December 2012. Treatment-related mortality was 3.9 %, and major complications occurred in 23.6 % of patients. The median survival rate was 15.8 months, with 1-, 2-, and 5-year survival rates of 66, 32 and 10.7 %, respectively, in the patients treated with combined treatment. Multivariate analysis identified pathologic response to BIPSC (p = 0.001), low tumor burden [peritoneal cancer index (PCI) ≤ 6] (p = 0.001), and completeness of CRS (CC-0, CC-1) (p = 0.001) as independent predictors for a better prognosis.

Conclusion

As a viable option, BIPSC with CRS and HIPEC for patients with PC arising from GC may be performed safely, with acceptable morbidity and mortality, in a specialized unit. Response to BIPSC, optimal CRS and limited peritoneal dissemination seem to be essential to achieve the best outcomes in these patients.