Clinical results of intraperitoneal hyperthermic perfusion combined with surgery in patients with peritoneal recurrence from gastric cancer

Six patients with peritoneal recurrence after radical operation for gastric cancer were treated by an intraperitoneal hyperthermic perfusion (IPHP) combined with surgery (IPHP group). Immediately after surgery, a 2-hour IPHP was performed, using a perfusate containing 10 micrograms/ml of MMC, warmed at the inflow temperature of 46.5 +/- 1.1 degree C. Within the same period of time, 5 patients with intra-abdominal recurrent gastric cancer (control group) were treated by an intraperitoneal administration of MMC 10 mg combined with surgery. These 11 patients had malignant peritoneal effusion and, although in 3 of the control group, ascitic effusion did re-accumulate rapidly soon after surgery, the 6 patients of IPHP group did not re-accumulate post-hyperthermically. The average survival duration of IPHP group is 13.6 +/- 10. 6 months, whereas that for controls is 3.0 +/- 2.1 months. Again, the survival rate for IPHP group surpassed that for controls at p = 0.012 and p = 0.008, in a generalized Wilcoxon method and Logrank method, respectively. Post-hyperthermically, hypoproteinemia and thrombocytopenia occurred transitorily. These results show that IPHP using MMC combined with surgery is a safe, reliable treatment for patients with peritoneal recurrence due to gastric cancer.     

Intraperitoneal hyperthermic perfusion with mitomycin C for colorectal cancer with peritoneal metastases

Background: Intraperitoneal (i.p.) metastases pose a special problem for surgical treatment because of their multiplicity and microscopic size. This study was designed to examine the feasibility and safety of i.p. hyperthermic perfusion (IPHP) with mitomycin C (MMC) for treating recurrent colorectal cancer. Methods: Fifteen patients with metastatic colon cancer were treated. All patients underwent cytoreductive procedures leaving only residual i.p. metastases <1 cm in diameter. All patients had received prior systemic chemotherapy, but their disease had progressed. Intraperitoneal chemotherapy was administered through three large catheters (28 French) using a closed system of two pumps, a heat exchanger, and two filters. After the patient’s abdominal temperature reached 41°C, 45–60 mg of MMC was circulated intraperitoneally for 1 h. Results: The majority of patients had various anastomoses: small bowel (n=11), large bowel (n=5), and urologic (n=5). No anastomotic complications occurred in any of the patients. One patient experienced severe systemic MMC toxicity, which caused cytopenia and respiratory depression. In all patients the carcinoembryonic antigen (CEA) level decreased after surgery and IPHP. Median follow-up was 10 months, and recurrence was defined as an elevation in CEA level. Disease recurred in three patients within 5 months, and disease recurred in seven other patients over the next 3 months; one patient remains clinically free of disease after 8 months. Conclusion: Our data suggest that IPHP is a safe palliative method of treatment for patients with peritoneal carcinomatosis. The median patient response duration of 6 months may warrant consideration of a repeat IPHP procedure at that time. Presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, March 18–21, 1993.     

Peritoneal carcinomatosis treated by cytoreductive surgery and intraperitoneal chemohyperthermia

STUDY AIM: The aim of this prospective non-randomized trial was to report a series of intraperitoneal carcinomatosis due to miscellaneous causes, treated by intraperitoneal hyperthermic perfusion (IPHP) and cytoreductive surgery. PATIENTS AND METHOD: From January 1995 to May 1999, 35 patients were treated by IPHP and 26 of them underwent maximal cytoreductive surgery. IPHP was performed for 60 minutes at an intraperitoneal temperature of 42 degrees C with Mitomycin C (10 mg/L) or cisplatinum (12 mg/L) at a flow rate of 0.9 L/min. RESULTS: There was one (2.8%) postoperative death due to respiratory complications on day 16. Three patients (8.5%) were admitted to the intensive care unit. A high morbidity rate (54%) was observed with intra-abdominal complications in 28.5% of patients, requiring reoperation in three patients. In patients with stages 1 and 2 peritoneal carcinomatosis (granulations less than 5 mm), the 12- and 24-month survival rates were 63.1% and 31.5%, respectively. In patients with advanced stage 3 (diffuse malignant nodules less than 2 cm) and stage 4 carcinomatosis (malignant nodules larger than 2 cm), the 12- and 24-month survival rates were 31.2% and 12%, respectively. Six patients survived for more than 30 months. CONCLUSION: IPHP appears to be an effective treatment for peritoneal carcinomatosis. IPHP combined with cytoreductive surgery is aggressive with a high morbidity rate. Rigorous patient selection is necessary. IPHP is still under evaluation. Prospective randomized trials with identical IPHP protocols are required.     

Results of Treatment of 385 Patients With Peritoneal Surface Spread of Appendiceal Malignancy

Introduction: In the past, peritoneal carcinomatosis, regardless of primary tumor type, has always been a lethal condition. Recently, special treatments using cytoreductive surgery with peritonectomy procedures combined with perioperative intraperitoneal chemotherapy have resulted in long-term survival. Appendiceal malignancy with a low incidence of liver and lymph node metastases may be especially appropriate for these aggressive local regional treatments.Methods: All patients treated with surgery before January 1999 are included. Patients left with gross residual disease after surgery were not given intraperitoneal chemotherapy, but were later treated with intravenous chemotherapy. The intraperitoneal chemotherapy was given in the perioperative period, starting with mitomycin C at 12.5 mg/m² for males and 10 mg/m² for females. For patients whose pathology showed adenomucinosis, intraperitoneal chemotherapy was limited to treatment in the operating theater with heated mitomycin C. Patients with mucinous adenocarcinoma or pseudomyxoma/adenocarcinoma hybrid had, in addition to mitomycin C, five consecutive days of intraperitoneal 5-fluorouracil at 650 mg/m2 instilled in 1–1.5 liters of 1.5% dextrose peritoneal dialysis solution. A complete cytoreduction was defined as tumor nodules <2.5 mm in diameter remaining after surgery. The histopathology categorized the patients as having adenomucinosis, adenomucinosis/carcinomatosis hybrid, or mucinous carcinomatosis. A previous surgical score was used to estimate the extent of previous surgical procedures.Results: The morbidity of treated patients was 27% and the mortality was 2.7%. In a multivariate analysis, prognostic factors for survival included the completeness of cytoreduction (P < .0001), the histopathological character of the appendix malignancy (P < .0001), and the extent of previous surgical interventions (P = .001). Patients with a complete cytoreduction and adenomucinosis by pathology had a 5-year survival of 86%; with hybrid pathology, survival at 5 years was 50%. Incomplete cytoreduction had a 5-year survival of 20% and 0% at 10 years.Conclusions: Cytoreductive surgery and perioperative intraperitoneal chemotherapy can be used to salvage selected patients with peritoneal surface spread of appendiceal primary tumors. Similar strategies for other patients with peritoneal surface malignancy such as peritoneal carcinomatosis from colon or gastric cancer, peritoneal sarcomatosis, or peritoneal mesothelioma should be pursued.Presented at the 52nd Annual Meeting of the Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999     

Peritonectomy and Intraperitoneal Hyperthermic Perfusion (IPHP): A Strategy That Has Confirmed its Efficacy in Patients with Pseudomyxoma Peritonei

Background: Pseudomyxoma peritonei (PMP) is a rare disease with a poor prognosis characterized by a complete redistribution of mucin within the peritoneal cavity. The aim of this multicentric study was to evaluate the survival, morbidity, toxicity, and mortality of patients with PMP treated by cytoreductive surgery (CRS) with intraperitoneal hyperthermic perfusion (IPHP).Methods: Thirty-three patients with PMP (21 males and 12 females) were enrolled in a phase II clinical trial. One patient underwent surgery twice because of disease recurrence. CRS was performed with peritonectomy procedures. The closed abdomen technique was employed for IPHP with use of cisplatin (25 mg/m²/L) plus mitomycin-C (3.3 mg/m²/L) for 60 minutes under hyperthermic conditions (42.5°C).Results: Thirty-one patients (92%) were optimally cytoreduced. Five-year overall survival, progression-free survival, and locoregional progression-free survival rates were 97%, 43%, and 59%, respectively. Grade II and grade III morbidity was observed in 5 patient (15%) and 6 patients (18%), respectively. There was one treatment-related death (3%), 21 days after treatment.Conclusions: CRS associated with IPHP permitted complete tumor removal with an acceptable morbidity and mortality for patients with PMP. This study confirms the efficacy of the combined treatment in terms of long-term survival and local disease control.     

The location of the primary colon cancer has no impact on outcomes in patients undergoing cytoreductive surgery for peritoneal metastasis

Background

The impact of the location of colorectal cancer on patient outcomes has been reported in several settings. The objective of this study was to assess the prognostic impact of the location of the primary colon cancer among patients with colorectal cancer peritoneal metastases undergoing complete cytoreductive surgery.

Treatment of peritoneal carcinomatosis from adenocarcinoid of appendiceal origin

BACKGROUND: Mucinous peritoneal carcinomatosis arising from appendiceal adenocarcinoid is uncommon and treatment options have been poorly defined. This study examined the effect of combined cytoreductive surgery and intraperitoneal chemotherapy on survival in these patients. METHODS: Of 810 patients with peritoneal malignancy of appendiceal origin treated by cytoreductive surgery and intraperitoneal chemotherapy, 22 patients (mean age 45 years; 17 women) had adenocarcinoid. RESULTS: The overall median survival was 18.5 (range 3.2-95.1) months, with 2- and 5-year survival rates of 39 and 25 per cent respectively. Survival after combined surgery and chemotherapy depended on the Peritoneal Cancer Index (P = 0.008) and the extent of cytoreduction (P = 0.007). CONCLUSION: Peritoneal carcinomatosis from adenocarcinoid of appendiceal origin is as invasive as peritoneal surface malignancy from colorectal adenocarcinoma. Patients in whom complete or near-complete surgical removal is possible should be considered for cytoreduction in combination with intraperitoneal chemotherapy.     

Peritoneal lavage cytology in patients with oesophagogastric adenocarcinoma

Background:

The aim of the study was to determine the value of performing peritoneal lavage cytology during laparoscopy in the management of oesophagogastric adenocarcinoma.

Methods:

Laparoscopy combined with peritoneal cytology was performed in patients with potentially resectable oesophagogastric adenocarcinoma. Macroscopic peritoneal findings at laparoscopy and the presence of free peritoneal tumour cells were recorded. All patients were followed to death or the census point. Patients with overt peritoneal disease or positive cytology were offered palliative chemotherapy, subject to performance status.

Results:

Forty‐eight (18·8 per cent) of 255 patients had overt peritoneal metastases at staging laparoscopy. Fifteen (7·2 per cent) of the remaining 207 patients had positive cytology; these patients had a median (95 per cent confidence interval) survival of 13 (3·1 to 22·9) months, versus 9 (7·4 to 10·6) months for those with overt peritoneal metastases (P = 0·517). Of patients receiving chemotherapy, those without overt metastases had a slight survival advantage over patients with metastases (median 15 (10·8 to 19·2) versus 9 (7·4 to 10·7) months; P = 0·045).

Conclusion:

Positive peritoneal cytology in the absence of overt peritoneal metastases is not uncommon in oesophagogastric adenocarcinoma. It is a marker of poor prognosis even in the absence of overt peritoneal metastases. Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Early Postoperative Intraperitoneal Chemotherapy Following Cytoreductive Surgery in Patients with Very Advanced Gastric Cancer

Background The survival of patients with stage IV gastric cancer is poor due to frequent peritoneal failure. The aim of this study was to investigate the impact of early postoperative intraperitoneal chemotherapy (EPIC) after cytoreductive surgery on the long-term survival of these patients, as determined by residual disease status. Methods A total of 154 patients with stage IV gastric cancer were enrolled in our study. All patients underwent potentially curative or palliative resections. After surgery, the residual disease states of the patients were recorded. All patients received EPIC. Results Of all 154 patients, R0 resection was achieved in 37, R1 in 56, and R2 in 61. All patients received a mean of 4.3 EPIC perfusions. After a mean followup period of 29 months, 14 patients remained alive. The median survival of all 154 patients was 11.4 months. Survival times were analyzed according to the type of residual tumor; the median survival time was 25.5 months in the R0 group, 15.6 months in the R1 group, and 7.2 months in the R2 group (p < .001). Upon multivariate analysis, the residual tumor states and the cycle of EPIC perfusion were found to be independent prognostic predictors (p < .001 and p = .018, respectively). Conclusions The residual tumor status is the most important predictor for the survival of very advanced gastric cancer patients who received cytoreductive surgery and EPIC. Therefore, complete cytoreductive surgery yielding R0 resection is mandatory for achieving the beneficial effects of EPIC. J.-H. Cheong and J. Y. Shen contributed equally to this work.     

Appendiceal cancer and peritoneal carcinomatosis: a report of 29 cases

Peritoneal surface malignancies of appendiceal origin arise from a perforated neoplasm with gradual expansion of the tumor within the abdomen. We report our experience with 29 patients. Between February 2000 and November 2004, 29 patients were classified into one of three groups based on the features of their peritoneal dissemination. Group 1 included those with extracellular mucin with little cellular atypia (disseminated peritoneal adenomucinosis/low-grade mucinous adenocarcinomas). Group 2 included those with peritoneal mucinous carcinomatosis/high-grade mucinous adenocarcinomas, and Group 3 included those with nonmucinous carcinomatosis. There were 17 patients in Group 1, 9 in Group 2, and 3 in Group 3. The majority had cytoreductive surgery and intraperitoneal chemotherapy. There were no operative deaths. Mean follow-up was 21 months. Median survival for Groups 1 and 2 has not been reached. Group 3 patients were more likely to die than Group 1 patients, with a hazard ratio of 48.0 (P = 0.001), and Group 2 patients with a hazard ratio of 7.8 (P = 0.029). Median survival for Group 3 was 5 months. These data add to the growing evidence that supports cytoreductive surgery and intraperitoneal chemotherapy in a selected group of patients. Those with mucinous peritoneal dissemination are more likely to benefit from this approach. It appears that in patients with nonmucinous carcinomatosis, the biology of the tumor predicts their outcome.     

Ovarian preservation with subcutaneous transposition in the setting of cytoreductive surgery

INTRODUCTIONIn recent years, cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has gained increasing acceptance as a treatment modality for peritoneal carcinomatosis. In female patients, this procedure involves a total hysterectomy and bilateral saphingo-oophorectomy to remove the pelvic peritoneum. We present a case of an unfortunate female adolescent with peritoneal carcinomatosis who underwent cytoreductive surgery and HIPEC. In view of the compelling circumstance, an innovative surgical technique was used to attempt ovarian preservation.PRESENTATION OF CASEA 14 year old girl with carcinoma of the sigmoid colon and peritoneal metastases was offered cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy. In view of her age, ovarian preservation with subcutaneous transposition was performed during cytoreductive surgery. She is currently well 6 months post surgery and has resumed normal menstruation. We review the literature regarding ovarian preservation with subcutaneous transposition and discuss its benefit in pre-menopausal women undergoing peritonectomy and cytoreductive surgery for peritoneal carcinomatosis.DISCUSSIONSubcutaneous transposition of the ovary in pre-menopasual patients requiring cytoreductive surgery spares them the sequelae of surgical castration. The subcutaneous location of the transposed ovary conveys advantages such as the ease of ultrasound surveillance and removal in event of disease recurrence. It also retains the possibility of future conception as the transposed ovary can easily be accessed for ovum extraction with assisted reproductive techniques.CONCLUSIONOvarian preservation with subcutaneous transposition is a technique worth considering in the treatment of pre-menopausal women who require cytoreductive surgery for peritoneal carcinomatosis.     

Peritoneal Carcinoembryonic Antigen Level for Predicting Locoregional and Distant Spread of Gastric Cancer

Purpose Peritoneal recurrence is not an uncommon cause of death after surgery for gastric cancer, even after surgery with curative intent. This indicates that there is undetected residual disease in the peritoneal cavity. We conducted this study to determine the value of peritoneal and serum carcinoembryonic antigen (CEA) levels and peritoneal washing cytology in predicting the locoregional and distant spread of gastric cancer. Methods We prospectively evaluated 70 consecutive patients with gastric cancer by measuring peritoneal CEA (pCEA) and serum CEA (sCEA) levels and peritoneal washing cytology results, and studying their effect on the histopathologic properties. The effect of the pCEA level on disease-free survival (DFS) and overall survival (OS) was also evaluated in patients treated with curative intent. Results Twenty-one (30%) patients had sCEA levels >10 ng/ml, whereas 25 patients (35.7%) had pCEA levels >10 ng/g protein and 26 patients (37.1%) had positive cytology. The pCEA levels were significantly higher in patients with hepatic metastases (P = 0.034), or serosal (P = 0.028), and peritoneal (P = 0.026) involvement, whereas the sCEA levels were significantly higher only in patients with hepatic metastases (P = 0.04). Similarly, positive cytology was mainly detected in patients with hepatic metastases (P = 0.004). The pCEA levels significantly affected DFS (P = 0.002) and OS (P = 0.01) in 34 patients treated with curative intent. Conclusion Since pCEA levels are more useful for predicting locoregional recurrence, their measurement during surgery may help plan the most appropriate surgical strategy and adjuvant therapy.     

Survival and Recurrence After a Sphincter-Saving Resection and Abdominoperineal Resection for Adenocarcinoma of the Rectum At or Below the Peritoneal Reflection: A Multivariate Analysis

Purpose. The purpose of this study was to determine whether the type of operation [sphincter-saving resection (SSR) or abdominoperineal resection (APR)] for primary adenocarcinoma of the rectum at or below the peritoneal reflection affects survival and recurrence after curative surgery. Methods. This retrospective study included 184 patients who underwent curative surgery achieved by the following two types of operation between 1989 and 1998: (1) SSR (n = 116 patients) including a low anterior resection with either double-stapling technique (n = 86) or transanal coloanal anastomosis (n = 30); (2) APR (n = 91). The outcome factors evaluated were survival and tumor recurrence. Both univariate and corrected (multivariate Coxs and logistic regression) analyses were used to evaluate the data. The median follow-up was 47.4 months for patients alive at study conclusion. Results. Disease-free and disease-specific survivals, and the frequency and location of recurrence after surgery did not differ between the two types of operations. Multivariate analyses showed that the type of operation was not a significant independent variable in predicting disease-free survival or in the development of both local and distant recurrences after surgery. In addition, tumor-related factors (stage or histologic grade) were significant predictors of the outcome after surgery. Conclusions. The type of operation (SSR or APR) did not affect the survival or recurrence after a curative resection for adenocarcinoma of the rectum at or below the peritoneal reflection.     

Cytoreductive surgery and intraperitoneal chemohyperthermia for peritoneal carcinomatosis arising from gastric cancer

HYPOTHESIS: The most common cause of palliative resection and recurrence in gastric cancer is peritoneal seeding. This study evaluates the efficacy of intraperitoneal chemohyperthermia after cytoreductive surgery in patients with peritoneal carcinomatosis arising from gastric cancer. DESIGN: Prospective clinical trial. SETTING: Surgical department at a university academic hospital. PATIENTS: Forty-nine consecutive patients with peritoneal carcinomatosis treated between January 1, 1989, and February 29, 2000. INTERVENTIONS: All patients underwent intraperitoneal chemohyperthermia with mitomycin C (40-60 mg); 21 patients had previously undergone extensive cytoreductive surgery. MAIN OUTCOME MEASURES: Clinicopathologic factors that affect overall survival rates. RESULTS: With median follow-up of 99 months, overall median survival was 10.3 months. Two factors were significant independent predictors of survival by multivariate analysis: preoperative ascites (P =.04) and completeness of cancer resection (CCR) by cytoreductive surgery (P<.001). Median survival was 21.3 months for patients with CCR-0 (macroscopic complete resection) or CCR-1 (diameter of residual nodules <5 mm) and 6.1 months for patients with CCR-2 (diameter of residual nodules >5 mm) (P<.001). Four patients survived longer than 5 years. CONCLUSIONS: An aggressive management strategy combining intraperitoneal chemohyperthermia with cytoreductive surgery is effective for patients with peritoneal carcinomatosis arising from gastric cancer. In highly selected patients (good general status, resectable primary tumor, resectable peritoneal carcinomatosis), this therapy may result in long-term survival.     

Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for advanced gastric cancer

Peritoneal carcinomatosis is a common and universally fatal sequelae of gastric carcinoma. Treatment of peritoneal carcinomatosis from appendiceal and colorectal sources with intraperitoneal hyperthermic chemotherapy (IPHC) combined with aggressive cytoreductive surgery has been shown to be effective. There are few data on this treatment modality for carcinoma of the stomach. This study evaluates cytoreductive surgery and IPHC with peritoneal carcinomatosis from gastric carcinoma. Thirty-four patients with peritoneal carcinomatosis due to gastric carcinoma underwent gastric resection with cytoreductive surgery followed by IPHC with mitomycin C. A control group consisting of 40 contemporaneous patients, who underwent radical gastrectomy without extended nodal resection, was identified through the tumor registry. Despite more advanced disease in the IPHC group compared to the control group (P < 0.001), overall survival in the two groups was similar. Proportional-hazards regression analysis shows that only resection status is significantly correlated with improved survival (P = 0.0068). Within the IPHC group, patients who underwent an R0/R1 resection had increased survival times (11.2 vs. 3.3 months, P = 0.015) vs. those who underwent R2 resection. The group who had an R0/R1 resection had 1- and 2-year survival rates of 45% and 45% compared to 16% and 8%, respectively, in the R2 group. Cytoreductive surgery and IPHC is a modality with limited potential for the treatment of peritoneal carcinomatosis from gastric carcinoma. Careful patient selection for this procedure is imperative, and patients in whom an R0/R1 resection can be achieved are the best candidates.     

Radiofrequency Ablation for Metachronous Liver Metastasis from Colorectal Cancer after Curative Surgery

Background We compared outcomes of surgery and radiofrequency thermal ablation (RFA) in patients with metachronous liver metastases. Methods Between October 1995 and December 2005, 59 patients underwent hepatic resection and 30 underwent RFA for metachronous liver metastases. Patients with extra-hepatic metastases, those who underwent both types of treatment, and those with synchronous hepatic metastasis were excluded. Results The two groups had similar mean age, sex ratio, comorbid medical conditions, primary disease stage, and frequency of solitary metastases. Preoperative mean serum carcinoembryonic antigen (CEA) level was significantly higher in the RFA group (13.4 ng/mL vs. 7.7 ng/mL; p = 0.02). Mean diameter of hepatic metastases was significantly greater in the resection than in the RFA group (3.1 cm vs. 2.0 cm; p = 0.001). Recurrence after treatment of metastasis was observed in 18 of 30 (60.0%) RFA and 33 of 59 (56%) resection patients. Local recurrence at the RFA site was observed in 7 of 30 (23%) patients. Time to recurrence (15 vs. 8 months, p = 0.02) and overall survival (56 vs. 36 months, p = 0.005) were significantly longer in the resection than in the RFA group. In the 69 patients with solitary metastases of diameter ≤3 cm, time to recurrence (p = 0.004) and overall survival were significantly greater in the resection group. Conclusions Compared with hepatic resection, RFA for metachronous hepatic metastases from colorectal cancer was associated with higher local recurrence and shorter recurrence-free and overall survival rates, even in patients with solitary, small (≤3 cm) lesions.     

Appendiceal Neoplasms With Peritoneal Dissemination: Outcomes After Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy

Background Appendiceal neoplasms frequently present with peritoneal dissemination (PD) and have a clinical course marked by bowel obstruction and subsequent death. Few data have correlated outcome with appendiceal histology after cytoreductive surgery and intraperitoneal hyperthermic chemotherapy (IPHC). We have reviewed our experience with cytoreductive surgery and IPHC for PD from the appendix. Methods A total of 110 cases of PD from proven appendiceal neoplasms treated with IPHC were identified from a prospectively managed database. Tumor samples were classified on pathologic review as disseminated peritoneal adenomucinosis (n = 55), peritoneal mucinous carcinomatosis (PMCA) with intermediate features (n = 18), PMCA (n = 29), or high-grade nonmucinous lesions (n = 8). A retrospective review was performed with long-term survival as the primary outcome measure. Results A total of 116 IPHCs were performed on 110 patients for appendiceal PD between 1993 and 2004. The 1-, 3-, and 5-year survival rates for all cases were 79.9% ± 4.1%, 59.0% ± 5.7%, and 53.4% ± 6.5%, respectively. When stratified by histology, disseminated peritoneal adenomucinosis and intermediate tumors had better 3-year survival rates (77% ± 7% and 81% ± 10%) than PMCA and high-grade nonmucinous lesions (35% ± 10% and 15% ± 14%; P = .0032 for test of differences between groups). Age at presentation (P = .0134), performance status (P < .0001), time between diagnosis and IPHC (P = .0011), resection status (P = .0044), and length of hyperthermic chemoperfusion (P = .0193) were independently associated with survival. Conclusions The data show that long-term survival is anticipated in most patients who are treated with cytoreduction and IPHC for appendiceal PD. The findings presented herein underscore the important prognostic characteristics that predict outcome after IPHC in patients with PD. In all, this work establishes a framework for the consideration of IPHC in future trials for appendiceal PD.     

Prognostic Analysis of Clinicopathologic Factors in 49 Patients With Diffuse Malignant Peritoneal Mesothelioma Treated With Cytoreductive Surgery and Intraperitoneal Hyperthermic Perfusion

Background Diffuse malignant peritoneal mesothelioma (DMPM) is a subset of peritoneal mesothelioma with a poor clinical outcome. We performed a prognostic analysis in a cohort of DMPM patients treated homogeneously by cytoreductive surgery and intraperitoneal hyperthermic perfusion (IPHP). Methods Forty-nine DMPM patients who underwent 52 consecutive procedures were enrolled onto the study. Cytoreductive surgery was performed according to the peritonectomy technique, and the IPHP was performed with cisplatin plus doxorubicin or cisplatin plus mitomycin C. We assessed the correlation of the clinicopathologic variables (previous surgical score, age, sex, performance status, previous systemic chemotherapy, carcinomatosis extension, completeness of cytoreduction, IPHP drug schedule, mitotic count [MC], nuclear grade, and biological markers [epidermal growth factor receptor, p16, matrix metalloproteinase 2 and matrix metalloproteinase 9]) with overall and progression-free survival. Results The mean age was 52 years (range, 22–74 years). The mean follow-up was 20.3 months (range, 1–89 months). Regarding the biological markers, the rates of immunoreactivity of epidermal growth factor receptor, p16, matrix metalloproteinase 2, and matrix metalloproteinase 9 were 94%, 60%, 100%, and 85%, respectively. The strongest factors influencing overall survival were completeness of cytoreduction and MC, whereas those for progression-free survival were performance status and MC. No biological markers were shown to be of prognostic value. Conclusions Completeness of cytoreduction, performance status, and MC seem to be the best determinants of outcome. These data warrant confirmation by a further prospective formal trial. No biological markers presented a significant correlation with the outcome. The overexpression of epidermal growth factor receptor, matrix metalloproteinase 2, and matrix metalloproteinase 9 and absent or reduced expression of p16 might be related to the underlining tumor kinetics of DMPM and warrant further investigation with other methods.     

Incomplete cytoreduction in 174 patients with peritoneal carcinomatosis from appendiceal malignancy

OBJECTIVE: The aim of this study was to analyze the survival of patients with peritoneal dissemination of appendiceal malignancy having incomplete cytoreductive surgery. SUMMARY BACKGROUND DATA: Cytoreductive surgery plus perioperative intraperitoneal chemotherapy has emerged as a new and potentially curative treatment option for patients with peritoneal dissemination of appendiceal mucinous tumors. The goal of surgery is to remove all visible disease. Nevertheless, in some patients, complete cytoreduction is not possible. METHODS: Over a 30-year period, 645 patients with epithelial peritoneal surface malignancy of appendiceal origin were treated with cytoreductive surgery and intraperitoneal chemotherapy by a single surgeon. One hundred seventy-four (27.1%) of these patients had an incomplete cytoreduction. A critical statistical analysis of the impact of selected clinical features on survival was performed from a prospective database. RESULTS: Mortality and morbidity rates were 0% and 33.3%, respectively. Median survival of these 174 patients was 20.5 months and their 1-year, 3-year, and 5-year survival rates were 71%, 34%, and 15%, respectively. By multivariate analysis, the presence of signet ring cells and lymph node involvement were independent prognostic indicators of poor survival (P = 0.047 and P < 0.001, respectively). Patients who underwent more than 1 cytoreduction or repeat intraperitoneal chemohyperthermia showed significant improvement in survival (P = 0.018 and P < 0.001, respectively) CONCLUSION: Incomplete cytoreduction plus perioperative intraperitoneal chemotherapy of peritoneal dissemination from appendiceal malignancy results in limited long-term survival. Patients with signet ring histology or lymph node involvement have an especially poor outcome. Repeat cytoreduction and intraperitoneal chemohyperthermia may improve outcome.     

Peritoneal Mesothelioma Treated by Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy: Results of a Prospective Study

Background Peritoneal mesothelioma is a rare disease with few therapeutic options. Recently, the combination of cytoreductive surgery with intraperitoneal hyperthermic chemotherapy (HIPEC) has shown promising results. Methods Fifteen patients with peritoneal mesothelioma who were treated by cytoreductive surgery and HIPEC between 1989 and 2004 were identified from a prospective database. HIPEC was performed with cisplatin and mitomycin C for 90 minutes by using the closed-abdomen technique. Results All patients but one (multicystic) had malignant disease of the following pathologic types: 12 epithelial and 2 biphasic. After surgical resection, 11 patients were considered to have a CC-0 or CC-1 resection (macroscopic complete resection or diameter of residual nodules <2.5 mm). No postoperative death occurred, and six postoperative complications were recorded. All but one patient had resolution of ascites. The overall median survival for the 14 patients with malignant mesothelioma was 35.6 months. The median survival was 37.8 months for patients treated with a CC-0 or CC-1 resection, whereas it was 6.5 months for those treated with a CC-2 or CC-3 resection (diameter of residual nodules >2.5 mm; P < .001). In a univariate analysis, the only other significant prognostic factor was the carcinomatosis extent (P = .02). Conclusions A therapeutic strategy combining cytoreductive surgery with HIPEC seems to provide an adequate and efficient locoregional treatment for peritoneal mesothelioma. It is associated with acceptable morbidity when performed by an experienced surgical team. The completeness of cytoreduction is the major determinant of survival.