Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis: Our Initial Experience

Abstract

RezumatIntroducere: Carcinomatoza peritoneală reprezintă un stadiu avansat al cancerelor abdominale în general şi a cancerului colorectal în particular. Singurele metode de tratament disponibile la momentul actual pentru această patologie sunt chimioterapia sistemică (caracter paliativ) şi chirurgia citoreductivă (CR) asociată cu chimioterapie intraperitoneală hipertermică (HIPEC). După revizuirea literaturii şi a ghidurilor de specialitate, putem afirma că procedura CR+HIPEC trebuie luată în considerare în managementul pacienţilor cu carcinomatoză peritoneală de origine colorectală, ovariană şi mucocel apendicular. Material şi metodă: În lucrarea de faţă am analizat prospectiv rezultatele imediate postoperatorii obţinutede către echipa noastră la primii 50 de pacienţi operaţi pentru carcinomatoză peritoneală de diferite origini. Am descris protocolul de selecţie, caracteristicile pacienţilor care au fost incluşi în programul nostru de CR+HIPEC şi am analizat incidenţa complicaţiilorşi a deceselor. Rezultate: Din ianuarie 2015 până în decembrie 2018 am evaluat pentru tratament 98 de pacienţi cu carcinomatoză peritoneală. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis: Our Initial Experience Chirurgia, 114 (2), 2019 www.revistachirurgia.ro 223 Dintre aceştia, doar 51 au beneficiat de tratament radical (CR+HIPEC); 33 nu au fost potriviţi pentru intervenţia chirurgicală datorită criteriilor de excludere şi la 15 s-a practicat doar laparotomie exploratorie. În ceea ce priveşte originea histopatologică, 30 de paciente au avut cancer ovarian; 19 pacienţi au avut carcinomatoză cu origine colorectală sau pseudomixom peritoneal de origine apendiculară. Nu a existat mortalitate la 30 de zile. Incidenţa complicaţiilor postoperatorii semnificative a fost de 15%. Concluzii: Chirurgia citoreductivă urmată de chimioterapie intraperitoneală hipertermică este o procedură complexă însoţită de o incidenţă acceptabilă a complicaţiilor şi a deceselor postoperatorii, rezultatele putând fi optimizate prin management perioperator standardizat şi selecţia atentă a pacienţilor. Rezultatele iniţiale obţinute de echipa noastră subliniază fezabilitatea acestei proceduri, cu rezultate imediate bune, obţinute ca rezultat a respectării unui protocol standardizat de selecţie a pacienţilor şi a managementului perioperator. Cuvinte cheie: carcinomatoză peritoneală, cancer colorectal, cancer ovarian, pseudomixom peritoneal, chimioterapie intraperitoneală hipertermică, rezecţii multiorgan. AbstractIntroduction: Peritoneal carcinomatosis represents an advanced stage of tumor dissemination of abdominal cancers in general and colorectal cancer in particular. The only therapeutic methods currently available for the treatment of this pathology are systemic chemotherapy (palliative character) and cytoreductive surgery (CR) with intraperitoneal chemotherapy. After evaluation of evidence-based medical literature and current guide lines we can state that CR + HIPEC procedure is considered to...

Hematological Alterations after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

“…Fefermann [ 31 ] found a 7% incidence of leukopenia (defined as <2000/mm 3 ) in 242 patients treated with CRS and HIPEC with mitomycin C, with a median nadir on day 5 postoperatively, who had a significantly longer ICU stay with respect to patients who did not develop leukopenia (11 vs. 6 days, p < 0.05). Bartos et al [ 4 ] found that only 2 of the 50 patients included in their study (4%) developed leukopenia; they included patients with peritoneal carcinomatosis of different origin. Wong et al [ 32 ] found an incidence of 12.3% of leukopenia (defined as <4000/mm 3 ) in 220 patients treated with CRS and HIPEC, with a median duration of leukopenia of 1 day (1–3 days).…”

“…Several postoperative complications have been described after CRS and HIPEC, related to surgery, hyperthermia, and/or chemotherapy. The described morbidity rates are 25% to 51%, and up to 21–30% patients develop severe postoperative complications, requiring surgical, endoscopic, or radiological reintervention or readmittance to the intensive care unit (ICU) [ 2 , 3 , 4 ]. The described mortality rate varies between 0 and 18% [ 5 , 6 ].…”

Ultrasound for Preoperatively Predicting Pathology Grade, Complete Cytoreduction Possibility, and Survival Outcomes of Pseudomyxoma Peritonei

“…In the low-grade subgroup, the appendiceal neoplasm epithelial cells were positioned in a single row and the mucin secretion was typically exuberant, whereas the cells in the high-grade group were belt-shaped, island, or cribriform-shaped with severe dysplasia. The secretory function of the columnar cells was severely damaged, which led to a decrease in mucus secretion ( 2 , 6 , 18 ). Moreover, the concentrated tumor mass resulted in liver scalloping and omental cake ( 19 , 20 ).…”

“…The recommended treatment for PMP is cytoreductive s u r g e r y ( C R S ) p l u s h y p e r t h e r m i c i n t r a p e r i t o n e a l chemotherapy (HIPEC) (6). This combination treatment is undoubtedly the optimal strategy associated with improved clinical outcomes.…”

Effect of Intraperitoneal Chemotherapy with Regorafenib on IL-6 and TNF-α Levels and Peritoneal Cytology: Experimental Study in Rats with Colorectal Peritoneal Carcinomatosis

“…In addition, IPEC includes the regional administration of chemotherapy of cytotoxic drugs in a concentrated dose, providing a higher cytotoxic effect to peritoneal tumor cells and low systemic cytotoxicity via localized delivery due to the plasma-peritoneal barrier [7]. What is more, HIPEC is based on the fact that antineoplastic agents above 41 • C present selective cytotoxicity to tumor cells, and increased absorption and penetration of the tumor tissue [8]. However, PRODIGE 7, a phase III clinical trial, suggested that in patients with PM from CRC, HIPEC was associated with a higher rate of complications, without improving the OS, when compared to cytoreductive surgery alone.…”