Antonios-Apostolos K. Tentes

Adjuvant Perioperative Intraperitoneal Chemotherapy in Locally Advanced Colorectal Carcinoma: Preliminary Results

Background and Aims. Intraperitoneal chemotherapy is a basic tool in the treatment of peritoneal malignancy. The purpose of the study is to investigate the effect of adjuvant perioperative intraperitoneal chemotherapy in the treatment of locally advanced colorectal cancer. Patients and Methods. Patients with T3 and T4 colorectal carcinomas that underwent R0 resection received either hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC group = 40 patients) or early postoperative intraperitoneal chemotherapy (EPIC group = 67 patients). The survival, the recurrences and the sites of recurrence were assessed. Results. The 3-year survival rate for HIPEC group was 100% and for EPIC group 69% (P = .011). Nodal infiltration was found to be the single prognostic indicator of survival. The incidence of recurrence in EPIC group was higher than in HIPEC group (P = .009). The independent indicators of recurrence were the use of HIPEC and the degree of differentiation (P < .05). Conclusions. Intraperitoneal chemotherapy, particularly HIPEC, as an adjuvant in locally advanced colorectal carcinomas appears to improve survival and decrease the incidence of recurrence.

Cytoreductive surgery combined with hyperthermic intraperitoneal intraoperative chemotherapy in the treatment of advanced epithelial ovarian cancer.

Background/Aims. Intraperitoneal intraoperative hyperthermic chemotherapy (HIPEC) has been used in the treatment of ovarian cancer. The purpose of the study is to determine the efficacy of HIPEC after cytoreductive surgery in advanced ovarian cancer. Patients/Methods. From 2006 to 2010 patients with advanced ovarian cancer were enrolled in a prospective nonrandomized study to undergo cytoreductive surgery combined with HIPEC. Clinical and histopathological variables were correlated to hospital mortality, morbidity, survival, and recurrences. Results. The mean age of 43 women was 59.9 ± 13.8 (16–82) years. The hospital mortality and morbidity rate were 4.7% and 51.2%, respectively. Complete cytoreduction was possible in 69.8%. The overall 5-year survival rate was 54%. The prognostic indicators of survival were the extent of prior surgery (P = 0.048) and the extent of peritoneal dissemination (P = 0.011). The recurrence rate was 30.2%. Conclusions. Maximal cytoreductive surgery combined with HIPEC is a well-tolerated, feasible, and promising method of treatment in advanced ovarian cancer.

Preliminary Results of Hyperthermic Intraperitoneal Intraoperative Chemotherapy as an Adjuvant in Resectable Pancreatic Cancer

Background and Aims. 5-year survival in patients with pancreatic cancer is poor. Surgical resection is the only potentially curative resection. The results of adjuvant treatment either with chemotherapy or with radiotherapy have been contradictory and the incidence of local-regional recurrence remains high. If local-regional recurrence is controlled survival may be expected to increase. Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) may be used in order to control local-regional recurrences. The purpose of the study is to identify the effect of HIPEC in patients with pancreatic cancer undergoing potentially resection. Patients and Methods. From 2007–2011, 21 patients, mean age 69.4 ± 9.5 (50–86) years, underwent tumor resection, and HIPEC with gemcitabine. The hospital mortality and morbidity rate was 9.5% and 33.3%, respectively. 5-year and median survival was 23% and 11 months, respectively. The recurrence rate was 50% but no patient developed local-regional recurrence. No patient was recorded with gemcitabine-induced toxicity. Conclusions. This clinical study of 21 patients is the first to combine an R0 pancreas cancer resection with HIPEC. Increased morbidity and mortality from intraoperative gemcitabine was not apparent. Patients with pancreatic cancer undergoing potentially curative resection in combination with HIPEC may be offered a survival benefit. Data suggested that local-regional recurrences may be greatly reduced. Further studies with greater number of patients are required to confirm these findings.

Results of surgery for colorectal carcinoma with obstruction

Background/aimsEmergency surgery for obstructing colorectal carcinoma is thought to be associated with poor survival. The aim of the study is to assess the results of surgery for obstructing colorectal cancer.Materials and methodsFrom 1987 to 2004, 80 patients underwent emergency surgery for completely obstructing colorectal carcinoma (COC), and 171 patients underwent elective surgery for non-obstructing cancer (NOC). Morbidity, mortality, and the late outcome were assessed.ResultsThe groups were comparable for age, gender, tumor distribution, histopathologic characteristics, stage, morbidity, concomitant operations, recurrence, and sites of recurrence. High ASA class, poor performance status, and high mortality rate were recorded in COC group (p < 0.05). Mortality was related to ASA class (p < 0.001), performance status (p < 0.001), and obstruction (p = 0.014). ASA class was the single independent factor of morbidity (p < 0.001). The groups were comparable for survival (p > 0.05).ConclusionsObstructing colorectal carcinoma seems to be associated with high mortality rate, but long-term survival seems to be the same with non-obstructing carcinoma.

Multicystic peritoneal mesothelioma.

Summary Background: Multicystic peritoneal mesothelioma is a rare disease. It is not certain if it is a benign or a borderline tumor. Although many therapeutic approaches have been used, complete cytoreductive surgery in combination with hyperthermic intraoperative intraperitoneal chemotherapy has gained acceptance. Case Report: A case of multicystic peritoneal mesothelioma in a 16-year old patient is reported. The patient underwent complete cytoreduction and received intraoperative hyperthermic intraperitoneal chemotherapy. The patient is disease-free one year after surgery. Conclusions: Complete cytoreductive surgery in combination with hyperthermic intraoperative intraperitoneal chemotherapy appears to be a rational therapeutic approach in multicystic peritoneal mesothelioma.

The effect of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) as an adjuvant in patients with resectable pancreatic cancer

Abstract Background – aims: The long-term survival of pancreatic cancer is poor even after potentially curative resection. The incidence of local-regional failures is high. There is evidence that hyperthermic intraperitoneal intraoperative chemotherapy (HIPEC) is effective in controlling the local-regional failures. The purpose of the study is to identify the effect of HIPEC after surgical removal of pancreatic carcinoma. Patients – Methods: Prospective study including 33 patients with resectable pancreatic carcinomas. All patients underwent surgical resection (R0) and ΗIPEC as an adjuvant. Morbidity and hospital mortality were recorded. The patients were followed-up for 5 years. Survival was calculated. Recurrences and the sites of failure were recorded. Results: The mean age of the patients was 67.8 ± 11.1 years (38–86). The hospital mortality was 6.1% (2 patients) and the morbidity 24.2% (8 patients). The overall 5-year survival was 24%. The mean and median survival was 33 and 13 months, respectively. The median follow-up time was 11 months. The recurrence rate was 60.6% (20 patients). Three patients were recorded with local-regional failures (9.1%) and the others with liver metastases. Conclusions: It appears that HIPEC as an adjuvant following potentially curative resection (R0) of pancreatic carcinoma may effectively control the local-regional disease. Prospective randomised studies are required.

Cytoreductive surgery and perioperative intraperitoneal chemotherapy in recurrent ovarian cancer

BACKGROUND AND AIMS Cytoreductive surgery with perioperative intraperitoneal chemotherapy is another approach for recurrent ovarian cancer. The purpose of the study was to assess the feasibility and the effect of cytoreduction and perioperative intraperitoneal chemotherapy in recurrent ovarian cancer. PATIENTS AND METHODS Twenty-nine women with recurrent ovarian cancer underwent cytoreductive surgery. Clinical variables were correlated to morbidity, hospital mortality, recurrences, and survival. RESULTS Complete cytoreduction was possible in 58.6%. Extensive seeding of the small bowel and distant metastases excluded the possibility of performing complete cytoreduction. Perioperative intraperitoneal chemotherapy was given in 75.9%. Morbidity and hospital mortality rates were subsequently 24.1% and 3.4%. Recurrence was recorded in 48.3%. The extent of peritoneal dissemination was an independent variable of recurrence (P= 0.014). The 5-year survival rate was 30%. The extent of peritoneal dissemination and the completeness of cytoreduction were related to survival (P <0.05). The completeness of cytoreduction independently influenced survival (P= 0.013). CONCLUSIONS Secondary cytoreduction with intraperitoneal chemotherapy is feasible in most women with recurrent ovarian cancer with acceptable morbidity and mortality. Complete cytoreduction is not possible if distant and unresectable metastases are present or if the small bowel is extensively seeded. Long-term survivors are patients with limited peritoneal dissemination who may undergo complete cytoreduction.

Treating peritoneal mesothelioma with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. A case series and review of the literature

Abstract Background: Encouraging results on survival of patients with malignant peritoneal mesothelioma have been shown with the use of cytoreductive surgery and perioperative intraperitoneal chemotherapy. This study explores the impact of aggressive surgical treatment on overall survival of peritoneal mesothelioma. Methods: This is a retrospective analysis of prospectively collected clinical data of all patients with diagnosis of malignant peritoneal mesothelioma treated in a designated referral centre in Greece. All patients were offered cytoreductive surgery and intraperitoneal chemotherapy. Patient’s characteristics, operative reports, pathology reports, and discharge summaries were stored in an electronic database and later reviewed and analysed. Results: Cytoreduction for peritoneal mesothelioma was performed on 20 patients (15 men and 5 women) with a mean age of 59.4 years (SD 16.1). Mean peritoneal cancer index was 16.1 (SD 10.4) and the median completeness of cytoreduction score was 2 (range 1–2). Mean overall survival was 46.8 months (SE 4.03) with a mean of 21.4 and median of 18 months of follow-up. Disease-specific survival was 100% for the observed period. Univariate analysis showed the completeness of cytoreduction as the only possible predictor of survival. A median of 10 (range 4–14) peritonectomy procedures were performed per patient. Median hospital stay was 14 (range 10–57 days). Grade III and IV complications occurred post-operatively in 5 patients (25%). Two patients died in the post-operative period of pulmonary embolism and myocardial infarction. Conclusion: Cytoreductive surgery with HIPEC has proved the most effective treatment even when taking account of the cost of significant morbidity.

Liver hydatid cyst perforated into the large bowel: a case report

Perforation of the liver hydatid cyst into hollow abdominal organs is an extremely rare complication. A case of two synchronous hydatid cysts in an old lady is presented. The patient had one multilobular cyst perforated into the right colon and another one uncomplicated located at the right ovary. She underwent partial cystectomy, omentoplasty, right hemicolectomy, and total hysterectomy, and had an uneventful recovery.

Combined Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for the Treatment of Advanced Ovarian Cancer

Ovarian cancer is the leading cause of death from gynecologic cancer and the fifth cause of cancer deaths in women in developed countries (Yancik, 1993; Cannistra, 1993). The number of deaths seems to increase the last few years. More than 70% of the patients with ovarian cancer have advanced disease at the time of initial diagnosis because they remain asymptomatic in early stages (Roberts, 1996). Ovarian cancer is the most frequent intraceolomic malignancy presenting with peritoneal spread. In the past debulking surgery combined with systemic chemotherapy offered long-term survival in less than 10% of the patients (Smith & Day, 1979). The standard treatment of advanced ovarian cancer is cytoreductive surgery followed by systemic chemotherapy (Hacker et al, 1983; Neijt et al, 1991; Hoskins et al, 1992). Despite systemic chemotherapy based on platinum and taxanes 5 and 10-year survival rate do not exceed 20% and 10% respectively because the majority of the patients develop recurrence (Mc Guire & Ozols, 1998; Piccart et al, 2000). The disease remains characteristically confined to the peritoneal surfaces for most of its natural course (Bergmann, 1996). Surgical resection of the tumor may not be complete and microscopic or even macroscopic residual tumor may be left behind. In these situations the intraperitoneal route of administration of cytostatic drugs is a logical approach. Patients with diseases that have similar biological behavior to ovarian cancer are offered significant survival benefit when they are treated with perioperative intraperitoneal chemotherapy integrated in cytoreductive surgery. In pseudomyxoma peritonei (Sugarbaker, 2006), peritoneal sarcomatosis (Rossi et al, 2004), peritoneal mesothelioma (Yan et al, 2007), colorectal cancer with peritoneal dissemination (Elias et al, 2009; Mahteme et al, 2004; Verwaal et al, 2008), as well as in gastric cancer with peritoneal carcinomatosis (Yonemura et al, 1996; Yu et al, 1998) survival is improved with this treatment strategy. The last two decades the method has been used in ovarian cancer with promising results.