Grace Hwei Ching Tan

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Asian Patients: 100 Consecutive Patients in a Single Institution

BackgroundCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to improve survival in selected patients with peritoneal carcinomatosis. We review our institutional experience with the procedure and evaluate the overall survival (OS) and disease-free survival (DFS) rates in 100 consecutive patients.MethodsData were prospectively collected from 100 consecutive patients with peritoneal carcinomatosis treated by CRS and HIPEC at the National Cancer Centre Singapore between April 2001 and May 2012. Our primary end points were OS and DFS.ResultsOf the 100 patients, 84 were of Chinese ethnicity, 3 were Malay, 6 were Indian, and 7 were of other ethnicities. Primary tumors were ovarian cancer (nxa0=xa039), colorectal cancer (nxa0=xa028), primary peritoneal (nxa0=xa06), appendiceal cancer (nxa0=xa020), and mesothelioma (nxa0=xa07). Median follow-up duration was 21xa0months. At 5xa0years, the DFS was 26.3xa0% and OS was 50.9xa0%. Factors influencing OS and DFS were cytoreductive score, primary cancer, and disease-free interval of more than 12xa0months on univariate analysis. The only factors that remained significant for prognosis after multivariate analysis were primary cancer and cytoreductive score. Thirty-day morbidity was 56xa0%, and there were no 30-day mortalities.ConclusionsCRS and HIPEC can be safely carried out in Asian patients with peritoneal carcinomatosis from ovarian, colorectal, appendiceal, mesothelioma, and primary peritoneal origins. Overall, the ovarian, appendiceal, mesothelioma, and primary peritoneal cancer patients tended to do better than the colorectal patients, but careful patient selection ensuring that optimal cytoreduction can be achieved is essential for the success of this procedure.

Prospective Quality of Life Study for Colorectal Cancer Patients with Peritoneal Carcinomatosis Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is becoming accepted treatment for peritoneal carcinomatosis (PC) from colorectal cancer. Quality of life (QoL) for patients after surgery is still a concern amongst physicians despite studies that show that QoL recovers after surgery. We conducted a prospective QoL study on patients undergoing CRS and HIPEC and attempt to identify factors that affect the QoL. Patients who underwent CRS and HIPEC for PC from colorectal cancer from March 2012 to January 2015 were included. The European Organization for the Research and Treatment of Cancer Core Quality of Life Questionnaire (QLQ-C30) and the colorectal module (QLQ-CR29) were administered prior to surgery and thereafter at 3, 6, and 12xa0months. Twenty-three patients underwent 25 procedures. Median disease-free survival was 12.9xa0months [95xa0% confidence interval (CI) 2.5–19.3]. Physical and role functioning scores decreased at 3xa0months but returned to baseline at 6xa0months. There were significant increases in emotional and social functioning scores at 6–12xa0months and improvements in all symptoms scales at 6–12xa0months, especially the fatigue and appetite scores. A higher PCI score, longer duration of surgery, the presence of a stoma, and recurrence within 3xa0months were associated with a poorer QoL. QoL after CRS and HIPEC improved or returned to baseline in all categories by 6–12xa0months after surgery. Patient selection is important not only for improved survival but also for improved QoL.BackgroundCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is becoming accepted treatment for peritoneal carcinomatosis (PC) from colorectal cancer. Quality of life (QoL) for patients after surgery is still a concern amongst physicians despite studies that show that QoL recovers after surgery. We conducted a prospective QoL study on patients undergoing CRS and HIPEC and attempt to identify factors that affect the QoL.MethodsPatients who underwent CRS and HIPEC for PC from colorectal cancer from March 2012 to January 2015 were included. The European Organization for the Research and Treatment of Cancer Core Quality of Life Questionnaire (QLQ-C30) and the colorectal module (QLQ-CR29) were administered prior to surgery and thereafter at 3, 6, and 12xa0months.ResultsTwenty-three patients underwent 25 procedures. Median disease-free survival was 12.9xa0months [95xa0% confidence interval (CI) 2.5–19.3]. Physical and role functioning scores decreased at 3xa0months but returned to baseline at 6xa0months. There were significant increases in emotional and social functioning scores at 6–12xa0months and improvements in all symptoms scales at 6–12xa0months, especially the fatigue and appetite scores. A higher PCI score, longer duration of surgery, the presence of a stoma, and recurrence within 3xa0months were associated with a poorer QoL.ConclusionsQoL after CRS and HIPEC improved or returned to baseline in all categories by 6–12xa0months after surgery. Patient selection is important not only for improved survival but also for improved QoL.

Does early post-operative intraperitoneal chemotherapy (EPIC) for patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) make a difference?

Abstract Introduction: Peritoneal carcinomatosis (PC) is increasingly being treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), with or without early post-operative intraperitoneal chemotherapy (EPIC). We compared the morbidities, overall survival (OS) and disease free survival (DFS) between two groups of patients who underwent CRS and HIPEC alone and with EPIC at our institution. Methods: A retrospective review of 111 patients with PC who were treated with CRSu2009+u2009HIPEC or CRSu2009+u2009HIPECu2009+u2009EPIC in a single institution between January 2008 and April 2014 was performed. EPIC with 5-fluorouracil or paclitaxel was utilised, depending on the primary tumour. Results: Patients who received EPIC had a higher proportion of grade III and above post- operative complications (58% versus 25%; pu2009=u20090.048) and a longer duration of hospitalisation (16 days versus 13 days; pu2009=u20090.019) than patients without EPIC. There were no significant OS and DFS differences between the EPIC and no EPIC groups (log-rank pu2009=u20090.231 and pu2009=u20090.144, respectively). Conclusion: The use of EPIC after CRSu2009+u2009HIPEC for PC potentially results in increased morbidity and longer hospitalisation, and is unlikely to affect survival outcomes. Based on our experience, EPIC is not recommended after CRS and HIPEC.

Repeat Cytoreductive Surgery and HIPEC for Peritoneal Surface Malignancy and Peritoneal Carcinomatosis

BackgroundPeritoneal-based malignancy (PBM), especially peritoneal carcinomatosis from gastrointestinal malignancies traditionally carries a poor prognosis. Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) have been shown to attain long median survival of 34–92xa0months and 5xa0year survival of 29–59xa0% in patients with favorable histopathological subtypes. Recurrence after CRS and HIPEC poses a management dilemma. This paper evaluates our institution’s experience with repeat CRS and HIPEC, its associated morbidity and outcomes.MethodsOne-hundred and thirty underwent CRS and HIPEC for PBM from April 2001 to June 2013. 49 had peritoneal recurrences, of which 24 had peritoneal only recurrence. 7 out of the 24 underwent a second CRS and HIPEC.ResultsFive females and two males with median age of 51 (37–63), underwent a second CRS and HIPEC. The primary malignancies were: 1 peritoneal mesothelioma, 3 appendiceal, 2 ovarian, and 1 colorectal cancers. Median peritoneal cancer indices for the initial and second CRS were 19 and 12, respectively. Completeness of cytoreduction score of 0 was achieved for all patients. Median hospitalization after second CRS and HIPEC was 12xa0days (7–60). 1 out of 7 (14xa0%) experienced grade 3 or 4 post-operative complications. There was no 30-day or inpatient mortality. Median follow-up was 13xa0months (1–97). Median disease-free interval between the first CRS and HIPEC to peritoneal recurrence was 20xa0months (14–87). Median disease-free survival of 6xa0months (1–97) was achieved after the second CRS and HIPEC. Six patients remained alive without disease and one passed away with disease. Two had recurrences at 12 and 71xa0months after second CRS and HIPEC, 1 died and the other, still alive, went on to have a third CRS.ConclusionRepeat CRS and HIPEC can achieve prolonged survival in selected patients with peritoneal-based malignancies, and can be performed with acceptable morbidity and mortality.

Prognostic Relevance of the Peritoneal Surface Disease Severity Score Compared to the Peritoneal Cancer Index for Colorectal Peritoneal Carcinomatosis.

Background. Peritoneal Carcinomatosis Index (PCI) is a widely established scoring system that describes disease burden in isolated colorectal peritoneal carcinomatosis (CPC). Its significance may be diminished with complete cytoreduction. We explore the utility of the recently described Peritoneal Surface Disease Severity Score (PSDSS) and compare its prognostic value against PCI. Methods. The endpoints were overall survival (OS), progression-free survival (PFS), and survival less than 18 months (18u2009MS). Results. Fifty patients underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for CPC from 2003 to 2014, with 98% achieving complete cytoreduction. Median OS was 28.8 months (95% CI, 18.0–39.1); median PFS was 9.4 months (95% CI, 7.7–13.9). Univariate analysis showed that higher PCI was significantly associated with poorer OS (HR 1.11; 95% CI, 1.03–1.20) and PFS (HR 1.09; 95% CI, 1.03–1.14). Conversely, PSDSS was not associated with either endpoint. Multivariate analysis showed that PCI, but not PSDSS, was predictive of OS and PFS. PCI was also able to discriminate survival outcomes better than PSDSS for both OS and PFS. There was no association between 18 MS and either score. Conclusion. PCI is superior to PSDSS in predicting OS and PFS and remains the prognostic score of choice in CPC patients undergoing CRS/HIPEC.

Colorectal peritoneal carcinomatosis treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: The experience of a tertiary Asian center

INTRODUCTIONnCompared with intravenous chemotherapy, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to improve survival in patients with recurrent colorectal disease confined to the peritoneum. We report our experience with CRS and HIPEC for colorectal cancer patients with peritoneal carcinomatosis, evaluating prognostic factors for disease-free survival (DFS), overall survival (OS), and perioperative morbidity and mortality.nnnMETHODSnAll patients who underwent CRS and HIPEC were included in our study. Clinical characteristics, operative data, and 30-day morbidity and mortality were collected and evaluated.nnnRESULTSnBetween January 2001 and December 2012, there were 35 consecutive patients who underwent CRS and HIPEC at our institution. Thirty-three patients (94%) had optimal cytoreduction. No 30-day mortality was reported, but 14 patients had postoperative complications. The median DFS was 9.4 months (95% confidence interval 5.5-18.7 months), and DFS at 1 year, 3 years, and 5 years were 43.8%, 22.3%, and 22.3%, respectively. The median OS was calculated to be 27.1 months (95% confidence interval 15.3-39.1), and the OS at 1 year, 3 years, and 5 years were 83.7%, 38.2%, and 19.1%, respectively.nnnCONCLUSIONnCRS and HIPEC can provide survival benefit, with reasonable morbidity and mortality for Asian patients with peritoneal carcinomatosis from colorectal cancer. Patient selection and perioperative management of the patients are key to the success of the procedure.

Surgical Management of Colorectal Peritoneal Metastases: Treatment and Outcomes Compared with Hepatic Metastases

PurposeThe liver and peritoneum are common sites of colorectal metastases. Hepatectomy for colorectal liver metastases (CLM) is considered gold standard treatment. We attempt to compare the survival outcomes for CLM patients after hepatectomy to that of patients with colorectal peritoneal metastases (CPM) who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsA retrospective review of patients with CPM and CLM who underwent surgery between January 2003 and May 2011 was performed. The overall (OS) and disease-free survivals (DFS) were compared.ResultsThere were 22 patients with CPM who underwent CRS and HIPEC and 186 patients who underwent hepatectomy for CLM. Patients with CPM had a 3-year OS of 39xa0% and DFS of 27.7xa0%. CLM patients showed a 3-year OS of 58.5xa0% and a DFS of 28.8xa0%. Most recurrences for CPM occurred within 2xa0years, while CLM patients continue to develop systemic recurrences over 3xa0years, showing a gradual decline in DFS and OS during this period of time.ConclusionOur results show that CRS and HIPEC for CPM confer good OS and DFS rates and that the DFS after CRS and HIPEC is comparable to that after hepatectomy for CLM.

Hypoglycaemia in a 63-Year-Old Female with a Large, Recurrent, Metastatic Gastrointestinal Stromal Tumour (GIST)

IntroductionNon-islet cell tumour-induced hypoglycaemia (NICTH) is rare, with few cases reported in patients with gastrointestinal stromal tumour (GIST).Case ReportA 63-year-old Chinese female with known metastatic GIST presents with persistent hypoglycaemia. Investigations revealed a likely diagnosis of NICTH, and she underwent debulking surgery. There was complete resolution of her hypoglycaemia post-operativelyDiscussionNICTH should be considered in patients with GIST and hypoglycaemia. Surgical debulking is recommended as part of the management of NICTH.

Unresectability during open surgical exploration in planned cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Abstract Background: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are the treatment of choice for selected patients with peritoneal metastasis. Despite a stringent selection process, some patients were found to be unresectable only at surgery, which leads to disappointment and poor utilisation of limited infrastructural resources. This study aims to determine the pre-operative factors associated with unresectability in planned CRS and HIPEC. Methods: Retrospective analysis of 172 consecutive patients eligible for CRS and HIPEC at the National Cancer Centre Singapore from April 2004 to May 2014 was performed. Pre-operative factors (clinical presentation, disease factors, and investigation findings) between the unresectable (13%) and the successful groups (87%) were compared. Results: Patient demographics between the two cohorts were comparable. In terms of clinical presentation, the unresectable group was more likely to present with bloating (pu2009=u2009.00), altered bowel habits (pu2009=u2009.04), abdominal distension (pu2009=u2009.00), palpable abdominal masses (pu2009=u2009.00) and palpable pouch of Douglas nodules (pu2009=u2009.00). Differences were also noted in disease factors with the unresectable group having more high-grade tumours (pu2009=u2009.01), inadequate initial resections (pu2009=u2009.01), progression through chemotherapy (pu2009=u2009.00) and shorter median disease-free intervals (pu2009=u2009.03). In addition, investigations in the unresectable group revealed more patients with elevated tumour markers (pu2009=u2009.01), thrombocytosis (pu2009=u2009.00) and computed tomography findings of ascites (pu2009=u2009.00), omental thickening (pu2009=u2009.00), lymphadenopathy (pu2009=u2009.02) and small bowel disease (pu2009=u2009.00). Conclusions: Significant factors associated with unresectability that were identified in our study could potentially create a new treatment algorithm and refine current selection process to exclude patients at risk of unresectability in planned CRS and HIPEC.

Role of Pelvic Exenteration in the Management of Locally Advanced Primary and Recurrent Rectal Cancer

AimA review of a single-centre experience of pelvic exenteration as a treatment modality for patients with locally advanced primary and recurrent rectal cancer. The perioperative outcomes, morbidity and long term oncological outcomes are reviewed.Materials & MethodsPatients undergoing pelvic exenterations for recurrent and locally advanced rectal cancer between 1 January 2006 and 1 August 2012 were identified from a prospective database. All patients underwent pre-operative staging investigations with computed tomography (CT) scan of chest, abdomen and pelvis and pelvic magnetic resonance imaging (MRI). Patients with locally advanced primary rectal cancer were counselled for pre-operative chemoradiation. Structures such as the urinary bladder and female reproductive organs were resected en bloc where indicated with the lesion. Urological or plastic reconstructions were employed where indicated. The primary outcome measured was overall survival and secondary outcomes measured were time to local recurrence (LR) and systemic recurrence. Disease-free survival was examined by the Kaplan–Meier Method (Fig.xa01).ResultsPelvic exenterations were performed in 13 patients with a median age of 59 (range 26–81). The rate of major post-operative complications was 8xa0% (nu2009=u20091), where the patient had anastomotic leakage. There were no mortalities in the perioperative period. All patients were operated with curative intent and negative circumferential margins were shown in 9 out of 13 patients (70xa0%). The DFS was 19.4 and the OS was 22.5xa0months.ConclusionAn aggressive approach with en bloc resection of organs involved provides survival benefit to patients with locally advanced primary and recurrent rectal cancer with an acceptable morbidity profile.