Editorial
Advanced Abdominal and Thoracic Malignancies. Cytoreduction and Cavity Hyperthermic Chemoperfusion Treatment
Enricomaria Pasqual* and Stefano Bacchetti
Department of Surgical Oncology, University of Udine, Italy
*Corresponding author: Enrico Maria Pasqual, Department of Surgical Oncology, Prof. Semeiotica Chirurgica University of Udine, AOU Udine, Piazzale Santa Maria della Misericordia
Published: 24 Jan, 2018
Cite this article as: Pasqual E, Bacchetti S. Advanced
Abdominal and Thoracic Malignancies.
Cytoreduction and Cavity Hyperthermic
Chemoperfusion Treatment. Clin Surg.
2018; 3: 1895.
Editorial
Since the end of 90’ there has been an increasing applying of peritoneal cavity chemo-
Hyperthermic Perfusion (HIPEC) to treat peritoneal carcinos is from abdominal solid tumours.
Following the pioneering experience of Paul Sugarbaker, more than 200 world-wideCenters now
treat selected cases of PC from Ovarian, Gastric, Colon, Pseudomyxoma peritonei tumours and
those coming directly from the peritoneal serosa, Mesothelioma. Hipec is a suitable and logical
option particularly following complete (absence of residual tumour) or optimal (residual tumour
less than 2.5 mm in diameter) cyto reduction and it has the goal of killing those Peritoneal Free
Cancer Cells (PFCCs) present at the end of the surgical tumour removal in more than 75% of cases.
Results from thousands of pubblications and cytations in literature demonstrates that in presence
of limited peritoneal carcinosis [1,2] but even in more selected diffused cases the advantage of the
treatment combination, Complete cyto reducion and Hipec, is clear in more than 40% of cases,
reaching long term survival and even definitive cure in lots of patients. Complete resection of
coexistent hepatic metastases doesn’t impact on successful rates [3].
Strict exclusion criteria for curative HIPEC are miliary diffused peritoneal metastases and
extra-abdominal metastases (Bone, Brain, Lung)[1,2]. After the first procedure, recurrence of
tumour is frequent (about 50% of cases) and are still located into the peritoneal cavity in 45% of
cases, particularly in case of ovarian, pseudomyxoma and colonic primary tumours. To repeat the
procedure in these cases allows a success rate in 35-45% of patient resembling the same outcome
after the first procedure [4]. Another very captivating indication for HIPEC is prevention of
peritoneal carcinosis and even hepatic metastases, in those tumours at risk of metastases. Based on
pivotal studies from Asiatic Group’s experience. HIPEC has been administered after radical surgery
for T3-4 advanced gastric cancer with good results [5,6]. With the same rationale in 2021 it will
be finish a randomized study from European Groups approaching the question of Hipec or not
after curative gastric cancer surgery [7]. Randomized studies for gastric and ovarian cancers are
now on going with definitive result coming soon. In practice the supposed high complication rate
after these procedures is the main reason why these procedure are not still fully applied worldwide.
CRS is associated with significant morbidity and low mortality rates. Intraperitoneal heated
chemotherapy (HIPEC) may cause additional morbidity and toxicity. Changing the intraoperative
chemotherapy protocols may be associated with an increased morbidity. However, postoperative
complications are mainly associated with the extent of surgery and the performed surgical
procedures. In the literature morbidity rates range from 23% to 45% depending on the assessment
and definition of perioperative complications. Complication’s rate are mainly dependent on the
skill of the Center. Growing experiences demonstrate that the more volume of treatment a Center
produces the less complication’s rate is obtained [8]. A palliative role for Hipec has been explored in
case of persistent untreatable malignant ascitis (MA). Literature on the use of laparoscopic HIPEC
in MA refers only on small numbers of patients, but all showing successful control of ascites. It is a
beneficial treatment for the management and palliation of refractory MA and results are excellent
with complete resolution observed in many patients [9]. Similarly, recent experiences have been
made with hyperthermic chemoperfusion of the pleuralcavity. In case of pleural mesothelioma,
lung, breast, ovarian tumors involving the pleura and even chronic pleural fluid collection, an
Hyperthermic Thoracic Cavity Chemoperfusion (HITHOC) was given to the patients. Those who
received HITHOC had significantly longer median survival length compared to the patients without
HITHOC. This is a procedure that can be applied in some caseeven with a mini-invasive approach,
thoracoscopy, and a more extensive indications for this treatment is expected here after [10].
Peritoneal and pleural cavity hyperthermic chemoperfusion following
R0, CC0 surgical cytoreduction need high level of expertise with an
ideal learning curve exceeding 100 cases treated. Therefore dedicated
multidisciplinary team services, made by surgeons, radiotherapists,
oncologists, radiologists, perfusionists and pathologistsare now being
offered in many third refferal Hospital worlwide. It seems reasonable
therefore to promote world-wideinstitution of Surgical oncological
Units dedicated to the treatment of relapsing or metastatic disease
from abdominal and chest tumors.
References
- Paul Sugarbaker. The Seven Best from PSOGI 2016. Ann Surg Oncol. 2017;24(4):870-4.
- Proceeding ASCO. 2017.
- El-Nakeep S, Rashad N, Oweira H, Schmidt J, Helbling D, Giryes A, et al. Intraperitoneal chemotherapy and cytoreductive surgery for peritoneal metastases coupled with curative treatment of colorectal liver metastases: an updated systematic review. Expert Rev Gastroenterol Hepatol. 2017;11(3):249-58.
- Sardi A, Jimenez WA, Nieroda C, Sittig M, Macdonald R, Gushchin V. Repeated cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in peritoneal carcinomatosis from appendiceal cancer: analysis of survival outcomes. Eur J Surg Oncol. 2013;39(11):1207-13.
- Yonemura Y, de Aretxabala X, Fujimura T, Fushida S, Katayama K, Bandou E, et al. Intraoperative chemohyperthermic peritoneal perfusion as an adjuvant to gastric cancer: final results of a randomized controlled study. Hepatogastroenterology. 2001;48(42):1776-82.
- Fujimoto S, Takahashi M, Mutou T, Kobayashi K, Toyosawa T. Successful intraperitoneal hyperthermic chemoperfusion for the prevention of postoperative peritoneal recurrence in patients with advanced gastric carcinoma. Cancer. 1999;85(3):529-34.
- Glehen Olivier, Guillaume Passot, Laurent Villeneuve, Delphine Vaudoyer, Sylvie Bin-Dorel, Gilles Boschetti, et al. GASTRICHIP: D2 resection and hyperthermic intraperitoneal chemotherapy in locally advanced gastric carcinoma: a randomized and multicenter phase III study. Cancer. 2014;14:183.
- McConnell YJ, Mack LA, Francis WP, Ho T, Temple WJ. HIPEC + EPIC versus HIPEC-alone: differences in major complications following cytoreduction surgery for peritoneal malignancy. J Surg Oncol. 2013;107(6):591-6.
- Valle SJ, Alzahrani NA, Alzahrani SE, Liauw W, Morris DL. Laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) for refractory malignant ascites in patients unsuitable for cytoreductive surgery. Int J Surg. 2015;23:176-80.
- Zhou Hua Zhou, WeiWu, Xiaoping Tang, Jianying ZhouYihong Shen. Effect of hyperthermic intrathoracic chemotherapy (HITHOC) on the malignant pleural effusion. Medicine (Baltimore). 2017;96(1):e5532.