Multisocietal Consensus on the Use of Cytoreductive Surgery and HIPEC for the Treatment of Diffuse Malignant Peritoneal Mesothelioma: A GRADE Approach for Evidence Evaluation and Recommendation.

The Peritoneal Surface Oncology Group International (PSOGI) previously issued a recommendation endorsing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for treating diffuse malignant peritoneal mesothelioma (DMPM). However, broader acceptance of this approach, particularly within some segments of medical oncology, remains limited. To address this, PSOGI initiated a multisociety consensus effort, involving multidisciplinary International Societies, to strengthen and expand the endorsement of CRS-HIPEC for DMPM.

Unexpected peritoneal metastases diagnosed at the time of primary colon cancer resection: controversies regarding options for management.

Peritoneal metastases synchronously occurring in the patient with primary colon cancer causes that patient to be at high risk for subsequent disease progression within the abdomen and pelvis. If peritoneal metastases are preoperatively diagnosed, patients are likely to be treated with neoadjuvant chemotherapy with or without biological therapy prior to cytoreductive surgery (CRS). However, if one only considers patients with peritoneal metastases unexpectedly identified at the time of primary colon cancer resection, the optimal management strategy is neither standardized nor evidence based.

Review of Options to Traditional HIPEC for Prevention and Treatment of Peritoneal Metastases.

Cytoreductive surgery with HIPEC has definite application to the management of selected patients with peritoneal metastases. Patients who profit most have a complete cytoreductive surgery. Higher-grade tumors such as colorectal cancer, gastric cancer, and ovarian malignancy are benefited by CRS and HIPEC only under limited circumstances.

Critical appraisal of total gastrectomy plus total colectomy with hyperthermic intraperitoneal chemotherapy as a treatment for advanced pseudomyxoma peritonei.

Background: The absolute requirement for a long-term favorable result with cytoreductive surgery for pseudomyxoma peritonei is a complete resection of all visible disease. A combination of parietal peritonectomy procedures and visceral resections is required for this to occur. The cytoreductive surgery is supplemented by hyperthermic intraperitoneal chemotherapy.

Cellularity of mucus is a prognostic variable in low-grade appendiceal mucinous neoplasms.

For peritoneal metastases from a primary appendiceal mucinous neoplasm to exist, the thin wall of the appendix must perforate to allow mucus or mucus plus tumor cells to gain access to the peritoneal spaces. The proportion of specimens containing tumor cells within mucus as compared to mucus only outside the appendix may have prognostic significance. The histopathology of tumor masses was determined from the specimens resected at the cytoreductive surgery (CRS).

Critical reappraisal of prognostic indicators for 949 mucinous appendiceal neoplasm patients.

Background And Objectives: The standard of care for treatment of an appendiceal mucinous neoplasm with peritoneal dissemination is cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). These two treatments are combined in the operating room. A crucial requirement for benefit long-term is proper patient selection.

It Is What the Surgeon Does Not See That Kills the Patient.

Background: Patients with colon cancer may present at multiple different stages of the disease process. Many patients can be cured of colon cancer as a result of a simple surgical procedure usually performed by minimally invasive techniques. However, there are a variable number of patients, estimated at approximately 10%, who have a more advanced disease.

Phase 1 trial of same day cytology to guide the use of HIPEC.

Background: Peritoneal metastases from gastrointestinal or gynecologic malignancy are a prominent part of the natural history of these diseases. Peritoneal metastases, if not effectively treated, will result in a decreased survival and cause an impaired quality of life. Hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment specifically designed to combat peritoneal metastases.

Randomized trial of intravenous versus bidirectional chemotherapy after cytoreductive surgery for malignant peritoneal mesothelioma.

Background: Malignant peritoneal mesothelioma (MPM) is a rare disease that progresses within the peritoneal cavity and only disseminates to systemic sites in the terminal months of the disease. For this malignancy, there are several regimens of chemotherapy that have been accepted as standard, principally intraperitoneal chemotherapy (IPC) and intravenous chemotherapy (IVC); however, there is no standardized method of treatment. Selected patients with MPM who are amenable to cytoreductive surgery (CRS) and are fit for surgery typically undergo resection with hyperthermic intraperitoneal chemotherapy (HIPEC).

Use of early postoperative intraperitoneal 5-fluorouracil with index cytoreduction improves survival with secondary cytoreductive surgery.

Background: In patients with appendiceal mucinous neoplasm with peritoneal dissemination, a cytoreductive surgery (CRS) with perioperative chemotherapy may result in long-term survival. Disease progression may require secondary cytoreductive surgery (SCRS) and other treatments in selected patients to improve survival and preserve an optimal quality of life.

Methods: The clinical- and treatment-related variables associated with the index CRS and SCRS were statistically assessed for impact on survival after SCRS.

Determinants of Outcome with Reoperative Surgery for Pseudomyxoma Peritonei in 186 Patients.

Objective: To describe the long-term survival and clinical- and treatment-related variables that determine the outcome of repeat cytoreductive surgery (CRS) for mucinous appendiceal neoplasms with peritoneal dissemination.

Summary Background: After patients with peritoneal dissemination of an appendiceal mucinous neoplasm have a CRS, disease progression may require secondary cytoreductive surgery (SCRS) and other treatments performed in a timely manner to prolong survival and help preserve an optimal quality of life.

Methods: The clinical- and treatment-related variables associated with the index CRS and the SCRS were statistically assessed for their impact on survival.

Extent of Disease on Visceral Peritoneal Surfaces of Mucinous Appendiceal Neoplasms Controls Survival.

Objective: To determine causes of treatment failure of low-grade appendiceal mucinous neoplasms (LAMN).

Background: For 3 decades, LAMN have been treated by cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy. This combined treatment has resulted in a large change in the survival of these patients.

A narrative review of what can HIPEC do.

Intraperitoneal chemotherapy as in hyperthermic intraperitoneal chemotherapy (HIPEC) has limited efficacy. It should not be expected to eradicate even the smallest vascularized tumor nodules. Neither should it be used in an attempt to eradicate tumor cells from within scar tissue.

Selection Factors for Treatment and Stratification of Rare Abdominal or Pelvic Tumors with Peritoneal Metastases.

To maximize the results of treatments for peritoneal metastases for rare abdominal or pelvic tumors, selection of patients with a possibility for long-term success is necessary. Because these malignancies are rare, data from which these selection factors can be extracted do not exist. In order to facilitate knowledgeable patient selection for treatment, the well established clinical and histopathologic features of the common malignancies treated for peritoneal metastases were reviewed.

Prognostic indicators for colorectal peritoneal metastases are different for patients with complete versus incomplete cytoreductive surgery.

Background: In the management of peritoneal metastases in patients with colorectal cancer, the completeness of cytoreduction has consistently been the most prominent prognostic indicator. Other clinical and histologic features have been described that may also have an impact on survival.

Methods: The colorectal peritoneal metastases patients treated by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy were divided into two groups.

Response to Nivolumab followed by complete cytoreductive surgery with HIPEC resulted in long-term survival in a patient with sarcomatoid-predominant biphasic peritoneal mesothelioma. A case report.

Introduction And Importance: Sarcomatoid-predominant biphasic peritoneal metastases is a rapidly progressing and deeply invasive variant of this disease with survival measured in months. Although cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a standard of care for epithelioid peritoneal mesothelioma, the sarcomatoid variant is so aggressive, the standard treatment is not recommended. Immunotherapy has recently been utilized for pleural mesothelioma.

Ten-year survival of pancreas cancer with liver metastases treated by intraoperative and long-term intraperitoneal gemcitabine. A case report.

Introduction And Importance: Progress in the management of pancreas cancer has been slow to occur. Resection of the primary cancer in the head of the pancreas is possible and has become a standard of care in operable patients. Unfortunately, long-term survival after this extensive surgical procedure is nearly nonexistent.

Pathogenesis of histologic variations of appendiceal mucinous neoplasms.

Background: In order for peritoneal metastases from a primary appendiceal mucinous neoplasm to occur, the wall of the appendix must perforate to allow mucus with tumor cells access to the peritoneal spaces. With progression the peritoneal metastases show a broad spectrum of tumor biology varying from indolent to aggressive activity.

Methods: The histopathology of peritoneal tumor masses was determined from the clinical material resected at the time of cytoreductive surgery (CRS).

Clinical and Histopathologic Features of 35 Patients Treated for Colorectal Peritoneal Metastases Who Survived 5 Years.

Background: Currently, patients with a limited extent of peritoneal metastases from colon and rectal cancer are treated by cytoreductive surgery combined with perioperative chemotherapy performed at experienced centers.

Objective: To statistically evaluate features that may impact survival of ≥5 years. These data are used in the risk/benefit analyses performed by the multidisciplinary team.

Palliation of mucinous appendiceal neoplasms with peritoneal metastases with total abdominal colectomy.

Background: Incomplete cytoreduction for mucinous appendiceal neoplasms is often required to temporarily alleviate symptoms. The surgical technology for this intervention may be complex and result in extensive morbidity and even mortality. Knowledgeable patient selection for this surgery is mandatory.