gastric peritoneal carcinomatosis, hipec

Varese, 13-‐03-‐15 Prof. A Donini

La Carcinosi Peritoneale : Indicazioni e Limiti del Trattamento HIPEC

La Carcinosi Peritoneale : Indicazioni e Limiti del Trattamento HIPEC Prof. A Donini

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Sasako M, H Van de Velde, et al, Lancet Oncol ,2010

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Gastric Cancer Pa9ern of Recurrence

Roviello, et al. BrJSurg, 2003 Maehara Y. et al. Br J Surg,2003


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1995 - 2012 : 5,220 patients were diagnosed with gastric cancer in the Eindhoven Cancer Registry.

- 2,029 patients (39%) presented with metastatic disease

PC was present in 706 patients (14% of total, 35% of patients with metastatic disease)

Of these patients, 491 patients (9% of total, 24% of patients with metastatic disease) had PC as the only metastatic site


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Median survival of patients with PC as the only metastatic site was 4.6 and 3.3 months in patients with PC combined with other metastases

Resection of the primary tumor in the presence of PC resulted in a longer median survival (9.9 vs. 3.7 months)


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Int J Cancer 2014

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Is There a Possibility of a Cure in Patients with Gastric Peritoneal Carcinomatosis ?


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7La Carcinosi Peritoneale : Indicazioni e Limiti del Trattamento HIPEC Prof. A Donini

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Chemotherapy and Gastric carcinomatosis

-‐Chu (Cancer 1989) : n=100 (prospective) Palliative treatment / 5-‐FU.

0% at 10 months

-‐Sadeghi EVOCAPE 1 (Cancer 2000) : n=127. (prospective) Palliative systemic chemotherapy. Median survival : 3 months1/3 of synchronous carcinomatosis

03 La Carcinosi Peritoneale : Indicazioni e Limiti del Trattamento HIPEC Prof. A Donini

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Patients with stage IV disease should be considered for palliative chemotherapy, which improves survival compared with best supportive care alone [28 [I, A].

“Irrespective of the positive impact of any presently available chemotherapy, the prognosis of patients with advanced gastric cancer remains desperate, with a median survival of only 7 to 10 months in most of the larger clinical studies.”


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Acta Oncologica 2013

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Median survival of patients with PC was 4 months.

In conclusion, the usage of chemotherapy increased in patients with PC of gastric origin but this did not result in prolongation of survival on a population-based level.


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Acta Oncologica 2013


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Chemotherapy and Surgey ?


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Scopus -‐ HIPEC from 1985 -‐ Present: 886 document


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Scopus -‐ HIPEC and Gastric Cancer from 1980 -‐ Present : 296


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Ann of Surg Onc Jul 2007


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Author,year year Country N Med. surv Comparison Type study

Loggie, 2000 USA 22 10,1 case serie

Rossi, 2003 Italy 13 15 case serie

Hall, 2004 USA 34 11,2 vs 3,3 R0/1 vs R2 case serie

Glehen, 2004 France 49 21,3 vs 6,6 R0/1 vs R2 case serie

Scaringi, 2008 France 26 15 vs 3,9 R0/1 vs R2 case serie

Glehen, 2010 France 159 15 vs 5 R0/1 vs R2 case serie

Hultman, 2012 Sweden 10 17,1 vs 11,1 HIPEC vs sCTx match case control

Hultman, 2013 Sweden 18 19,1 vs 10,2 R0/1 vs R2 case serie

Magge, 20014 USA 23 9,5 case serie

Konigsrainer, 2014 Germany 18 8,9 vs 1,1 R0/1 vs R2 case serie

Rudloff, 2014 USA 16 11,3 vs 4,3 HIPEC vs sCTx RCT

Levine, 2014 USA 46 6,1 case serie

HIPEC in gastric cancer in Western Studies

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Which PaXents may be considered for HIPEC treatment?

PaXents at high risk of development of PC: -‐ Serosal Invasion of Gastric Wall (Advanced T-‐Stage)

PaXents with occult peritoneal carcinomatosis : -‐ Posi?ve Cytology at Peritoneal Washing

PaXents with peritoneal carcinomatosis macroscopically evident


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Indipendent Risk Factors according to recurrent pa9ern by logisXc regression

BJS,2000


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BJS,2002


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Median OS of paXents with CY1 with no macroscopic evident desease is similar to that of paXents with CY1 and gross metastaXc desease at laparoscopy

Ann Surg Onc, 2008

3y OS P0C1 is the same of P1C0

Lee S.D. et al, BJS, 2012

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January, 2014

Mortality at 1 year


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Mortality at 2 year

F. Coccolini et al. / EJSO 40 (2014)


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Mortality at 3 year


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Mortality at 5 year



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Which PaXents may be considered for HIPEC treatment?

PaXents at high risk of development of PC: -‐ Serosal Invasion of Gastric Wall (Advanced T-‐Stage)

PaXents with occult peritoneal carcinomatosis : -‐ Posi?ve Cytology at Peritoneal Washing

PaXents with peritoneal carcinomatosis macroscopically evident


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Gastric Carcinomatosis

Randomisation

Cytoreduc?ve Surgery +

HIPEC with CDDP and MMC Cytoreduc?ve Surgery

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Ann Surg Oncol (2011)


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Ann Surg Oncol (2011)


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Survival rates

1-‐year: 43%

3-‐year: 18%

5-‐ year: 13%

Disease-‐free survival rates 1-‐year: 31%

3 years: 12%


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Glehen, Elias D., et al, 2010

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2013

Grade 3–4 morbidity and mortality in series using

Common Terminology Criteria for Adverse Events (CTCAE)


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O. Glehen, , Ann Surg Oncol (2010)

Mortality 10 paXents (6.5%)

Major complicaXons (grade 3–4 complicaXons) occurred in 38 paXents (27.8%)

Diges?ve fistula : 16% • Reopera?on: 14%

Mean post-‐operaXve stay : 24,2 ± 19 days

159 paXents from 15 insXtuXons


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Morbidity

January, 2014


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OUR EXPERIENCEVariables N° pts %

n° of cases 21

M/F 12/9

Median age (y) 60,52

Average PCI 3.33 ± 6.01 (range0 -‐ 19)

CC 0 18 85.71

CC 1 2 9.52

CC 2 1 4.77Neoadjuvant chemo 12 57.14

Adjuvant chemo 16 76.19Prophylactic HIPEC 12 57.14

Therapeutic HIPEC 9 42.86

Morbidity (grade I-‐II-‐III) 2 9.52

Morbidity (grade IV) 1 4.77

Mortality 1 4.77

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5 y -‐ OS = 58 %5y-0S Stage III: 18%

5Y-OS Stage IV: 13%

Advances stages OS No HIPEC


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Advances stages OS HIPEC

5y-0S : 58%


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“The patient is killed by what the surgeon doesn’t see” P.H.Sugarbaker


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CytoreducXve surgery and HIPEC should be considered as it is the only treatment that may offer long-‐term survival in paXents with gastric carcinomatosis

Which paXents? •Young paXents with very good general status ︎

•Possibility of complete cytoreducXve surgery (Only independant prognosXc factor )

•Limited carcinomatosis (PCI 12) PROPHYLACTIC HIPEC

Conclusion

gastric peritoneal carcinomatosis, hipec

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