• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Peritoneal Surgery and Intraperitoneal Chemotherapy | Mesothelioma Applied Research Foundation
 

Peritoneal Surgery and Intraperitoneal Chemotherapy | Mesothelioma Applied Research Foundation

on

  • 967 views

Peritoneal Surgery and ...

Peritoneal Surgery and
Intraperitoneal Chemotherapy, presented by Garrett Nash, MD of Memorial Sloan-Kettering at the Mesothelioma Applied Research Foundation's conference in New York, NY on September 28, 2012. www.curemeso.org

Statistics

Views

Total Views
967
Views on SlideShare
705
Embed Views
262

Actions

Likes
1
Downloads
8
Comments
0

3 Embeds 262

http://www.curemeso.org 256
http://www.kintera.com 5
http://www.google.com 1

Accessibility

Categories

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Peritoneal Surgery and Intraperitoneal Chemotherapy | Mesothelioma Applied Research Foundation Peritoneal Surgery and Intraperitoneal Chemotherapy | Mesothelioma Applied Research Foundation Presentation Transcript

    • Peritoneal Mesothelioma Cytoreductive Surgery and Intraperitoneal Chemotherapy Garrett Nash MD, MPH Assistant Attending Surgeon Memorial Sloan-Kettering Cancer Center September 28th, 2012
    • Peritoneal Mesothelioma About me • Training in Colorectal Surgery and Surgical Oncology • Peritoneal based diseases – Appendix Cancer – Metastatic Colorectal Cancer – Peritoneal Mesothelioma
    • Peritoneal Mesothelioma Peritoneal Mesothelioma • What is the disease? • What are the surgical options? • What are the outcomes after surgery?
    • Peritoneal Mesothelioma Peritoneal Mesothelioma • 2nd most common site of mesothelioma is the peritoneum – 10-30% of cases of mesothelioma – 300-400/cases in U.S. year
    • Peritoneal Mesothelioma Background • Causes – Asbestos exposure – Simian virus-40 – Radiation – Chronic inflammation of the peritoneum • Presentation – Increased abdominal girth – Ascites (fluid in the abdomen) – Abdominal pain – Weight loss
    • Peritoneal Mesothelioma Treatment Options • “Traditional” – Chemotherapy (doxorubicin and cisplatin) – Radiation – Drainage of abdominal fluid to alleviate pressure (palliative paracentesis) – Surgical excision of some of the tumor to alleviate intestinal blockage (palliative debulking)
    • Peritoneal Mesothelioma Annals of Oncology 18:827-834, 2007
    • Peritoneal Mesothelioma Surgical Options • Cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (IPC) – Surgical cytoreduction to eliminate visible disease by destroying tumor (burning/peeling/wiping) or removing organs – Delivery of chemotherapy directly to the peritoneal surfaces to eliminate microscopic disease
    • Peritoneal Mesothelioma Intraperitoneal Chemotherapy • EPIC – Early Postoperative Intraperitoneal Chemotherapy – Taxol/5FU • HIPEC – Hyperthermic (heated) Intraperitoneal Chemotherapy – Cisplatin/Doxorubicin/Mitomycin C
    • Peritoneal Mesothelioma Management of Ovarian Cancer 415 patients with peritoneal metastasis were randomized 1. Intraperitoneal chemotherapy (post operative) 2. Intravenous chemotherapy after cytoreductive surgeryGynecologic Oncology Group. N Engl J Med. 2006.5;354:34-43.
    • Peritoneal Mesothelioma Management of Colorectal Cancer 105 patients with peritoneal metastasis were randomized 1. Intravenous chemotherapy 2. Cytoreductive surgery + intraperitoneal chemo + intravenous chemo CRS + IPC + IVC IVCVerwaal. J Clin Oncol. 2003;21(20):3737-43.
    • Peritoneal Mesothelioma • Review of cytoreductive surgery and IPC • 7 non randomized studies • 240 patients
    • Peritoneal Mesothelioma Inclusion Criteria Exclusion Criteria • Histological diagnosis of • Surgical debulking without IPC diffuse malignant peritoneal • Studies that mix in other mesothelioma (DMPM) cancer types • Patients undergoing cytoreductive surgery (CRS) + intraperitoneal chemo (IPC)Annals of Oncology 18:827-834, 2007
    • Peritoneal Mesothelioma Survival after CRS with IPC Annals of Oncology 18:827-834, 2007
    • Peritoneal Mesothelioma Survival after CRS with IPC • Range of average survival by study: 3-7 years Annals of Oncology 18:827-834, 2007
    • Peritoneal Mesothelioma Complications and Mortality after Cytoreductive Surgery and IPC • Average length of operation 6-10 hours • Average hospital length of stay 16 days • Surgical complication rate 25-40% • Hematological toxicity 8-26% • Perioperative mortality 0-8%Annals of Oncology 18:827-834, 2007
    • Peritoneal Mesothelioma How can we predict prognosis? • No widely accepted staging system for peritoneal mesothelioma • No information on National Cancer Institute website (cancer.gov)
    • Peritoneal Mesothelioma • 8 institutions prospective collected data • 294 patients treated with cytoreductive surgery and intraperitoneal chemotherapyYan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma • Primary objective: Formulate a staging system through identification of prognostic factors.Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Patient Factors Associated with SurvivalYan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Pathology/Surgery Factors Associated with SurvivalYan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Classification of Peritoneal Mesothelioma • 3 histological subtypes – Epithelial – Sarcomatoid – Mixed/biphasic Sarcomatoid Epithelial
    • Peritoneal Mesothelioma Pathology/Surgery Factors Associated with SurvivalYan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Peritoneal cancer index (PCI) • During surgery • Tumor distribution (13 abdominal pelvic regions) •Tumor nodule size (0-3 points)Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Pathology/Surgery Factors Associated with SurvivalYan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Optimal Cytoreductive Surgery Residual visible tumor nodules • CC0 - none • CC1 - <2.5mm • CC2 - 2.5 mm-2.5cm • CC3 - >2.5cm
    • Peritoneal Mesothelioma Optimal Cytoreductive Surgery Residual visible tumor nodules • CC0 - none • CC1 - <2.5mm • CC2 - 2.5 mm-2.5cm • CC3 - >2.5cm
    • Peritoneal Mesothelioma Optimal Cytoreductive Surgery Residual visible tumor nodules • CC0 - none • CC1 - <2.5mm • CC2 - 2.5 mm-2.5cm • CC3 - >2.5cm
    • Peritoneal Mesothelioma Optimal Cytoreductive Surgery Residual visible tumor nodules • CC0 - none • CC1 - <2.5mm • CC2 - 2.5 mm-2.5cm • CC3 - >2.5cm
    • Peritoneal Mesothelioma TNM staging system • Most common system used for staging cancer • T stage – size or depth of tumor (1-4) • N stage – presence of lymph nodes with cancer (0-2) • M stage – presence of metastasis to organs (0- 1)
    • Peritoneal Mesothelioma TNM staging system • Most common system used for staging cancer • T stage – size or depth of tumor (1-4) • N stage – presence of lymph nodes with cancer (0-2) • M stage – presence of metastasis to organs (0- 1) • For colon cancer • Stage I = T1/2, N0, M0 • Stage II = T3/4, N0, M0 • Stage III = N1/2, M0 • Stage IV = M1
    • Peritoneal Mesothelioma Survival Stratified by T Stage Based on PCI • T1 = PCI 1-10 • T2 = PCI 11-20 • T3 = PCI 21-30 • T4 = PCI 30-39Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Survival Stratified by Nodal StageYan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Survival Stratified by M stage • M1 = extraabdominal disease (e.g. chest/skin)Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Overall survival stratified by TNM staging system 52 patients T1 N0 M0 166 patients T2-3 N0 M0 76 patients T4 or N1 or M1Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Combining TNM Stage with Histology and Optimal Surgery HR CI Sarcomatoid vs. epitheloid 5.5 2.9-10.5 Incomplete vs. complete CRS 2.0 1.2-3.2 Stage II vs. I 3.3 1.2-9.4 Stage III vs. I 5.9 2.1-17.2Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Summary • Appears to stratify patients for prognosis – Patients who do poorly • High volume disease • Extra-abdominal disease • Non-epitheloid histology – Patients who do ‘well’ • Low volume disease • Node negative – Selected patients undergoing CRSYan TD, et al. Cancer. 2011 May 1;117(9):1855-63
    • Peritoneal Mesothelioma Conclusions • Surgery offers good long term outcomes for selected patients with favorable tumors • Surgery is high risk • We need comparative studies that demonstrate how much surgery and intraperitoneal chemotherapy may benefit patients
    • Peritoneal Mesothelioma Thank You • Mesothelioma Applied Research Foundation and Lee Krug, MD
    • Peritoneal Mesothelioma Thank You • Mesothelioma Applied Research Foundation and Lee Krug, MD • My medical oncology collaborator, Andrea Cercek, MD
    • Peritoneal Mesothelioma Thank You • Mesothelioma Applied Research Foundation and Lee Krug, MD • My medical oncology collaborator, Andrea Cercek, MD • The patients who allow us to study their tumors