Role of the medical oncologist in a peritoneal surface malignancy program
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Discusses the vital role of the medical oncologist in a peritoneal surface malignancy program
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Role of the medical oncologist in a peritoneal surface malignancy program
- 1. { Role of the Medical Oncologist in a PSM Program Mary Ondinee Manalo Igot, MD Medical Oncologist / Neuro-Oncologist 26 August 2017 Southern Philippines Medical Center
- 2. Neoadjuvant Perioperative Pre-operative Intra-operative Post-operative “Adjuvant” Follow-up Outline
- 3. Most of these patients are Stage IV Most Stage IV patients benefit from palliative chemotherapy Why the medical oncologist?
- 5. Still a gray area, some studies supporting it Potential advantages: Reduction in tumor volume Greater chance for complete surgical removal Test the biology of the tumor Time to prepare for HIPEC logistocally Time to prepare the patient (nutrition, comorbidities) Might improve functional status Neoadjuvant chemotherapy
- 6. P: 53 primary ovarian CA with peritoneal mets from 2008 to 2014 I: 6 cycles of platinum + taxane >> CT for response assessment >> HIPEC was carried out if responded O: Toxicity of neoadjuvant chemo mostly grade 1-2, no mortality, major surgical complication rate was 13%, mean survival 35±20 months M: Prospective, single arm, observational
- 7. P: 58 patients with peritoneal mucinous adenocarcinoma, Jan 2005-Dec 2009 I: 5FU-based + oxaliplatin +/- bevacizumab O: Median overall survival was the same (50 months), reduction in tumor burden, less extensive cytoreduction M: Prospective, observational
- 8. P: 166 colorectal PC patients between 2002 - 2012 I: Neoadjuvant chemotherapy with (21%) or without (16%) bevacizumab O: OS was associated with extent of disease, neoadj chemo with bevacizumab, mean OS = 27 months M: Prospective
- 9. P: 115 patients underwent neoadj chemo I: Multivariate analysis was performed to identify predictors of survival and pathologic response (mean percentage of cancer cells remaining within all specimens) O: 9.7% had pCRs, 20.2% had major responses, while 70.1% had minor/no responses. Pathological response was the only independent predictor of survival (p=0.01) M: Retrospective review
- 11. PREOPERATIVE: “Second look” at patient and laboratories Perioperative Period
- 12. PREOPERATIVE: “Second look” at patient and laboratories HIPEC consent, give chemotherapy monograph Perioperative Period : My practice
- 14. HIPEC consent form of the Asian Hospital & Medical Center and De La Salle – University Medical Center
- 15. Chemotherapy monograph of Mitomycin - Taken from http://www.bccance r.bc.ca
- 19. PREOPERATIVE: “Second look” at patient and laboratories HIPEC consent, give chemotherapy monograph Write up and order the chemotherapy Make sure that all materials needed for chemo are available (extra bag of peritoneal dialysate) Perioperative Period : My practice
- 20. Example of HIPEC orders: Mitomycin 30 mg mixed in 3L of 1.5% dextrose peritoneal dialysate solution to be infused at 42C for 90 minutes. Please provide 1 extra bag of peritoneal dialysate. Perioperative Period : My practice
- 21. Intraop Period : My practice Waiting…
- 22. Intraop Period : My practice More waiting…
- 23. Anti-emetics? Premeds? Intraop Period : My practice
- 24. Febrile neutropenia – filgrastim and antibiotics Chemical pneumonitis – pulsing with steroids Postoperative Period : My practice
- 26. Although the HIPEC procedure is performed with the intent to cure a patient, it should be realized that peritoneal cancer is an aggressive disease, which often recurs even after a successful HIPEC procedure. To further improve outcomes after HIPEC, the medical oncologist may advise additional systemic chemotherapy. However, chemotherapy is not beneficial for all patients after HIPEC. “Adjuvant” chemotherapy
- 27. Skip IV chemotherapy: DPAM Review: PSEUDOMYXOMA PERITONEI Strictly speaking should be a pathologically and prognostically homogeneous group of cases characterized by histologically benign peritoneal tumors that are frequently associated with a ruptured appendiceal mucinous adenoma”. These cases are more recently categorized as disseminated peritoneal adenomucinosis (DPAM). Ronnett, Sugarbaker et al. Am J Surg Pathol Chua, Sugarbaker, et al. JCO 5-yr OS 5-yr OS Disseminated peritoneal adenomucinosis (DPAM) 84% 81% Intermediate features 38% 78% Peritoneal mucinous carcinomatosis (PMCA) 7% 59%
- 28. P: 231 colon CA with ISOLATED PC I: OS, PFS and RFS were compared with/without chemotherapy O: Mean OS = 43 months; post-operative chemotherapy does not improve OS M: Retrospective, multicenter study
- 29. 1. Retroperitoneal, viscera, gynecologic sarcoma 2. Neuroendocrine tumors 3. Urachal adenoCA 4. Low malignant potential ovarian tumors 5. Colonic polyps (traumatic resection) 6. Mesenteric cysts 7. Pararectal hamartoma 8. Adrenocortical adenocarcinoma 9. Desmoplastic small round cell tumor 10. Endocervical mucinous adenoCA Hepatocellular CA 11. Fibrolamellar hepatocellular CA 12. Germ cell testicular tumor 13. Pancreatic cancer 14. Nephroblastoma 15. Cylindroma 16. Adenocarcinoma of unknown primary List of rare diseases having isolated peritoneal metastases and possibly treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy
- 30. CT scan every 3-6 months, serum tumor markers, blood chemistry, etc. Follow-up
- 31. DR KENNY JUN DEMEGILLO : DAVAO CITY & TAGUM CITY Davao Doctors Hospital Metro Davao Medical and Research Center Davao Regional Medical Center DR ARTHUR LUI : DAVAO CITY Metro Davao Medical and Research Center Davao Doctors Hospital San Pedro Hospital DR NELSON LAJA : ZAMBOANGA CITY Ciudad Medical Zamboanga Zamboanga Doctors Hospital West Metro Medical Center Zamboanga Peninsula Medical Center Zamboanga City Medical Center KEY MESSAGE: Medical Oncologists in Mindanao trained in administering HIPEC
- 32. I treat cancers daily. What’s your superpower?
Editor's Notes
- Again, there’s no specific google-able material for this lecture, so I will be repeatedly be mentioning how we did it when I was training in Singapore or how I do it in my private practice.
- Most of these patients are Stage IV patients, most of the time or at one point in their lives, they will be referred to us. Most Stage IV patients benefit from palliative chemotherapy, and chemotherapy is our specialty. We have been trained to handle chemotherapy, know the right patients, anticipate side effects and manage complications.
- Neoadjuvant chemotherapy is still a gray area before HIPEC. There are some studies supporting it. But actually, the best patient is that patient who you can resect and do HIPEC upfront. Although the standard of care for patients presenting peritoneal mets is initial maximal CRS, this is not always possible because of medical factors. Neoadjuvant chemotherapy may reduce disease burden and increase tumor resectability while simultaneously allowing performance status to improve. Surgery after neoadjuvant chemotherapy is associated with less intraoperative blood loss, shorter operative times, fewer intensive care unit admissions, and a shorter duration of hospital stay. And if it works for breast cancers and other cancers, by principle it should work also for peritoneal cancers. Giving neoadjuvant chemotherapy will also be able to test the biology of the tumor …. Meaning if it responds to the IV chemo, then it should respond to the HIPEC. It will also give you time to prepare LOGISTICALLY for the HIPEC
- IS neoadjuvant chemotherapy SAFE? The results of this study indicate the feasibilty and safety of giving neadjuvant chemotherapy. The use of neoadjuvant chemotherapy is a useful tool to select patients who can potentially benefit from complete cytoreduction and HIPEC.
- DOES IT REDUCE RATES or EXTENT of CYTOREDUCTION?
- DOES ADDING BEVACIZUMAB IMPROVE OUTCOMES?
- DOES IT IMPROVE PATHOLOGIC RESPONSES?
- I usually go personally to the patient just to be VERY SURE that she doesn’t have an infection. Look at the labs. Reassure the patient.
- Then I make them sign a HIPEC consent. This is different from the consent given by surgeons. Then I also give them a chemotherapy monograph. Ill show it to you in the next few slides. I am very OC person when it comes to consent and explaining. Patients and their families DON’T SUE DOCTORS they like.
- Its very simple and straight to the point.
- But again, because I am OC I modified it a bit to make it more complex. This is the consent form that I made for Asian Hospital and the De La Salle Medical Center.
- In short, I just make sure that my partner surgeon will not worry about other things other than his surgery. It makes things easier for team if you are able to anticipate the needs of the other.
- In short, I just make sure that my partner surgeon will not worry about other things other than his surgery. It makes things easier for team if you are able to anticipate the needs of the other.
- Most of the time I spend waiting… taking selfies
- At 9 PM I was able to infuse the chemotherapy already… and by this time, as the surgeon, you don’t want to be the one to make sure that everything is in place, you just want to rest, eat, go to the CR. So that’s where I come in, so usually for at least half of the infusion of the HIPEC, I stay there, make sure that there are no reactions, assist also the technician manipulating the machine During this OR, I was able to go home already past midnight. So again, this takes time and commitment and dedication from the other doctors. Its very unusual for internists to go home very late.
- Surgeon calls me, I bring the prepared chemo. How about anti-emetics? Do I give?
- The rest were mostly surgical complications
- Although the HIPEC procedure is performed with the intent to cure a patient, it should be realized that peritoneal cancer is an aggressive disease, which often recurs even after a successful HIPEC-procedure. To further improve outcomes after HIPEC, the oncologist may advise additional systemic chemotherapy. The aim of the chemotherapy is to prevent or delay peritoneal recurrence and metastatic spread to other organs, such as the liver or lungs. However, chemotherapy is not beneficial for every patient following HIPEC, and the decision to pursue chemotherapy depends on many factors that should be considered in every individual patient.
- Pseudomyxoma peritonei is used now for almost all entities with peritoneal dissemination from mucus-producing adenocarcinomas of the appendix, intestines, lung, breast, pancreas, stomach, bile ducts, GB, fallopian tubes and ovary. However, strictly speaking, PMP is a unique condition characterized by diffuse collections of gelatinous material in the abdomen and pelvis, and mucinous implants on the peritoneal surfaces. The term PMP was originally applied to intraperitoneal mucinous spread originating from a cystadenoma of the appendix. As the tumor grows and occludes the lumen, mucus accumulates, and the appendix ruptures. The peritoneum is then seeded with mucus-producing cells, which continue to proliferate and produce mucus. The progressive accumulation of copious amounts of mucinous fluid gradually fills the peritoneal cavity, resulting in the characteristic "jelly belly" [25]. However, the term PMP should be limited to "a pathologically and prognostically homogeneous group of cases characterized by histologically benign peritoneal tumors that are frequently associated with an appendiceal mucinous adenoma" [25,26]. These cases are more recently categorized as disseminated peritoneal adenomucinosis (DPAM) [28].
- HOW ABOUT IF IT WAS JUST AN ISOLATED
- These are rare disease which have been reported in literature to have good response with HIPEC. Some of these are very complex, like neuroendocrine tumors, and you definitely would want us to comanage it with you. Enumerate …. HIPEC is also now being used for gastric cancers, they have a bidirectional way of infusing chemotherapy before the surgery. But I think that since this hospital is just starting, we might want to stick with appendiceal, colorectal, mesothelioma, and gynecologic.
- This is my last slide. So in essence, the medical oncologist will be your partners in treating your patients.
- Again, these are the oncologists you can call to help you.