The document discusses peritoneal carcinomatosis (PC) from gastric cancer, including indications and limitations of treatment with hyperthermic intraperitoneal chemotherapy (HIPEC). It provides background on patterns of gastric cancer recurrence and outcomes with chemotherapy alone. Studies on HIPEC for gastric cancer show median survival ranges from 8-21 months depending on completeness of cytoreduction. Factors that may indicate consideration of HIPEC include advanced T-stage with serosal invasion or positive peritoneal washing cytology.
1. Varese,
13-‐03-‐15 Prof.
A
Donini
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC
2. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
2
Sasako
M,
H
Van
de
Velde,
et
al,
Lancet
Oncol
,2010
3. 3
Gastric
Cancer
Pa9ern
of
Recurrence
Roviello,
et
al.
BrJSurg,
2003
Maehara
Y.
et
al.
Br
J
Surg,2003
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
4. 4
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
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
5. 5
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)
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
Int J Cancer 2014
6. 6
Is
There
a
Possibility
of
a
Cure
in
Patients
with
Gastric
Peritoneal
Carcinomatosis
?
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
7. 7
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
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
months
1/3
of
synchronous
carcinomatosis
8. 03 La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
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.”
9. 9
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
Acta
Oncologica
2013
10. 10
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.
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
Acta
Oncologica
2013
11. 11
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
Chemotherapy
and
Surgey
?
12. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
12
Scopus
-‐
HIPEC
from
1985
-‐
Present:
886
document
13. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
13
Scopus
-‐
HIPEC
and
Gastric
Cancer
from
1980
-‐
Present
:
296
14. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
14
Ann
of
Surg
Onc
Jul
2007
15. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
15
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
16. 16
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
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
17. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
17
Indipendent
Risk
Factors
according
to
recurrent
pa9ern
by
logisXc
regression
BJS,2000
18. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
18
BJS,2002
19. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
19
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
20. 3y OS P0C1 is the same of P1C0
Lee
S.D.
et
al,
BJS,
2012
21. 21
January,
2014
Mortality
at
1
year
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
22. 22
Mortality
at
2
year
F.
Coccolini
et
al.
/
EJSO
40
(2014)
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
23. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
23
Mortality
at
3
year
F.
Coccolini
et
al.
/
EJSO
40
(2014)
24. 24
Mortality
at
5
year
F.
Coccolini
et
al.
/
EJSO
40
(2014)
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
25. 25
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
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
26. 26
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
Gastric
Carcinomatosis
Randomisation
Cytoreduc?ve
Surgery
+
HIPEC
with
CDDP
and
MMC
Cytoreduc?ve
Surgery
27. 27
Ann Surg Oncol (2011)
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
28. 28
Ann Surg Oncol (2011)
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
29. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
29
32. 32
Survival
rates
1-‐year:
43%
3-‐year:
18%
5-‐
year:
13%
Disease-‐free
survival
rates
1-‐year:
31%
3
years:
12%
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
33. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
33
Glehen,
Elias
D.,
et
al,
2010
34. 34
2013
Grade
3–4
morbidity
and
mortality
in
series
using
Common
Terminology
Criteria
for
Adverse
Events
(CTCAE)
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
35. 35
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
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
36. 36
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
Morbidity
January,
2014
37. La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
37
OUR
EXPERIENCE
Variables 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 4.77
Neoadjuvant
chemo 12 57.14
Adjuvant
chemo 16 76.19
Prophylactic
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
38. 38
5
y
-‐
OS
=
58
%5y-0S Stage III: 18%
5Y-OS Stage IV: 13%
Advances stages OS
No HIPEC
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
Advances stages OS
HIPEC
5y-0S : 58%
40. 40
“The
patient
is
killed
by
what
the
surgeon
doesn’t
see”
P.H.Sugarbaker
La
Carcinosi
Peritoneale
:
Indicazioni
e
Limiti
del
Trattamento
HIPEC Prof.
A
Donini
Varese
13-‐03-‐15
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
