1. Chang-Yun Lu, Mao-Chih Hsieh
Prophylactic hyperthermic intra-peritoneal chemotherapy(HIPEC) in high risk patients for peritoneal carcinomatosis 腹腔溫熱化療對惡性腫瘤腹腔轉移之預防
Chang-Yun Lu, Mao-Chih Hsieh
呂 長運 謝 茂志 Department of Surgery, Division of General Surgery, Taipei medical university affiliated Wanfang Hospital
台北醫學大學 - 萬芳醫院 一般外科

2. Peritoneal carcinomatosis (PC)
Recurrence is frequent after surgery
Systemic chemotherapy is less effective for PC
Poor prognosis (median survival 7-12M)

3. Principle of CRS/HIPEC
Aggressive cytoreductive surgery (CRS) and visceral organ resection to remove gross peritoneal tumor.
Complete cytoreduction: residual tumor<2.5mm
Hyperthermic intraperitoneal chemotherapy (HIPEC) to eradicate microscopic residual cancer cell
Chemo-solution tissue penetrating depth: 2-3mm

4. Aggressive CRS combined HIPEC for peritoneal carcinomatosis treatment
Better survival compared with traditional treatment (Debulking surgery + systemic chemotherapy)
Debulking surgery
+ systemic chemotherapy
CRS/HIPEC
Gastric
Median survival:7-10M
5y survival: 20%
Colon
Median survival: 12M
5y survival: 40%
Mesothelioma
5y survival: 40-50%
Appendix
10y survival: 20-30%
10y survival: 80%

5. Limitation of CRS/HIPEC

6. The most two important prognostic factors of CRS/HIPEC treatment
Peritoneal cancer index (PCI)

7. The most two important prognostic factors of CRS/HIPEC treatment
Completeness of CRS (CC) score
CC-0
no residual tumor
Complete CRS
CC-1
residual tumor <2.5mm
CC-2
residual tumor mm
Incomplete CRS
CC-3
residual tumor >25mm

8. Aggressive cytoreductive surgery(CRS) combined HIPEC for peritoneal carcinomatosis treatment
Better survival compared with traditional treatment (Debulking surgery + systemic chemotherapy)
Debulking surgery
+ C/T
CRS/HIPEC
Gastric
Median survival:7-10M
5y survival: 20%
Colon
Median survival: 12M
5y survival: 40%
Mesothelioma
5y survival: 40-50%
Appendix
10y survival: 20-30%
10y survival: 80%
Only for CC 0-1 group patients

9. Wanfang data (2000-2016 May) CC 0-1 CC 2-3 PCI<20 119 (81%) 27 (19%
146
PCI>=20
26 (23%)
87 (77%)
113

10. Limitation of CRS/HIPEC
-Difficulty in complete tumor resection

11. Limitation of CRS/HIPEC
-Difficulty in complete tumor resection
-High morbidity and mortality rate
Morbidity Gr 3-4: 20-40% Morbidity 0-18%
-Wanfang data:
Morbidity Gr 3-4:11% Mortality:3%

12. Limitation of CRS/HIPEC
-Difficulty in complete tumor resection
-High morbidity and mortality rate
-Experienced surgical team
Long operation time
Multiple intra-abd organs involvement

13. Is there a better way to block peritoneal recurrence ?

14. Gastric cancer
Peritoneal recurrence develops in 60% of p’t with T4 tumor
Up to 40% of resectable gastric cancer p’t die as a direct result of peritoneal carcinomatosis

15. Colon cancer 17-50% T4 tumor => peritoneal recurrence
14-58% perforated tumor => peritoneal recurrence
40% to 80% of patients who died from peritoneal recurrence

16. Appendix 90% appendiceal tumor is mucinous type
Mucinous tumor rupture causing pseudomyxoma peritonei development

17. High risk of peritoneal recurrence
T4 tumor
Tumor perforation or rupture
Positive ascites cytology
(free cancer cell in ascites)

18. Prophylactic HIPEC
HIPEC as adjuvant therapy to eradicate free cancer cell in ascites, before development of peritoneal carcinomatosis

19. Prophylactic HIPEC in Wanfang hospital 2004-2016
Serosa exposure was noted during operation (sT4), or proved by pathologic exam
Positive ascites cytologic finding before operation
Tumor rupture or perforation were noted during operation or proved by pathologic examination
There is no evidence of peritoneal seeding, no distant metastasis at the time of treatment
Patient underwent HIPEC at initial OP or interval OP, with laparotomy or laparoscopic approach

20. Gastric cancer
Serosal involvement was suspected during operation (sT4)
One patient died 56 months after HIPEC due to distant metastasis (skin)
One patient died 15 months after HIPEC from liver metastases
The other 6 patients are disease free FU time: 48M (12-151)
Pathologic stage
IIA
IIIA
IIIB
IIIC No 1 2 4

21. Colon cancer
Serosal involvement was suspected during operation (sT4), or proved by pathologic exam
One patient with stage IIIB underwent 1st OP at other hospital
He was aware of high risk of peritoneal recurrence and came to Wanfang hospital for laparoscopic prophylactic HIPEC 1 month after 1st OP
All 3 patients are disease free, FU time: 62M (24-138)
Pathologic stage
IIIB
IIIC No 2 1

22. Appendix
Three patients presented as ruptured appendicitis and underwent appendectomy
Tumor rupture is proved by pathologic exam
No peritoneal recurrence FU time: 36M (30-50)
P’t
Clinical presentation FU 1
Mucinous neoplasm s/p laparoscopic HIPEC
30 M 2 3
Adenocarcinoma s/p right hemicolectomy/ HIPEC
50 M

23. Hepatoma
Four patients of ruptured HCC (stage IIIC) s/p Liver tumor resection + HIPEC
No peritoneal recurrence
patients
Clinical presentation FU
44/M
Lung meta and IVC thrombosis in 4 months
Death 9M after treatment
59/F
No recurrence
104 M
65/F
70 M
50/F
84 M

24. Gallbladder
68 y male presented of gallbladder stone and cholecystitis, who underwent laparoscopic cholecsytectomy
Gallbladder rupture was observed during OP
Pathologic exam: adenocarcinoma (stage II)
After 20 days, patient underwent Laparoscopic HIPEC
FU time: 15 months

25. Prophylactic HIPEC in Wanfang hospital 2004-2016
Patient number
FU time (M)
Gastric 8
48(12-151)
Colon 3
52(24-138)
Appendix
36(30-50)
Hepatoma 4
86(70-104)
Gallbladder 1 15 19
No peritoneal recurrence in all patients

26. Complication Two adverse effect (G2): 12.5% No surgical mortality
One pneumonia and one minor pancreatic leakage
No surgical mortality

27. Conclusion

28. Peritoneal carcinomatosis
CRS/HIPEC provide better prognosis
CRS/HIPEC is limited in advanced disease
CRS/HIPEC is combined with higher morbidity and mortality rate

29. High risk of peritoneal recurrence in patients with following characteristics
T3/T4 tumor
Tumor perforation or rupture
Positive ascites cytology
(free cancer cell in ascites)

30. Prophylactic HIPEC for patients with high risk of peritoneal recurrence
減少腹腔腫瘤復發的風險
並不增加併發症率與死亡率
相對簡單的技術

31. Thank you for your attention