Volume 3, Issue 4 -

Background The aim of this review was to analyze preclinical studies and clinical trials evaluating photodynamic therapy (PDT), and photothermal therapy (PTT) in peritoneal metastasis (PM) treatment. Content Systematic review according PRISMA guidelines. Electronic searches using PubMed and Clinical Trials. Summary A total of 19 preclinical studies analyzing PDT in PM treatment were included. Each new generations of photosensitizers (PS) permitted to improve tumoral targeting. Phase III preclinical studies showed an important tumoral biodistribution (ratio 9.6 vs normal tissue) and significant survival advantage (35.5 vs 52.5 days for cytoreductive surgery vs cytoreductive surgery+PDT, p<0.005). Height clinical trials showed important side effects (capillary leak syndrome and bowel perforation), mainly explained by low tumor-selectivity of the PS used (first generation mainly). Peritoneal mesothelioma apparition with carbon nanotubes first limited the development of PTT. But gold nanoparticles, with a good tolerance, permitted a limitation of tumoral growth (reduction of bioluminescence to 37 % 20 days after PTT), and survival benefit (35, 32, and 26 days for PTT with cisplatine, PTT alone and laser alone, respectively). Outlook Recent improvement in tumor-selectivity and light delivery systems is promising but further development would be necessary before PDT and PTT routinely applied for peritoneal carcinomatosis.

Background Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a drug-delivery method for patients with peritoneal metastasis (PM). The study objective was to investigate whether PIPAC is possible in an outpatient setting. Methods Data was extracted from the prospective PIPAC-OPC2 study (ClinicalTrials.gov NCT03287375). Patients with PM were treated by cisplatin and doxorubicin (PIPAC C/D), except patients with colorectal PM, who were treated by oxaliplatin (PIPAC OX). Patients were evaluated concerning the suitability for carrying out the PIPAC procedure in an out- patient setting. The preconditions for outpatient surgery were that the patient should be (1) freely mobilized, (2) adequately pain-relieved, (3) have untroubled urination and (4) without anxiety or discomfort caused by leaving the hospital. Results During the study period, 106 PIPAC procedures (79 PIPAC C/D, 27 PIPAC OX) were performed in 41 patients with gastrointestinal or ovarian PM. Ninety percent (37/41) of the patients were pretreated with systemic chemotherapy. Eight patients (20%) received bidirectional chemotherapy. Twenty-four percent (10/41) of the first PIPAC procedures were completed in an outpatient setting, which increased to 65% (13/20) in PIPAC no 3 (p=0.008). In the PIPAC C/D cohort, 28% and 80% of the PIPACs were performed in the outpatient setting at PIPAC 1 and 3 respectively, contrasting to only 11% and 20% in the PIPAC OX group. No readmissions after outpatient care. Postoperative morphine administration was more frequent in the PIPAC OX group. Conclusions The PIPAC procedure can be performed in an outpatient setting. The critical component for success is pain control.

Background To analyse the duration of parenteral nutrition (PN) in patients treated for peritoneal malignancy with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) over a 2 year period at a single UK National referral centre. Methods A retrospective analysis of prospective data for all patients (n=321) who underwent CRS and HIPEC for peritoneal malignancy at the Peritoneal Malignancy Institute Basingstoke between April 1, 2013 and March 31, 2015. Duration of PN was compared between primary tumour site (appendix, colorectal, mesothelioma and other); completeness of CRS (complete CRS vs. major tumour debulking) and pre-operative nutritional assessment measures (including Mid Upper Arm Circumference). Results The median duration of PN was 9 days (range 2–87 days). A total of 13 % of patients had PN for less than 7 days and 6 % for 5 days or less. There was no significant difference in duration of PN between the different tumour sites. Two factors that may increase the duration of PN include having major tumour debulking (MTD) and a baseline MUAC<23.5 cm. Conclusions Most patients who underwent CRS and HIPEC for peritoneal malignancy required PN for more than 7 days with poor pre-operative nutritional status and inability to achieve complete cytoreduction predictors of prolonged PN requirements.

Background Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is routinely used for selected patients with peritoneal metastasis, but can be associated with high complication rates, prolonged hospital stay, and mortality. Our objective was to determine the learning curve of CRS/HIPEC in our institution, representing the largest Asian cohort to date. Methods A total of 200 consecutive patients with peritoneal metastasis treated with CRS/HIPEC between 2001 and 2016 were grouped into four cohorts of 50 patients and studied. Primary outcomes were severe morbidity (Clavien-Dindo III-V), procedure-related mortality, and duration of ICU and hospital stays. Secondary outcome was duration of surgery. Results Median age was 53 years (10–75). There was no significant age, sex, or histology difference across cohorts. Rates of severe morbidity (23 %), and 60 day inpatient mortality (0.5 %) were comparable to previously reported data. Decreases in rates of serious morbidity, (34 %, 30 %, 12 %, 14 %, p<0.01) and duration of total hospital stay (14, 16, 13, 12 days, p=0.041) were seen across consecutive cohorts. Operation time decreased significantly after the first cohort (10, 7.8, 7.8, 7.2 h, p<0.01), despite increase in average PCI score after the first cohort (8, 14, 12, 13, p=0.063). Conclusions Whilst 50 cases were adequate for procedural familiarity and decreased average operation time, significant improvement in rate of serious morbidity was observed after 100 operations. We demonstrate a novel biphasic nature to the learning curve, reflecting initial training in which technical competence is achieved, followed by a subsequent period characterized by increasingly complex cases (higher PCI score) and finally refinement of patient selection.