95.13 CRS/HIPEC in the palliative treatment of peritoneal carcinomatosis: a single institution experience

Posted on January 31, 2019

E. A. Strong1, M. V. Hembrook1, S. Tsai1, K. K. Christians1, H. D. Mogal1, T. C. Gamblin1, C. N. Callisia1  1Medical College of Wisconsin,Surgical Oncology,Milwaukee, WI, USA

Introduction:  Palliation is a controversial indication for cytoreductive surgery (CRS) and hyperthermic intraperitoenal chemotherapy (HIPEC) in patients with peritoneal carcinomatosis (PC). However, with more effective systemic therapies, patients with metastatic disease are living longer and the role of palliative surgery is increasingly challenged. The purpose of this study is to evaluate the indications for surgery, morbidity, and symptom improvement from CRS/HIPEC in patients with advanced PC.  

Methods:  We performed a retrospective review of a prospectively maintained clinical registry of patients undergoing CRS/HIPEC at the Medical College of Wisconsin from February 2008 to February 2018. Patient undergoing surgeries with palliative intent were included in this study. Indications for surgery, clinical and pathological factors, operative details, and postoperative course were analyzed. Main endpoints included symptom improvement, discharge to home, progression-free (PFS), and overall survival (OS).   

Results: 277 patients were referred for CRS/HIPEC at our institution over this 10-year period. 18 patients underwent 19 procedures with palliative intent. 10 patients (56%) were female, 8 (44%) were male with a median age at surgery of 57 years (IQR:7).  All patients had an ASA class of 3 (68%) or 4 (32%).  Metastatic colorectal cancer was the most common malignancy treated [n=7 (39%)], followed by appendiceal cancer [n=6 (33%)], peritoneal mesothelioma [n=3 (17%)], gastric cancer [n=1 (6%)], and sarcoma [n=1 (6%)]. At time of surgery, 4 (21%) patients had an ECOG performance status of 0, 11 (58%) ECOG of 1, 3 (16%) ECOG of 2, and 1 (5%) ECOG of 3. Median preoperative serum albumin and prealbumin levels were 3.3 g/dL (IQR:0.6) and 13 mg/dL (IQR:7.5). Indications for palliative surgery were ascites 8 (42%), obstruction 5 (26%), abdominal pain 4 (21%), GI bleed 1 (5%), and other 1 (5%). 5 (26%) patients required preoperative admission for nutritional optimization. 9 (47%) patients underwent CRS and HIPEC, 1 (5%) underwent HIPEC only, 9 (47%) underwent CRS only. 30-day mortality was n=2 (10.5%). 11 (58%) patients had postoperative complications; 6 (32%) minor (Clavien I/II) and 5 (26%) major (Clavien ≥III) complications. Median hospital LOS was 11 days (IQR=12). 30-day readmission rate was 10.5%. 2 patients (11%) were discharged to hospice and subsequently died from their disease. 1 (5%) patient was discharged to a skilled nursing facility, the remaining 16 (84%) were discharged home. 17 (89%) had at least partial of symptom improvement at 30 postoperative days. Median PFS was 2.9 months (IQR:5.6), and median OS was 8.2 months (IQR:12).

Conclusion: Palliative CRS and/or HIPEC achieves adequate symptom palliation in patients with advanced peritoneal carcinomatosis. However, these interventions are associated with high morbidity and mortality.

 

54.07 Outcomes of Palliative Surgery in Retroperitoneal Sarcoma – Results from the US Sarcoma Collaborative

Posted on January 31, 2019

S. Z. Thalji1, M. Hembrook1, S. Tsai1, T. C. Gamblin1, C. Clarke1, M. Bedi2, J. Charlson3, C. G. Ethun4, T. B. Tran5, G. Poultsides5, V. P. Grignol6, J. H. Howard6, J. Tseng7, K. K. Roggin7, K. Chouliaras8, K. Votanopoulos8, D. Cullinan9, R. C. Fields9, K. A. Vande Walle10, S. Ronnekleiv-Kelly10, H. Mogal1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Department Of Radiation Oncology,Milwaukee, WI, USA 3Medical College Of Wisconsin,Department Of Medical Oncology,Milwaukee, WI, USA 4Emory University School Of Medicine,Division Of Surgical Oncology, Winship Cancer Institute,Atlanta, GA, USA 5Stanford University,Department Of Surgery,Palo Alto, CA, USA 6Ohio State University,Department Of Surgery,Columbus, OH, USA 7University Of Chicago,Department Of Surgery,Chicago, IL, USA 8Wake Forest University School Of Medicine,Department Of Surgery,Winston-Salem, NC, USA 9Washington University,Department Of Surgery,St. Louis, MO, USA 10University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Objective: While outcomes of patients with Retroperitoneal Sarcomas (RPS) who have microscopically or macroscopically positive margins after curative-intent resection has been studied, few studies have focused on outcomes in patients undergoing surgery with a palliative intent. This study aims to define common indications for and to elucidate factors that determine outcomes after palliative-intent resection of RPS.

 

Patients and

Methods: Using the retrospective 8-institution United States Sarcoma Collaborative (USSC) database, all patients who underwent resection of a primary or recurrent RPS (including intraabdominal or distant metastasis) with palliative intent between 2000 and 2016 were identified. Overall Survival (OS) was estimated by the Kaplan-Meier method and compared using the log-rank test. Multivariable logistic regression and Cox-proportional hazards models of patient- and treatment-related factors were constructed to determine their effect on postoperative complications and OS.

 

Results: Of a total of 3,088 patients, 70 patients underwent 87 distinct palliative-intent surgeries for RPS. Median age was 62.3 years (IQR 46.7–71.5) and 57% (n=50) were female. Most common indications for palliative surgery included pain (n=23, 26%), bowel obstruction (n=18, 21%), bleeding (n=7, 8%), and infection (n=2, 2%). Dedifferentiated liposarcoma (n=18, 21%) and leiomyosarcoma (n=17, 20%) were the predominant tumor types. Median OS for the entire cohort was 10.69 months (IQR 3.91-23.23). R2 resection status was the only factor independently associated with incidence of postoperative complications (OR 4.42, CI 1.01-19.38, p=0.049). The presence of complications (HR 3.25, CI 1.35-7.81, p=0.008) and high-grade histology (HR 4.45, CI 1.19-16.62, p=0.026) were associated with increased mortality. While OS was not independently affected by resection status, in patients who underwent R2 resections, the development of postoperative complications significantly reduced survival (p=0.042) (figure 1).

 

Conclusions: The occurrence of postoperative complications and high grade tumor biology rather than resection status determines survival in patients undergoing palliative-intent resections for RPS. Palliative-intent R2 resections should be cautiously performed for RPS given the higher-incidence of post-operative complications which may significantly lower survival.