Cytoreduction and hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis from pseudomixoma peritonei

AIM： To investigate the most important aspects of hyperthermic intraperitoneal chemotherapy （HIPEC） that has been accepted as the standard treatment for pseudomyxoma peritonei （PMP）, with special regard to morbidity, overall survival （OS） and disease free survival （DFS） over 10 years. METHODS： Fifty-three patients affected by PMP underwent cytoreduction （CCR） and HIPEC with a ＂semi-closed＂ abdomen technique in our institution. The peritonectomy procedure and completeness of CCR were classified according to Sugarbaker criteria. Preoperative evaluation always included thoracic and abdominal CT scan to stage peritoneal disease and exclude distant metastases. Fifty-one patients in our series were treated with a protocol based on administration of cisplatinum 100 mg/m^2 plus mitomycin C 16 mg/m^2, at a temperature of 41.5℃ for 60 min. Anastomoses were always performed at the end of HIPEC. The mean duration of surgery was 12 h including HIPEC. Continuous monitoring of hepatic and renal functions and hydroelectrolytic balance was performed in the postoperative period. RESULTS： Twenty-four patients presented with postoperative complications： surgical morbidity was observed in 16 patients and 6 patients were reoperated. All complications were successfully treated and no postoperative deaths were observed. Risk factors for postoperative morbidity were considered to be gender, age, body surface, duration of surgery,Peritoneal Cancer Index （PCI） and tumor residual value （CC score）. No statistically significant correlation was found during the multivariate analysis： only the CC score was statistically significant. The OS in our experience was 81.8%, with a DFS of 80% at 5 years and of 70% at 10 years. CONCLUSION： In our experience, even if HIPEC combined with cytoreductive surgery involves a high risk of morbidity, postoperative complications can be resolved favorably in most cases with correct patient selection and adequate postoperative care, thus minimizing mortality. The association of CCR and HIPEC can be considered as the standard treatment for PNP. The OS and DFS results confirm the validity of this combined approach for the treatment of this rare neoplasm. The impact of preoperative chemotherapy on OS, in our opinion, is due to a major aggressiveness of tumors in treated patients.

Any role for transarterial radioembolization in unresectable intrahepatic cholangiocarcinoma in the era of advanced systemic therapies?

Intrahepatic cholangiocarcinoma(iCCA)is recognized as the second most frequently diagnosed liver malignancy,following closely after hepatocellular carcinoma.Its incidence has seen a global upsurge in the past several years.Unfortunately,due to the lack of well-defined risk factors and limited diagnostic tools,iCCA is often diagnosed at an advanced stage,resulting in a poor prognosis.While surgery is the only potentially curative option,it is rarely feasible.Currently,there are ongoing investigations into various treatment approaches for unresectable iCCA,including conventional chemotherapies,targeted therapies,immunotherapies,and locoregional treatments.This study aims to explore the role of transarterial radioembolization(TARE)in the treatment of unresectable iCCA and provide a comprehensive review.The findings suggest that TARE is a safe and effective treatment option for unresectable iCCA,with a median overall survival(OS)of 14.9 months in the study cohort.Studies on TARE for unresectable iCCA,both as a first-line treatment(as a neo-adjuvant down-staging strategy)and as adjuvant therapy,have reported varying median response rates(ranging from 34%to 86%)and median OS(12-16 mo).These differences can be attributed to the heterogeneity of the patient population and the limited number of participants in the studies.Most studies have identified tumor burden,portal vein involvement,and the patient’s performance status as key prognostic factors.Furthermore,a phase 2 trial evaluated the combination of TARE and chemotherapy(cisplatin-gemcitabine)as a first-line therapy for locally advanced unresectable iCCA.The results showed promising outcomes,including a median OS of 22 mo and a 22%achievement in down-staging the tumor.In conclusion,TARE represents a viable treatment option for unresectable iCCA,and its combination with systemic chemotherapy has shown promising results.However,it is important to consider treatment-independent factors that can influence prognosis.Further research is necessary to identify optimal treatment combinations and predictive factors for a favorable response in iCCA patients.

Role of radiotherapy in oligometastatic breast cancer:Review of the literature

Metastatic breast cancer has been historically considered as an incurable disease.Radiotherapy(RT)has been traditionally used for only palliation of the symptoms caused by metastatic lesions.However,in recent years the concept of oligometastatic disease has been introduced in Cancer Medicine as a clinical scenario with a limited number of metastases(≤5)and involved organs(≤2)with controlled primary tumor.The main hypothesis in oligometastatic disease is that locoregional treatment of primary tumor site and metastasis-directed therapies with surgery and/or RT may improve outcomes.Recent studies have shown that not all metastatic breast cancer patients have the same prognosis,and selected patients with good prognostic features as those younger than 55 years,hormone receptor-positive,limited bone or liver metastases,a low-grade tumor,good performance status,long disease-free interval(>12 mo),and good response to systemic therapy may provide maximum benefit from definitive treatment procedures to all disease sites.While retrospective and prospective studies on locoregional treatment in oligometastatic breast cancer demonstrated conflicting results,there is an increasing trend in favor of locoregional treatment.Currently,available data also demonstrated the improvements in survival with metastasisdirected therapy in oligometastatic breast cancer.The current review will discuss the concept of oligometastases and provide up-to-date information about the role of RT in oligometastatic breast cancer.

Therapeutic strategies for post-transplant recurrence of hepatocellular carcinoma

Despite stringent selection criteria,hepatocellular carcinoma recurrence after liver transplantation(LT)still occurs in up to 20%of cases,mostly within the first 2–3 years.No adjuvant treatments to prevent such an occurrence have been developed so far.However,a balanced use of immunosuppression with minimal dose of calcineurin inhibitors and possible addition of mammalian target of rapamycin inhibitors is strongly advisable.Moreover,several pre-and posttransplant predictors of recurrence have been identified and may help determine the frequency and duration of post-transplant follow-up.When recurrence occurs,the outcomes are poor with a median survival of 12 mo according to most retrospective studies.The factor that most impacts survival after recurrence is timing(within 1–2 years from LT according to different authors).Several therapeutic options may be chosen in case of recurrence,according to timing and disease presentation.Surgical treatment seems to provide a survival benefit,especially in case of late recurrence,while the benefit of locoregional treatments has been suggested only in small retrospective studies.When systemic treatment is indicated,sorafenib has been proved safe and effective,while only few data are available for lenvatinib and regorafenib in second line.The use of immune checkpoint inhibitors is controversial in this setting,given the safety warnings for the risk of acute rejection.

Chinese expert consensus on conversion therapy for hepatocellular carcinoma(2021 edition)

Recent advances in systemic and locoregional treatments for patients with unresectable or advanced hepatocellular carcinoma(HCC)have resulted in improved response rates.This has provided an opportunity for selected patients with initially unresectable HCC to achieve adequate tumor downstaging to undergo surgical resection,a‘conversion therapy’strategy.However,conversion therapy is a new approach to the treatment of HCC and its practice and treatment protocols are still being developed.Review the evidence for conversion therapy in HCC and develop consensus statements to guide clinical practice.Evidence review:Many research centers in China have accumulated significant experience implementing HCC conversion therapy.Preliminary findings and data have shown that conversion therapy represents an important strategy to maximize the survival of selected patients with intermediate stage to advanced HCC;however,there are still many urgent clinical and scientific challenges for this therapeutic strategy and its related fields.In order to summarize and learn from past experience and review current challenges,the Chinese Expert Consensus on Conversion Therapy for Hepatocellular Carcinoma(2021 Edition)was developed based on a review of preliminary experience and clinical data from Chinese and non-Chinese studies in this field and combined with recommendations for clinical practice.Sixteen consensus statements on the implementation of conversion therapy for HCC were developed.The statements generated in this review are based on a review of clinical evidence and real clinical experience and will help guide future progress in conversion therapy for patients with HCC.