peritoneal tumour serviceperitoneal metastases colorectal cancer 2010 nice guidance clinical...

The Christie NHS Foundation Trust

Peritoneal Tumour Service


Pseudomyxoma Peritonei : PMP

2000 1995 Abdominal Tumours

Females

Treated as ovarian cancer

Resistant to chemotherapy Recurrent disease

Unexpected long term survival GI symptoms

? diagnosis


Washington Cancer Centre : Paul Sugarbaker

Appendix Tumours

Females Treated as ovarian cancer Resistant to chemotherapy

Recurrent disease Unexpected long term survival

GI symptoms

Pseudomyxoma Peritonei

Cytoreductive surgery Intraperitoneal chemotherapy

1999


PMP: Starts in the Appendix

2011 2013


Colorectal Metastases

Liver 40-50%

Bone 4-6%

Peritoneum 10-15%

Lung 16%

Brain 8 %

Standard Rx - palliative chemotherapy


Peritoneal Metastases Colorectal Cancer

2010 NICE guidance Clinical Commissioning Policy Cytoreduction surgery for patients with peritoneal Carcinomatosis April 2013

A08/P/a

2013


CRPM : CRS + HIPEC v chemotherapy alone Median overall survival

*Franko et al. Lancet Oncology 2016

16.3 0.00

0.25

0.50

0.75

1.00

Surv

ival

(%)

0 12 24 36 48 60 Time in months

CRS + HIPEC, Christie *Franko analysis

No surgery, Christie

46.0 13.2

Presenter

Presentation Notes

This is now the Christie data (2002-2015) on 114 patients undergoing CRS+HIPEC versus the Frank data on 193 patients (extracted using the Enguage software). The respective median survivals are 16.3 mo. versus 46.0 – a 30 month difference.


UK + Eire Peritoneal Centres

England : PMP (2) and PMCR (3)

x mesothelioma, ovary, gastric N Ireland : refers to England S Ireland : Dublin Scotland : Dundee (some to England) Wales : PMP refers to England CRPM not funded


European Centres

0 10 20 30 40 50 60 70 80

UK/Eire

Italy

Spain

Netherlands

France

Germany

Belgium

Centres by population/millions

Column1 Population Centres

England 3 centres for 53 million


Appendix & CRPM Referrals 2002-2017


PTS Activity


CRS + HIPEC: Principles of management Removal of peritoneal surface: peritonectomy

Resection of involved viscera Removal of ‘at risk’ tissue (target organs):

omentum, ovaries, falciform ligament

Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC)

Completeness of Cytoreduction: CC score

complete incomplete


CC Scores

65%

11%

6%

13%

5%

CC Scores – Appendix tumours

CC0 Count

CC1 Count

CC2 Count

CC3 Count

CC Score Missing

68%

8%

12%

10%

2%

CC Scores - CRPM

CC0 Count

CC1 Count

CC2 Count

CC3 Count

CC Score Missing


0.00

0.20

0.40

0.60

0.80

1.00

Sur

viva

l

38 19 9 5 3 1 1Major Debulk205 149 105 66 45 28 17Cyto & HIPEC

Number at risk

0 12 24 36 48 60 72Time - Months

Cyto & HIPEC Major Debulk

Appendix Ca - Cyto & HIPEC Vs Major Debulk

5year survival 45%

Outcomes 0.

000.

200.

400.

600.

801.

00S

urvi

val

110 80 55 39 19 11 6Major Debulk369 318 278 224 181 136 112Cyto & HIPEC

Number at risk

0 12 24 36 48 60 72Time - Months

Cyto & HIPEC Major Debulk

PMP - Cyto & HIPEC Vs Major Debulk

5year survival 85%

0.00

0.20

0.40

0.60

0.80

1.00

Sur

viva

l

0 12 24 36 48 60 72Time - Months

CRPM Cyto & HIPEC Vs Major Debulk

5year survival 40%


Non resectable disease Small bowel multilevel involvement

PIPAC: Pressurised Intraperitoneal Aerosolised Chemotherapy

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiwvob7g_jWAhUIZFAKHZwkBmMQjRwIBw&url=https://www.revmed.ch/RMS/2015/RMS-N-479/PIPAC-Chimiotherapie-intraperitoneale-vaporisee.-Un-traitement-innovateur-de-la-carcinose-peritoneale&psig=AOvVaw0St8oGqFir-rVvu8DwZCjq&ust=1508342301521487


PTS Education


Prodige 7 Trial – 2018 ASCO & PSOGI

CRPM Cytoreductive

Surgery

RANDOMISED

HIPEC 129

NO HIPEC 113

All patients received systemic chemotherapy for 6 months pre-op, post-op or both

• Multicentred (70% high, 30% low volume)

• PCI <25 • High dose Oxaliplatin (46mg/m2) • Study design: powered to detect increase in median OS from 30 to 48 m


Prodige 7 Trial Results

• Grades III-V 60-day complications (p=0.03) CRS/HIPEC 24.1% CRS 13.6%

• DFS CRS/HIPEC 13.1months CRS 11.1 months

• OS OS PCI 11-15 (p=0.02) CRS/HIPEC 41.7 m CRS/HIPEC 42m CRS 41.2 m CRS 32.7m


Prodige 7 Trial debate

• Impact of CRS alone was better than expected Study was not powered sufficiently to look at the incremental effect of HIPEC

PCI > 15 overrides HIPEC effect?

• Higher volume centres did better 30% of centres were low volume

• High dose Ox HIPEC has high complication rates Is this losing the beneficial effect of HIPEC?

What is the most effective dose?

• Unlike this study, not all our patients get

peritoneal tumour serviceperitoneal metastases colorectal cancer 2010 nice guidance clinical...

Documents