Adjuvant bidirectional chemotherapy using an intraperitoneal port

Our plain-English summary of Adjuvant bidirectional chemotherapy using an intraperitoneal port, by P.H. Sugarbaker, L. Bijelic (Gastroenterology Research and Practice, 2012).

The study

• Authors: P.H. Sugarbaker, L. Bijelic
• Journal: Gastroenterology Research and Practice
• Published: 2012;2012:752643
• Cited by: 16 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been established as treatment options for patients with peritoneal metastases or peritoneal mesothelioma. However, this novel treatment strategy remains associated with a large percentage of local-regional treatment failures. These treatment failures are attributed to the inadequacy of HIPEC to maintain a surgical complete response. Management strategies to supplement CRS and HIPEC are indicated. A simplified approach to the intraoperative placement of an intraperitoneal port for adjuvant bidirectional chemotherapy (ABC) was devised. Four different chemotherapy treatment plans were utilized depending upon the primary site of the malignancy. Thirty-one consecutive patients with an intraoperative placement of the intraperitoneal port were available for study. The incidence of adverse events that caused an early discontinuation of the bidirectional chemotherapy occurred in 75% of the 8 patients who had an incomplete cytoreduction and in 0% of patients who had a complete cytoreduction. All of the patients who had complete cytoreduction completed at least 5 of the scheduled 6 bidirectional chemotherapy treatments. Adjuvant bidirectional chemotherapy is possible following a major cytoreductive surgical procedure using a simplified method of intraoperative intraperitoneal port placement.

In plain English

This report described placing a chemotherapy port under the skin of the upper abdominal wall, with a catheter into the abdominal cavity, after cytoreductive surgery and heated intraperitoneal chemotherapy. It covered 31 consecutive patients at a Washington, DC cancer center. Nineteen had peritoneal mesothelioma. The others had appendiceal, pancreas, rectal or papillary serous cancers. It was used for "adjuvant bidirectional chemotherapy", mostly drugs given into the abdomen plus into a vein; the three pancreas cancer patients received only intraperitoneal gemcitabine. Mesothelioma patients received intraperitoneal pemetrexed with intravenous cisplatin. The article does not discuss asbestos. Twenty-three patients had complete or near complete tumor removal and eight had incomplete removal. Of the eight, six (75%) had events that stopped treatment, four of them from disease progression. Of the 23, two (9%) stopped treatment: one for cancer progression and one for a port infection. Four others had problems that did not significantly disrupt treatment. Results were not reported separately for the mesothelioma patients. The authors concluded the method was feasible and that trials against standard chemotherapy may now be appropriate. They noted its effectiveness had not been tested in a randomized study.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective case series describing a surgical technique. Elsewhere the authors also call it a phase II study that attempted to gather data prospectively.
• Who was studied: 31 consecutive patients (16 male, 15 female; median age 49, range 32 to 74) at the Washington Cancer Institute, Washington, DC. All had an intraperitoneal port placed after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Diagnoses: 19 peritoneal mesothelioma, 5 appendiceal adenocarcinoma, 3 pancreas cancer, 1 rectal cancer and 3 papillary serous cancer. Study dates are not given.
• Exposure: No asbestos exposure was studied. The treatment studied was a port placed during surgery in a pocket under the skin of the abdominal wall, with a catheter into the peritoneal cavity. It was used for combined intraperitoneal and intravenous chemotherapy. For peritoneal mesothelioma this was intraperitoneal pemetrexed (500 mg/m2) followed by intravenous cisplatin (75 mg/m2). Other diseases received other regimens. Pancreas cancer patients received intraperitoneal gemcitabine with no intravenous chemotherapy.
• Main results:
  • Of the 31 patients, 23 had complete or near complete cytoreduction and 8 had incomplete cytoreduction.
  • Among the 8 patients with incomplete cytoreduction, 6 (75%) had major events that ended the bidirectional chemotherapy. These were 4 with disease progression, 1 bowel perforation, and 1 port occlusion after 3 cycles.
  • Among the 23 patients with complete or near complete cytoreduction, there were 6 events. Two patients (9%, 2/23) stopped the bidirectional chemotherapy: one had systemic progression at cycle 3 and one had a methicillin-resistant Staphylococcus aureus port infection.
  • In the complete or near complete group, four further patients had events (port occlusions, a port infection with port replacement, repeated hospitalization) that did not significantly impede treatment. In some of these cases the final cycle was given intravenously.
  • The authors reported that a majority of patients with complete cytoreduction received at least 5 of their 6 treatments by the bidirectional route.
• The authors' conclusion: The authors concluded that adjuvant bidirectional chemotherapy was feasible with this port placement method and was thought acceptable to patients. They said trials comparing it with traditional systemic chemotherapy may now be appropriate, and that patient selection, based on completeness of cytoreduction, was necessary.
• Limitations the authors state:
  • The effectiveness of the combined treatments has not been tested in a randomized study against intravenous treatment.
  • The authors expect that other factors affecting long-term port function will be identified in a larger study.
  • Data on the extent of cytoreduction were not available, because all patients had very extensive cytoreduction.
  • Only patients with port placement during surgery were studied. Whether placement during surgery or after recovery is better was not determined.

Topics

Medical terms in this study, explained in our Lexicon: Chemotherapy, Cytoreductive Surgery, HIPEC, Peritoneal Mesothelioma.

Related studies

• Adjuvant bidirectional chemotherapy with intraperitoneal pemetrexed combined with intravenous Cisplatin for diffuse malignant peritoneal mesothelioma — L. Bijelic, O.A. Stuart, et al. (2012)
• Conversion to Complete Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Malignant Peritoneal Mesothelioma After Bidirectional Chemotherapy — F. Le Roy, M. Gelli, et al. (2017)
• Bidirectional Intraoperative Chemotherapy Using Cisplatin and Ifosfamide for Intraperitoneal Mesothelioma in Severe Renal Impairment: A Case Report — R. Almesned, A.Z. Azzam, et al. (2023)
• A 51-Year-Old Woman with Advanced Peritoneal Mesothelioma and Stage 3b Chronic Kidney Disease Treated with Cytoreductive Surgery and Bidirectional Intraperitoneal Cisplatin and Ifosfamide Chemotherapy: A Case Report — M. Alaswad, F. ElKordy, et al. (2023)
• Phase II Trial of Adjuvant Dendritic Cell Vaccine in Combination with Celecoxib, Interferon-α, and Rintatolimod in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Metastases — R. Ramanathan, H. Choudry, et al. (2021)
• Adjuvant dendritic cell-based immunotherapy after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with malignant peritoneal mesothelioma: a phase II clinical trial — M.V. Dietz, K.L.A. Quintelier, et al. (2023)

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