peritoneal tumour serviceperitoneal metastases colorectal cancer 2010 nice guidance clinical...
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The Christie NHS Foundation Trust
Peritoneal Tumour Service
The Christie NHS Foundation Trust
Pseudomyxoma Peritonei : PMP
2000 1995 Abdominal Tumours
Females
Treated as ovarian cancer
Resistant to chemotherapy Recurrent disease
Unexpected long term survival GI symptoms
? diagnosis
The Christie NHS Foundation Trust
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
The Christie NHS Foundation Trust
PMP: Starts in the Appendix
2011 2013
The Christie NHS Foundation Trust
Colorectal Metastases
Liver 40-50%
Bone 4-6%
Peritoneum 10-15%
Lung 16%
Brain 8 %
Standard Rx - palliative chemotherapy
The Christie NHS Foundation Trust
Peritoneal Metastases Colorectal Cancer
2010 NICE guidance Clinical Commissioning Policy Cytoreduction surgery for patients with peritoneal Carcinomatosis April 2013
A08/P/a
2013
The Christie NHS Foundation Trust
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
The Christie NHS Foundation Trust
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
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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
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Appendix & CRPM Referrals 2002-2017
The Christie NHS Foundation Trust
PTS Activity
The Christie NHS Foundation Trust
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
The Christie NHS Foundation Trust
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
The Christie NHS Foundation Trust
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%
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Non resectable disease Small bowel multilevel involvement
PIPAC: Pressurised Intraperitoneal Aerosolised Chemotherapy
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PTS Education
The Christie NHS Foundation Trust
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
The Christie NHS Foundation Trust
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
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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