Residual disease evaluation after cytoreductive surgery for peritoneal carcinomatosis Ppt Powerpoint Presentation slides Santiago Gonzalez-Moreno, MD,PhD Medical Slideshow pulmonary carcinomatosis definition of pulmonary carcinomatosis in .

Residual disease evaluation after cytoreductive surgery for peritoneal carcinomatosis

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Slide 1 :

METHODOLOGICAL CONSENSUS: Residual Disease Evaluation Santiago González-Moreno, MD, PhD

Slide 2 :

METHODOLOGICAL CONSENSUS: RESIDUAL DISEASE EVALUATION Size of residual disease remaing after CRS (the) Main prognostic factor in patients with peritoneal surface malignancy treated with CRS and PIC (determinant of survival) Constant throughout all studies and diseases

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Glehen et al. J Clin Oncol 2004 Yonemura et al. Surg Oncol Clin N Am 2003 Sugarbaker et al. Ann Surg Oncol 1999 Bristow. J Clin Oncol 2002 RESIDUAL DISEASE AS PROGNOSTIC FACTOR

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RESIDUAL DISEASE CLASSIFICATIONS UICC / AJCC Classification of Malignant Tumors R 0 No residual tumor R 1 Microscopic residual tumor (microscopic resection margin) R 2 Macroscopic residual tumor (no subcategories) AJCC Cancer Staging Manual. 6th Edition. New York: Springer, 2002 UICC: “ TNM Classification of Malignant Tumours, 4th ed. 2nd revision. Berlin: Springer, 1992.

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RESIDUAL DISEASE CLASSIFICATIONS CC Score (Washington Cancer Institute) No specific mention to microscopic residual disease or margins Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. Cancer Treat Res. 1996; 82:359-74.

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DEFINITION OF COMPLETE CYTOREDUCTION Surgical removal of peritoneal disease down to tumor nodules of a size that can be succesfully treated with intraperitoneal chemotherapy (complete tumor eradication) Defines distinct prognostic groups

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RESIDUAL DISEASE CLASSIFICATIONS: Questions Cut-off value for macroscopic residual tumor nodule size Intratumoral depth of penetration by i.p. Chemotherapy “from a few cell layers to a few milimeters” Anthracyclins/Taxanes most limited Cisplatin 2.5 – 3 mm (Los et al., 1990) (van der Waart et al, 1993) Mitomycin up to 5 mm (Fujimoto et al., 1992)

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Question 4.1. Which one is the current best classification for residual disease after cytoreductive surgery in patients affected by peritoneal surface malignancies? a) R Classification (AJCC) with Dutch modification (2.5 mm) b) R Classification (AJCC) with French modification (macro) c) R Classification (AJCC) with American modificat. (5/20mm) d) Completeness of Cytoreduction Score (2.5 / 25 mm)

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Best Classification for Residual Disease

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RESIDUAL DISEASE CLASSIFICATIONS: Questions Residual disease estimation: reproducibility Interobserver variability in tumor size estimation - Wide range of estimates: 0 – 12 cm for an actual size of 8.5 cm - Underestimation more common than overestimation - Erroneous categorization of 20 - 25 % of patients Prefontaine M, Gelfand AT, Donovan JT, Powell JL. Reproducibility of tumor measurements in ovarian cancer: a study of interobserver variability. Gynecol Oncol. 1994; 55(1):87-90.

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RESIDUAL DISEASE CLASSIFICATIONS: Questions Measurement / estimation of residual disease diameter Need for objective methods / standardization

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Question 4.2. What should be the ideal method to assess residual disease size after cytoreductive surgery? a) The experienced surgeon´s naked-eye estimation b) Direct measurement by a sterile ruler or calliper c) The average of the naked-eye estimation of all members of the operating team

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Ideal Method to Assess Residual Disease

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RESIDUAL DISEASE CLASSIFICATIONS: Questions Residual disease estimation: reproducibility Interobserver variability in CC category classification CC – 0 or CC – 1?

Slide 16 :

RESIDUAL DISEASE CLASSIFICATIONS: Problems Residual disease estimation: reproducibility Interobserver variability in CC category estimation

Slide 17 :

RESIDUAL DISEASE CLASSIFICATIONS: Problems “There is not such a thing as a complete cytoreduction” P.H. Sugarbaker

Slide 18 :

Question 4.3. Consider the case of a young patient affected by pseudomyxoma peritonei undergoing cytoreductive surgery. Initial PCI is 35, operating time including HIPEC is 11 hours, and there are no apparent visible disease nodules at the end of a very laborious cytoreductive procedure. What is your completeness of cytoreduction scoring? a) CC - 0 b) CC – 1 c) Other

Slide 19 :

CC score for clinical case

Slide 20 :

Question 4.4. Consider the same case. What is your R scoring? a) R 0 b) R 1 c) Other

Slide 21 :

R score for clinical case

Slide 22 :

Final score for clinical case CC-0 / R1 (microscopic disease)

Slide 23 :

Consider: CC-0 / R0 (en-bloc resection) CC-0 / R1 (microscopic disease)

Slide 24 :

RESIDUAL DISEASE CLASSIFICATIONS: Problems Is there a need for a microscopic residual disease category? Assessment of microscopic margins

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Question 4.5. Would you favor a further specification in the definition of a CC-0 or R0 cytoreduction? a)yes b)no

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Need for further specification of CC-0 / R0 definition?

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Slide 29 :

“COMPLETENESS OF CYTOREDUCTION” A DYNAMIC CONCEPT Disease process Chemosensitivity Infiltrative behavior Cellular cohesivity I.P. chemotherapy agent employed Depth of penetration

Slide 30 :

Peritoneal Mesothelioma Prognostic factors (n=33) Sebbag et al. Br J Surg. 2000; 87(11):1587-93. “COMPLETENESS OF CYTOREDUCTION”

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“COMPLETENESS OF CYTOREDUCTION” Yan TD et al. Prognostic indicators for patients undergoing cytoreductive surgery and perioperative intraperitoneal chemotherapy for diffuse malignant peritoneal mesothelioma. Ann Surg Oncol 2006;

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Slide 35 :

RESIDUAL DISEASE CLASSIFICATIONS: Problems Cut-off value for macroscopic residual tumor nodule size Intratumoral depth of penetration by i.p. Chemotherapy “from a few cell layers to a few milimeters” Anthracyclins /Taxanes most limited Cisplatin 2.5 – 3 mm (Los et al., 1990) (van der Waart et al, 1993) Mitomycin up to 5 mm (Fujimoto et al., 1992)

Slide 36 :

Courtesy of P.H. Sugarbaker

Slide 37 :

Question 4.6. Would you favor a redefinition of the completeness of cytoreduction according to the disease process? a)yes b)no

Slide 38 :

Need for redefinition of CC according to disease?

Slide 39 :

Question 4.7. Would you favor a redefinition of the completeness of cytoreduction according to the type of intraperitoneal cytotoxic agent(s) employed? a)yes b)no

Slide 40 :

Need for redefinition of CC according to chemotherapy agent?

Slide 41 :

METHODOLOGICAL CONSENSUS: CONCLUSIONS of the EXPERT WEB-BASED VOTING The Completeness of Cytoreduction Score (Sugarbaker, WCI) is considered the current best classification for residual disease after cytoreductive surgery in patients affected by peritoneal surface malignancies. The experienced surgeon´s naked-eye estimation is considered the ideal method to assess residual disease size after cytoreductive surgery. The definition of CC-0 or R0 cytoreduction needs further specification. A redefinition of “completeness of cytoreduction” according to disease process IS favored A redefinition of “completeness of cytoreduction” accoding to the type of intraperitoneal chemotherapy employed IS NOT favored

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