The PRECINCT (Pattern of peritoneal dissemination and REsponse to systemic Chemotherapy IN Common and uncommon peritoneal Tumors) is a prospective, multicenter, observational study. This report from phase I of PRECINCT outlines variations in recording the surgical peritoneal cancer index (sPCI) at experienced peritoneal malignancy centers and the incidence of pathologically confirmed disease in morphologically different peritoneal lesions (PL). The sPCI was recorded in a prespecified format that included the morphological appearance of PL. Six prespecified morphological terms were provided. The surgical and pathological findings were compared. From September 2020 to December 2021, 707 patients were enrolled at 10 centers. The morphological details are routinely recorded at two centers, structure bearing the largest nodule, and exact size of the largest tumor deposit in each region at four centers each. The most common morphological terms used were normal peritoneum in 3091 (45.3

ABSTRACT Background and Aim In this report from Phase 1 of the prospective, observational, PRECINCT ( P attern of peritoneal dissemination and RE sponse to systemic C hemotherapy IN C ommon and uncommon peritoneal Tumours) study, a correlation was performed between the radiological PCI (peritoneal cancer index; rPCI) and surgical PCI (sPCI). The impact of timing of peritoneal malignancy (PM) and previous abdominal surgery was also studied. Methods The rPCI and sPCI were considered the ‘same’ if they differed by ≤ 3 points. The agreement was assessed using Bland–Altman analysis and the strength of the agreement was assessed using the concordance correlation coefficient (CCC). The extent of prior surgery was classified according to prior surgical score (PSS). Results In 707 (79.4%) patients, rPCI and sPCI concurred in 280 (39.6%). In the Bland–Altman analysis, < 40% patients were in the ±3 PCI points limit of acceptable difference. The average difference between the two scores was 4.5 points (95% CI‐ −5.16 to −3.92). The CCC‐ was 0.59 for the whole cohort (‘moderate’ concordance) and was not influenced by imaging modality, timing of PM or PSS. Conclusions The rPCI underestimated sPCI by an average of 4.5 points. The role of peritoneal MRI in patients undergoing iterative procedures and the performance of imaging according to sites of recurrence need further evaluation.

A previous report from the Indian HIPEC registry showed acceptable early survival and morbidity in patients undergoing cytoreductive surgery (CRS) + / − hyperthermic intraperitoneal chemotherapy (HIPEC). The goal of this retrospective study was to evaluate the long-term outcomes in these patients. Three hundred seventy-four patients treated from December 2010 to December 2016 and enrolled in the Indian HIPEC registry were included. All patients had completed 5 years from the date of surgery. The 1-, 3-, 5- and 7-year progression-free (PFS) and overall survival (OS) and factors affecting these were evaluated. The histology was epithelial ovarian cancer in 209 (46.5

The aim of this study was to evaluate the potential role of optimal cytoreductive surgery with or without HIPEC in the management of peritoneal dissemination from rare histological subtypes of ovarian cancer and to report the prognostic factors affecting survival. In this retrospective multicentric study, all patients with diagnosis of locally advanced ca ovary with histology other than high-grade serous carcinoma and those having undergone cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy for the same were included. Factors affecting survival were evaluated in addition to studying the clinicopathological features. In the period from January 2013 to December 2021, 101 consecutive patients of ovarian cancer with rare histology underwent cytoreductive surgery with or without HIPEC. The median OS was not reached (NR), and the median PFS was 60 months. On evaluation of factors affecting overall survival (OS) and progression-free survival (PFS), PCI > 15 was associated with not only a decreased PFS ( p = 0.019) but also a decreased OS ( P = 0.019) on univariate and multivariate analysis. With respect to histology, the best OS and PFS were seen with granulosa cell tumor, mucinous tumors for which median OS and median PFS were NR respectively. Cytoreductive surgery can be performed with an acceptable morbidity in patients with peritoneal dissemination from ovarian tumors of rare histology. The role of HIPEC and impact of other prognostic factors on the treatment and survival outcome need further evaluation in larger series of patients.

We reviewed the current literature regarding patterns of peritoneal dissemination and extent of peritoneal resection that should be performed in patients with advanced epithelial ovarian cancer (EOC). The preliminary results of our prospective study evaluating the role of total parietal peritonectomy (TPP) and wide resection of the visceral peritoneum performed during interval cytoreductive surgery (CRS) are presented and discussed. Studies on peritoneal spread and response to systemic chemotherapy in EOC show that the incidence of occult disease is high in the peritoneum that appears ‘normal’ during surgery and is likely to be the source of recurrent disease. Hyperthermic intraperitoneal chemotherapy (HIPEC) acts on microscopic disease as well as free intraperitoneal cancer cells shed during surgery, thus, reducing the risk of recurrence. The addition of HIPEC to interval CRS showed a benefit in both progression-free and overall survival over interval CRS alone. The only definitive way to eradicate such occult disease completely is resection of the peritoneum. And thus, a TPP performed along with wide resection of the visceral peritoneum may be a more effective strategy for addressing this occult disease compared to other locoregional therapies like HIPEC and systemic therapies. The postoperative complications was acceptable. Both progression-free and overall survival are improved after TPP. The incidence of platinum resistance recurrence was much lower than previous reports.

BackgroundAggressive locoregional therapies like hyperthemic intraperitoneal chemotherapy(HIPEC) and total parietal peritonectomy(TPP) have been used to delay recurrence in patients with advanced ovarian cancer undergoing interval cytoreductive surgery(CRS). The aim of this retrospective study was to evaluate the incidence of platinum resistant recurrence (PRR) and early recurrence (ER)(recurrence within 6 months and 1 year of the last dose of platinum based therapy, respectively) in patients undergoing interval CRS. The secondary goal was to study impact of each of these therapies on PRR and ER. MethodsOne-hundred and fifty-three patients undergoing interval CRS from July 2018 to June 2020 were included. The surgical strategy was to perform a TPP in which the entire parietal peritoneum is resected irrespective of the disease extent or a selective parietal peritonectomy (SPP) in which only the peritoneum bearing visible residual disease is resected. The use of HIPEC was at the discretion of the treating oncologists. ResultsThe median surgical PCI was 15 [range, 0-37]. A CC-0 resection was obtained in 119 (77.7%) and CC-1 in 29 (18.9%) patients. Eighty-one (53%) patients had a TPP and 72 (47%) had SPP. HIPEC was performed in 98(64%) patients. Bevacizumab maintenance was administered to 31(19.6%) patients. No patients received PARP inhibitors during first-line therapy. PRR was observed in 8(5.2%) patients and ER in 30(19.6%). The respective incidences of PRR and ER were 4.9% and 16% in the TPP group, 4.1% and 23.6% in the SPP group, 9% and 20% in the no-HIPEC group and 3% and 19.3% in the HIPEC groups. On multivariate analysis, CC-0(p=0.014) resection and HIPEC(p=0.030) were independent predictors of a low ER. All patients with PR and 70% with ER had peritoneal recurrence with or without extra-peritoneal sites of recurrence. ConclusionsThe incidence of PRR and ER in this cohort was low as compared to historical data. This low incidence could be attributed to the use of aggressive locoregional therapies like TPP and HIPEC. In future, studies should be conducted to confirm these findings and evaluate the potential additive benefit of TPP and HIPEC coupled together as well as their combination with maintenance therapies.

Taxanes have a favorable pharmacokinetic profile for intraperitoneal application. We report our initial experience with taxane-PIPAC (pressurized intraperitoneal chemotherapy) for unresectable peritoneal metastases from different primary sites in terms of safety, feasibility, response rate, and conversion to resectability. In this retrospective study, PIPAC was performed alone or in combination with systemic chemotherapy. Paclitaxel was used as a single agent, whereas docetaxel was used in combination with cisplatin-adriamycin or oxaliplatin-adriamycin. From December 2019 to December 2021, 47 patients underwent 82 PIPAC procedures (1 PIPAC in 55.3

The aim of the present study was to report the clinical outcome and factors affecting survival in patients with first recurrence of AGC treated with cytoreductive surgery with or without HIPEC. The second aim was to study the disease distribution in the peritoneal cavity according to the peritoneal carcinomatosis index (PCI) and the morphology of peritoneal deposits. In this retrospective multicentric study, all patients of adult granulosa cell tumor with peritoneal recurrence were treated with CRS with or without HIPEC. Relevant clinical and demographic data were captured. Multivariable logistic regression was performed to evaluate the factors affecting recurrence after CRS ± HIPEC. Factors affecting survival and second recurrences were evaluated in addition to studying the disease distribution at first recurrence. In the period from January 2013 to December 2021, 30 consecutive patients of recurrent adult type granulosa cell tumor of the ovary undergoing CRS ± HIPEC were included in this study. The median follow-up duration was 55 months [12–96 months]. The median rPFS and rOS were both not reached. HIPEC (p = 0.015) was the only factor independently associated with a longer rPFS. CRS with or without HIPEC can be performed with an acceptable morbidity in patients with the first recurrence from adult granulosa cell tumours. The role of HIPEC, patterns of peritoneal spread and impact of other prognostic factors on the treatment outcome all need further evaluation in larger series of patients.

Objective: The morbidity of hyperthermic intraperitoneal chemotherapy (HIPEC) in relation to the extent of surgical resection has not been analyzed in advanced ovarian cancer. The goal was to evaluate the perioperative outcomes in patients treated with a total parietal peritonectomy (TPP) and multi-visceral resections with/without HIPEC at different time points in the history of advanced ovarian cancer. Methods: This is a retrospective study of 144 patients treated from 1 December 2018 to 30 June 2020. In the interval setting, a TPP was performed as part of a registered protocol (CTRI 2018/12/016789) and in the primary and recurrent setting when the extent of disease necessitated it. The analysis of the perioperative outcomes included evaluation of the 90-day grade 3-4 morbidity and mortality and time to starting adjuvant chemotherapy. Results: Thirty (20.8%) patients had primary cytoreductive surgyer (CRS), 90 (62.5%) interval CRS and 24 (16.2%) CRS for recurrence. HIPEC was performed in 57 (39.5%) patients. 93.7% had all 7 peritonectomies, 61% had more than three visceral resections and 62.5% had at least one bowel anastomosis. Grade 3-4 morbidity was seen in 31.9% and was similar with/without HIPEC. On multi-variable logistic regression analysis, patients receiving neoadjuvant chemotherapy (p = 0.031) and undergoing small bowel resection (p = 0.038) had a higher risk of grade 3-4 morbidity and those with peritoneal cancer index (PCI)<10 (p = 0.001) had a lower risk. All except two patients started chemotherapy within 6 weeks of surgery. Conclusions: In this study, the addition of HIPEC to TPP and multi-visceral resections had an acceptable morbidity. The morbidity was affected by the disease extent and the extent of surgery performed and not by HIPEC.

Background: The reported incidence of platinum resistant recurrence (PRR) (recurrence within 6 months of the last dose of platinum therapy) after interval debulking/cytoreductive surgery (CRS) is high compared to that after primary CRS. The goal was to study PRR following a total parietal peritonectomy (TPP), that addresses occult disease more completely. Methods: This is a prospective multi-center study (CTRI/2018/08/015350). A TPP was performed during interval CRS following a fixed surgical protocol. Patients with a follow-up of 6 months(M) or more were included in this analysis. The incidence and patterns of PRR and factors affecting recurrence were analyzed. Results: From July 2018 to October 2019, 70 patients with serous carcinoma were included. The median surgical PCI was 15 [range 5-37]. A CC-0 resection was obtained in 55 (78.5%); CC-1 in 10 (14.2%). Occult residual disease was seen in 40%. At a median follow-up of 13 months, 17 (24.2%) had developed recurrence/progression. PRR was seen in 5 (7.1%) patients. The sites of progression (>1 in 2 patients) were pleura (n = 1), visceral peritoneum (n = 2), retroperitoneal nodes (n = 2), mediastinal nodes (n = 1) and small bowel mesentery (n = 2). Overall, though the most common site of recurrence was the visceral peritoneum (N = 9), seven (>40%) patients did not develop recurrence in the visceral peritoneum. Patients with high PCI and grade 3-4 complications had a higher probability of developing recurrence. Conclusions: TPP performed during interval CRS resulted in a very low incidence of PRR. These findings need confirmation in a larger series. The benefit of TPP over conventional surgery should be evaluated in a randomized trial. (C) 2021 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Background and aim: The greater omentum(GO) is a common site of residual disease in patients receiving neoadjuvant chemotherapy for advanced epithelial ovarian cancer. The presence of tumor in the GO could predict presence of disease in other peritoneal regions. The goal of this study was to perform a correlation between the greater-omentum lesion-score(GOLS) and presence of disease in different peritoneal regions and determine its potential utility in guiding interval cytoreductive surgery(CRS). Methods: This prospective study included 134 patients undergoing interval CRS from July 1, 2018 to June 30, 2020. Each region of Sugarbaker's Peritobneal Cancer Index(PCI) was given a lesion score(LS) from 0 to 3 according to the diameter of the largest tumor in the region. The GOLS was recorded separately from other structures in the region. Correlation between the GOLS and surgical and pathological LS in each region was performed. Results: As the GOLS increased, the incidence of disease(surgical LS) in other regions of the peritoneal cavity increased. Receiver operating characteristic(ROC) curves showed area under curve more than 80% for regions 1-2 and 7-8 indicating a high probability of disease in these regions in patients with GOLS 1-3. The positive predictive value(PPV) of preoperative imaging for GOLS was 95.7%. No cut-off of the GOLS could predict presence of disease on pathology with more than 70% accuracy. Conclusions: Presence of disease in the GO warrants performing upper abdominal exploration and/or cytoreduction and interval CRS should be planned accordingly in these patients. Imaging has a high PPV in detecting disease in the GO. (C) 2021 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Introduction: Residual disease in 'normal appearing' peritoneum is seen in nearly 30% of the patients following neoadjuvant chemotherapy (NAG) for advanced ovarian cancer. The goal was to study the sequence of response in different regions, the commonest sites of occult residual disease, its incidence in different peritoneal regions and the potential therapeutic implications of these. Methods: This was a prospective multi-centre study (July 2018-June 2019). Pathological evaluation of cytoreductive surgery specimens was performed according to a fixed protocol. Prevalence of residual disease in different regions was used to study patterns of response and distribution of residual disease. Result: In 85 patients treated between July 2018 to June 2019, microscopic disease in 'normal appearing' peritoneal regions was seen in 22 (25.2%) and in normal peritoneum around tumor nodules in 30 (35.2%) patients. Regions 4 and 8 of Sugarbaker's PCI had the highest incidence of occult disease and regions 9 and 10 the lowest. The response to chemotherapy occurred in a similar manner in over 95%- the least common site of residual disease was the small bowel mesentery, followed by upper regions (regions 1 -3), omentum and middle regions (regions 0, 4, 8), lower regions (regions 5-7) and lastly the ovaries. Conclusions: During interval CRS, based on the disease mapping provided in this manuscript, regions that have a high probability of residual disease should be explored and dissected. Complete resection of involved the peritoneal region can completely address the occult disease. The role of resection of the entire region as well as 'normal appearing' parietal peritoneal regions should be prospectively evaluated. (C) 2020 Elsevier Ltd, BASO - The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Background: Selected patients with platinum sensitive recurrent ovarian cancer may benefit from cytoreductive surgery (CRS). The aim was to study the pattern of peritoneal involvement in these patients that has not been done before. Methods: A comparison was made between the surgical and pathological findings in 60 patients undergoing salvage CRS from July 2018 to December 2019. The sites of residual disease, correlation with surgical and pathological peritoneal cancer index (PCI), small bowel involvement and regional lymph node involvement were studied. Results: Fifty-eight (96.6%) had serous carcinoma and 2 (3.4%) clear cell carcinoma. The median surgical PCI (sPCI) was 7 [range 0-27] and median pathological PCI (pPCI) 4 [range 0-21]. CC-0 resection was performed in 81.6%. The upper regions (region 1,2,3) were the commonest sites of residual disease (63.3%) followed by lower regions (region 5,6,7) in 55.0%, middle regions (regions 0,4,8) in 53.3% and small bowel regions (regions 9-12) in 26.6%. Small bowel involvement was associated with a higher sPCI and pPCI (p < 0.001 for both). Regional nodes were involved in 46.6%. A pathological complete response was seen in 8 (13.3%) patients of which 2 had residual disease in regional nodes. Microscopic disease in 'normal appearing' peritoneum was seen in 21%. Conclusions: The parietal peritoneum was the commonest site of recurrence. Small bowel involvement occurred late and was associated with more extensive disease. Regional lymph node involvement was seen nearly 50% and was a common site for occult disease. The role of more extensive parietal peritoneal resection for recurrent disease should be evaluated prospectively. (C) 2020 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Background and Aim Though interval cytoreductive surgery (CRS) following neoadjuvant chemotherapy (NACT) is considered non-inferior to primary CRS, the incidence of platinum resistance is high. A total parietal peritonectomy (TPP) can address occult microscopic disease more completely and could reduce the rates of early recurrence. The early results of a prospective study evaluating the role of TPP are presented in this manuscript. Methods This is a prospective, multi-centric interventional study. A TPP was performed in all patients undergoing interval CRS. A fixed surgical protocol was followed. Grade 3-4 morbidity was recorded. Factors affecting grade 3-4 morbidity, early recurrence and progression-free survival (PFS) were evaluated. Results From July 2018, 70 patients with serous carcinoma were included. The median surgical PCI was 15 [range 5-37]. A CC-0 resection was obtained in 55(78.5%) patients; CC-1 in 10(14.2%). Grade 3-4 complications were seen in 15(21.4%) patients of which the commonest complication was intraperitoneal fluid collection. Occult disease in the peritoneum was seen in 40%. Early recurrence (platinum resistance) was seen in 5(7.1%). The median PFS was 18 months [range 0-21months]. Patients with a lower PCI and with no grade 3-4 complications had a significantly longer PFS. A pathological PCI>15 was the only independent predictor of a shorter PFS (p=0.001). Conclusions TPP performed as a part of interval CRS resulted in a very low incidence of platinum resistance. The post-operative morbidity was acceptable. These findings should be confirmed in a larger series and a randomized trial performed to demonstrate demonstrate its benefit over conventional surgery.

Total parietal peritonectomy (TPP) removes areas of “normal-appearing” parietal peritoneum bearing microscopic residual disease and has the potential to improve survival of patients undergoing interval cytoreductive surgery (CRS) for advanced serous epithelial ovarian cancer. This report presents the morbidity outcomes for the first 50 patients enrolled in TORPEDO (CTRI/2018/12/016789), a prospective study. All the patients underwent a TPP during interval CRS. A surgical protocol that includes a description of the boundaries for each of the five peritonectomies was followed. The common toxicology criteria for adverse events (CTCAE) classification was used to record 90-day morbidity and mortality. The median Peritoneal Cancer Index (PCI) for 50 patients was 15 (range, 5–37). A complete cytoreduction (CC-0 resection) was obtained in 80%, a CC-1 resection in 16%. A bowel resection was performed in 70% of the patients. Grade 3 or 4 complications were seen in 11 patients (22%), and one patient died within 90 days after surgery due to intraperitoneal hemorrhage. The most common complications were postoperative fluid collection requiring aspiration (n = 5), intraperitoneal hemorrhage (n = 2), abdominal wound dehiscence (n = 2), pseudo-obstruction (n = 1), urinary sepsis (n = 2), and ileostomy-related complications (n = 2). No bowel fistulas or anastomotic leaks occurred. Microscopic disease in ‘normal appearing’ peritoneum adjacent to tumor nodules was observed in 46% of the patients, and in regions given a lesion score of 0 in 34%. The parietal peritoneal regions (0–8) had a higher incidence of residual disease (p < 0.001) and occult disease (p < 0.001). During interval CRS, TPP can be performed with acceptable morbidity and mortality. The pathologic findings further support this therapeutic rationale. Survival outcomes should determine the future role of such a procedure in routine clinical practice.

The peritoneal cancer index (PCI) is one of the strongest prognostic factors in patients undergoing cytoreductive surgery (CRS) for colorectal peritoneal metastases. Using pathological evaluation, however, the disease extent differs in a large proportion of patients. Our aim was to study the correlation between the radiological (rPCI), surgical (sPCI) and pathological (pPCI) PCI in order to determine factors affecting the discordance between these indices and their potential therapeutic implications.

Background: The aim was to study the patterns of target region (greater omentum, lesser omentum, falciform and umbilical round ligament) involvement in patients undergoing cytoreductive surgery (CRS) from various primary tumors, factors affecting involvement and implications on surgical practice. Methods: All patients undergoing CRS from July 2018 to December 2018 were included in this prospective study. The incidence of target region involvement in presence and absence of visible disease and the impact of primary tumor site, PCI and other variables on target region involvement was evaluated. Results: In 191 patients, greater omentum was involved in over 15% of patients irrespective of the primary tumor type and in 15.7% in absence of visible disease. 75% of these had PCI <20. The involvement of the other three target regions was higher than 20% in ovarian cancer, appendiceal tumors and peritoneal mesothelioma. Involvement of these 3 regions was associated with a higher PCI (p <0.001 for all) and omental involvement (p < 0.001for all). 2.1% of colorectal cancer patients had umbilical round ligament involvement, 4.2% had falciform ligament involvement and none had lesser omentum involvement. Conclusions: Target region involvement varies according to primary tumour site and disease extent. Resection of the greater omentum should be performed during CRS for PM arising from all primary sites. Resection of other target organs may be performed for selected patients with ovarian cancer, peritoneal mesothelioma and mucinous appendiceal tumors in absence of visible disease. For other patients, it should be done only in presence of visible disease. (C) 2019 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Recent advances in minimal access/invasive surgeries in head and neck (robotic/endoscopic assisted) allow neck dissection without a visible scar through a retroauricular approach unlike conventional approach giving visible scar and its sequelae. We retrospectively reviewed prospectively collected data of 80 neck dissections in 72 patients from April 2017 to June 2018 for all newly diagnosed squamous cell carcinoma of oral cavity. We compared between the operative and postoperative outcomes in open- and endoscopic-assisted retroauricular approach (RA) in these patients undergoing neck dissections. Thirty-two out of seventy-two patients underwent retroauricular (RA) approach neck dissection while 40/72 patients underwent conventional open approach neck dissection. RA group had more early staged oral cancers 20/32 (62.5%) as compared to 9/40 (22.5%) in the open approach (p = 0.025). Average nodal yield and nodal yield according to levels were not statistically different in both groups. Nodal failure in both groups was also not statistically significant (p = 0.82). Postoperative complications like marginal weakness, hematoma, microvascular-related problems, and wound problems were not significantly related to the type of approach. We recommend in select group of early oral cancers the retroauricular-assisted neck dissection as minimally invasive, cost-effective, and oncologically safe approach for a scar-free neck surgery.

Background The surgical peritoneal cancer index (sPCI) is calculated based on a subjective evaluation of the extent of peritoneal disease during surgery. The pathologic PCI (pPCI) may be a more accurate and objective method for determining the PCI. This study aimed to compare the sPCI and pPCI and to study the potential pitfalls and clinical implications of using the pPCI. Methods This prospective study (July to December 2018) included all patients undergoing cytoreductive surgery (CRS). The pPCI was calculated for each patient and compared with the sPCI. The impact of potential confounding factors on the difference between pPCI and sPCI was evaluated. Results Among 191 patients undergoing CRS at four centers, the pPCI and sPCI were concordant for 37 patients (19.3%). The pPCI was lower than the sPCI for 125 patients (65.4%) and higher for 29 patients (15.1%). The concordance between the two groups was maximum for gastric cancer (38.8%) and colorectal cancer (27.6%) and least for mesothelioma (6.7%) and rare primary tumors (5.6%) ( p = 0.04). The difference was 0 to 3 points for 119 patients (62.3%), 4 to 5 points for 27 patients (14.1%), and more than 5 points for 45 patients (23.5%). The rate of concordance was not influenced by the use of neoadjuvant chemotherapy (NACT) ( p = 0.4), but the difference was greater when NACT was used ( p = 0.03). Conclusions The pPCI strongly differs from the sPCI for patients undergoing CRS for peritoneal disease and may provide a more accurate evaluation of the peritoneal disease extent. Further studies are needed to determine its prognostic value compared with sPCI, and consensus guidelines are needed for calculating it.