Surg Today DOI 10.1007/s00595-014-1080-4
ORIGINAL ARTICLE
The modified Glasgow prognostic score for early mortality in patients with synchronous peritoneal carcinomatosis from colorectal cancer Tomohiro Adachi · Takao Hinoi · Minoru Hattori · Hiroyuki Egi · Manabu Shimomura · Yasufumi Saito · Hiroyuki Sawada · Masashi Miguchi · Hiroaki Niitsu · Shoichiro Mukai · Takuya Yano · Hideki Ohdan
Received: 25 June 2014 / Accepted: 14 October 2014 © Springer Japan 2014
Abstract Purpose Few studies have investigated the risk factors in patients with peritoneal carcinomatosis (PC) from colorectal cancer (CRC) who die within 3 months of undergoing surgical intervention and systemic chemotherapy. This study aimed to identify the risk factors associated with the post-treatment 3-month mortality rate. Methods Retrospectively collected data from Hiroshima University were analyzed for patients presenting with synchronous PC from CRC between 1992 and 2012. The clinical, histological and survival data were evaluated and correlated with the overall survival rate at 3 months after surgical intervention. Results In patients who underwent surgical intervention with systemic chemotherapy for synchronous PC from
CRC (N = 65), a Kaplan–Meier analysis and the log-rank test revealed that systemic chemotherapy (P = 0.023) and the modified Glasgow Prognostic Score (mGPS) (P = 0.00001) were associated with the 3-month mortality rate. Multivariate analyses using these two factors revealed that the mGPS (0/1, 2) (odds ratio 8.087; 95 % CI 1.512– 43.25; P = 0.015) was an independent risk factor for the 3-month mortality rate. Conclusion The mGPS is an important independent predictor of the 3-month mortality rate in patients who undergo surgical intervention with systemic chemotherapy for synchronous PC from CRC. The mGPS could aid surgeons in choosing the appropriate treatment strategy and best care for patients.
T. Adachi (*) · T. Hinoi · H. Egi · M. Shimomura · H. Ohdan Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1‑2‑3 Kasumi Minami‑ku, Hiroshima 7348551, Japan e-mail: [email protected]
Y. Saito e-mail: [email protected]
T. Hinoi e-mail: thinoi@hiroshima‑u.ac.jp H. Egi e-mail: [email protected] M. Shimomura e-mail: [email protected] H. Ohdan e-mail: hohdan@hiroshima‑u.ac.jp M. Hattori · Y. Saito · H. Sawada · M. Miguchi Department of Surgery, Division of Frontier Medical Sciences, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, Kasumi Minami‑ku, Hiroshima, Japan e-mail: m‑hattori@hiroshima‑u.ac.jp
H. Sawada e-mail: [email protected] M. Miguchi e-mail: [email protected] H. Niitsu · S. Mukai · T. Yano Department of Gastroenterological and Transplant Surgery Division of Medicine, Program of Medicine, Biomedical Sciences Major, Graduate School of Biomedical & Health Sciences, Hiroshima University, Kasumi Minami‑ku, Hiroshima, Japan e-mail: [email protected] S. Mukai e-mail: [email protected] T. Yano e-mail: yano‑[email protected]
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Keywords Colorectal cancer · Peritoneal carcinomatosis · Synchronous · The modified glasgow prognostic score (mGPS) · Early mortality
Introduction Synchronous peritoneal carcinomatosis (PC) from colorectal cancer (CRC) is detected in 4.8–7 % of patients at the time of the first diagnosis of a primary colorectal tumor [1, 2]. PC from CRC is considered to be a terminal condition [median survival time (MST): 5.2–12.6 months] [2–4]. Recently, multi-modality therapy approaches, using systemic chemotherapy plus complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to significantly increase the overall survival. A randomized trial demonstrated a statistically significant survival advantage for this therapeutic approach compared to systemic chemotherapy alone [5]. Another study reported that those treated with CCRS plus HIPEC demonstrated an extended MST of 48–63 months and a 5-year survival rate of 51 % [6]. However, the patient population in that study was limited to patients younger than 66 years old, with asymptomatic PC from CRC with no extra-abdominal malignancy, who had a good general status and no disease progression after 2–3 months of neoadjuvant chemotherapy. In addition, the treatment regimen caused a high rate of complications (23–53 %) [5, 7–9]. These findings indicate the possibility that there may be no benefit of this treatment for patients who die within 3 months of intervention. In particular, the 5-year survival rate of synchronous PC from CRC (8.1 %) was worse than that of metachronous PC from CRC (25.4 %) [10]. The presence and extent of PC from CRC is frequently diagnosed during surgery, with 91 % of cases of PC from CRC not preoperatively detected [11]. This presents an issue to the operating surgeon in choosing the appropriate treatment strategy, which can include CCRS plus intraperitoneal chemotherapy (IP) and systemic chemotherapy; temporary surgery, such as a stoma; systemic chemotherapy alone or best supportive care (BSC). The specific aim of this study was to investigate the risk factors associated with the 3-month mortality rate in patients with synchronous PC from CRC, who underwent surgical intervention, to identify risk factors to predict early mortality in patients with synchronous PC from CRC.
Surg Today
at Hiroshima University between September 1992 and December 2012 were included in the study. These patients were selected perioperatively according to the following criteria: surgically and histologically proven synchronous PC from CRC, with an Eastern Cooperative Oncology Group (ECOG) performance status >2. Patients with metachronous PC from CRC, appendiceal carcinoma or peritoneal pseudomyxoma were excluded. Routine laboratory measurements, including the levels of serum C-reactive protein (CRP), albumin and tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9), were sampled within a month prior to surgical intervention in all patients. Ethical approval for the study was granted by the Local Board of Ethics and all the study participants provided written informed consent prior to the commencement of the study. Surgical intervention All patients were considered to have undergone either CCRS or non-CCRS, based on the results of preoperative abdominal computed tomography (CT), magnetic resonance imaging (MRI) and/or positron emission tomography (PET)–CT. The suitability of a curative or non-curative operation for each patient was based on the consensus reached at multidisciplinary meetings. The presence of peritoneal metastasis was diagnosed at the time of the operation and was confirmed by a pathological analysis. All patients included in this study received a final diagnosis of PC from CRC at the time of the operation for colorectal cancer and underwent surgical intervention. CCRS was performed in all cases with a preoperative diagnosis when it was possible to perform a curative operation to remove all visible intraperitoneal tumor deposits (R0 resection), the primary colorectal tumor (which included D2 systemic mesenteric lymph node dissection) and other metastases (which included hepatic, ovarian or uterine metastases), except in cases with gross peritoneal or lung metastases. Patients with 1.0 mg/dL and serum albumin
ORIGINAL ARTICLE
The modified Glasgow prognostic score for early mortality in patients with synchronous peritoneal carcinomatosis from colorectal cancer Tomohiro Adachi · Takao Hinoi · Minoru Hattori · Hiroyuki Egi · Manabu Shimomura · Yasufumi Saito · Hiroyuki Sawada · Masashi Miguchi · Hiroaki Niitsu · Shoichiro Mukai · Takuya Yano · Hideki Ohdan
Received: 25 June 2014 / Accepted: 14 October 2014 © Springer Japan 2014
Abstract Purpose Few studies have investigated the risk factors in patients with peritoneal carcinomatosis (PC) from colorectal cancer (CRC) who die within 3 months of undergoing surgical intervention and systemic chemotherapy. This study aimed to identify the risk factors associated with the post-treatment 3-month mortality rate. Methods Retrospectively collected data from Hiroshima University were analyzed for patients presenting with synchronous PC from CRC between 1992 and 2012. The clinical, histological and survival data were evaluated and correlated with the overall survival rate at 3 months after surgical intervention. Results In patients who underwent surgical intervention with systemic chemotherapy for synchronous PC from
CRC (N = 65), a Kaplan–Meier analysis and the log-rank test revealed that systemic chemotherapy (P = 0.023) and the modified Glasgow Prognostic Score (mGPS) (P = 0.00001) were associated with the 3-month mortality rate. Multivariate analyses using these two factors revealed that the mGPS (0/1, 2) (odds ratio 8.087; 95 % CI 1.512– 43.25; P = 0.015) was an independent risk factor for the 3-month mortality rate. Conclusion The mGPS is an important independent predictor of the 3-month mortality rate in patients who undergo surgical intervention with systemic chemotherapy for synchronous PC from CRC. The mGPS could aid surgeons in choosing the appropriate treatment strategy and best care for patients.
T. Adachi (*) · T. Hinoi · H. Egi · M. Shimomura · H. Ohdan Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1‑2‑3 Kasumi Minami‑ku, Hiroshima 7348551, Japan e-mail: [email protected]
Y. Saito e-mail: [email protected]
T. Hinoi e-mail: thinoi@hiroshima‑u.ac.jp H. Egi e-mail: [email protected] M. Shimomura e-mail: [email protected] H. Ohdan e-mail: hohdan@hiroshima‑u.ac.jp M. Hattori · Y. Saito · H. Sawada · M. Miguchi Department of Surgery, Division of Frontier Medical Sciences, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, Kasumi Minami‑ku, Hiroshima, Japan e-mail: m‑hattori@hiroshima‑u.ac.jp
H. Sawada e-mail: [email protected] M. Miguchi e-mail: [email protected] H. Niitsu · S. Mukai · T. Yano Department of Gastroenterological and Transplant Surgery Division of Medicine, Program of Medicine, Biomedical Sciences Major, Graduate School of Biomedical & Health Sciences, Hiroshima University, Kasumi Minami‑ku, Hiroshima, Japan e-mail: [email protected] S. Mukai e-mail: [email protected] T. Yano e-mail: yano‑[email protected]
13
Keywords Colorectal cancer · Peritoneal carcinomatosis · Synchronous · The modified glasgow prognostic score (mGPS) · Early mortality
Introduction Synchronous peritoneal carcinomatosis (PC) from colorectal cancer (CRC) is detected in 4.8–7 % of patients at the time of the first diagnosis of a primary colorectal tumor [1, 2]. PC from CRC is considered to be a terminal condition [median survival time (MST): 5.2–12.6 months] [2–4]. Recently, multi-modality therapy approaches, using systemic chemotherapy plus complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to significantly increase the overall survival. A randomized trial demonstrated a statistically significant survival advantage for this therapeutic approach compared to systemic chemotherapy alone [5]. Another study reported that those treated with CCRS plus HIPEC demonstrated an extended MST of 48–63 months and a 5-year survival rate of 51 % [6]. However, the patient population in that study was limited to patients younger than 66 years old, with asymptomatic PC from CRC with no extra-abdominal malignancy, who had a good general status and no disease progression after 2–3 months of neoadjuvant chemotherapy. In addition, the treatment regimen caused a high rate of complications (23–53 %) [5, 7–9]. These findings indicate the possibility that there may be no benefit of this treatment for patients who die within 3 months of intervention. In particular, the 5-year survival rate of synchronous PC from CRC (8.1 %) was worse than that of metachronous PC from CRC (25.4 %) [10]. The presence and extent of PC from CRC is frequently diagnosed during surgery, with 91 % of cases of PC from CRC not preoperatively detected [11]. This presents an issue to the operating surgeon in choosing the appropriate treatment strategy, which can include CCRS plus intraperitoneal chemotherapy (IP) and systemic chemotherapy; temporary surgery, such as a stoma; systemic chemotherapy alone or best supportive care (BSC). The specific aim of this study was to investigate the risk factors associated with the 3-month mortality rate in patients with synchronous PC from CRC, who underwent surgical intervention, to identify risk factors to predict early mortality in patients with synchronous PC from CRC.
Surg Today
at Hiroshima University between September 1992 and December 2012 were included in the study. These patients were selected perioperatively according to the following criteria: surgically and histologically proven synchronous PC from CRC, with an Eastern Cooperative Oncology Group (ECOG) performance status >2. Patients with metachronous PC from CRC, appendiceal carcinoma or peritoneal pseudomyxoma were excluded. Routine laboratory measurements, including the levels of serum C-reactive protein (CRP), albumin and tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9), were sampled within a month prior to surgical intervention in all patients. Ethical approval for the study was granted by the Local Board of Ethics and all the study participants provided written informed consent prior to the commencement of the study. Surgical intervention All patients were considered to have undergone either CCRS or non-CCRS, based on the results of preoperative abdominal computed tomography (CT), magnetic resonance imaging (MRI) and/or positron emission tomography (PET)–CT. The suitability of a curative or non-curative operation for each patient was based on the consensus reached at multidisciplinary meetings. The presence of peritoneal metastasis was diagnosed at the time of the operation and was confirmed by a pathological analysis. All patients included in this study received a final diagnosis of PC from CRC at the time of the operation for colorectal cancer and underwent surgical intervention. CCRS was performed in all cases with a preoperative diagnosis when it was possible to perform a curative operation to remove all visible intraperitoneal tumor deposits (R0 resection), the primary colorectal tumor (which included D2 systemic mesenteric lymph node dissection) and other metastases (which included hepatic, ovarian or uterine metastases), except in cases with gross peritoneal or lung metastases. Patients with 1.0 mg/dL and serum albumin
