Fluorescence-guided surgery of peritoneal carcinomatosis: Safe and feasible.

Patients with peritoneal carcinomatosis of colorectal origin depend on an optimal cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) as a curative treatment – and, until now, surgeons have depended on visual inspection and palpation for tumor detection. There is room for improvement in this area, say Dutch surgeons at the renowned University of Groningen, and the technique to make it happen may be molecular fluorescence-guided surgery. The advantages of this approach could be twofold – one, an improved detection of tumor tissue to attain a complete cytoreduction of metastatic lesions, and two, the prevention of overtreatment by avoiding resection of benign lesions. The results of the (small) study are certainly promising: Molecular fluorescence-guided surgery was deemed safe and feasible.

The authors enrolled seven patients with colorectal peritoneal metastases scheduled for cytoreductive surgery and HIPEC. Two days before surgery, the patients were given 4.5 mg i.v. of the near-infrared fluorescent tracer bevacizumab-IRDye800CW. The primary endpoints were safety and feasibility, i.e. “safe” if no allergic or anaphylactic reactions or serious adverse events occurred that were linked to bevacizumab-IRDye800CW, and “feasible” if bevacizumab-IRDye800CW enabled detection of fluorescence signals during surgery.

–        The safety results:

o   Two patients developed serious adverse events, but both were attributed to the surgical cytoreductive surgery and HIPEC procedure.

o   By contrast, there were no serious adverse events related to bevacizumab-IRDye800CW.

–        The feasibility results:

o   Fluorescence was seen intraoperatively in all patients.

o   In two patients, the fluorescence-guided surgery managed to spot additional tumour tissue initially missed by the surgeon.

o   29 areas were ‘non-fluorescent’, all of these were found to contain only benign tissue

o   51 areas were fluorescent, 27 of which contained tumor tissue.

Using molecular fluorescence-guided surgery with the near-infrared fluorescent tracer bevacizumab-IRDye800CW is safe and feasible, conclude the authors, and might improve patient selection as well as optimizing cytoreductive surgery. As this was a small, single-center study, the authors now call for a multicenter phase 2 trial to confirm the diagnostic accuracy and to investigate the effect of this technique on clinical decision making.


Patients with Peritoneal Carcinomatosis from Gastric Cancer Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Is Cure a Possibility?



Peritoneal carcinomatosis is an increasingly common finding in gastric carcinoma. Previously, patients were treated as terminal, and median survival was poor. The use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in this context is still highly debatable.


The aim of this study was to evaluate the long-term outcomes associated with CRS and HIPEC, and define prognostic factors for cure, if possible.


All patients with gastric carcinomatosis from five French institutions who underwent combined complete CRS and HIPEC and had a minimum follow-up of 5 years were included in this study. Cure was defined as a disease-free interval of more than 5 years from the last treatment until the last follow-up.


Of the 81 patients who underwent CRS and HIPEC from 1989 to 2009, 59 had a completeness of cytoreduction score (CCS) of 0 (complete macroscopic resection), and the median Peritoneal Cancer Index (PCI) score was 6. Mitomycin C was the most commonly used drug during HIPEC (88 %). The 5-year overall survival (OS) rate was 18 %, with nine patients still disease-free at 5 years, for a cure rate of 11 %. All ‘cured’ patients had a PCI score below 7 and a CCS of 0. Factors associated with improved OS on multivariate analysis were synchronous resection (p = 0.02), a lower PCI score (p = 0.12), and the CCS (p = 0.09).


The cure rate of 11 % for patients with gastric carcinomatosis who are deemed terminal emphasizes that CRS and HIPEC should be considered in highly selected patients (low disease extent and complete CRS).