Peritoneal progression after pancreaticoduodenectomy is a devastating surgical treatment failure: HIPEC gemcitabine is an option

Perhaps it is a surprise to our readers of this Focused Issue that 4 manuscripts concerning PM from pancreas cancer are included (1-4). However, peritoneal recurrence is a devastating part of the natural history of this disease. David Padilla-Valverde and colleagues from Ciudad Real, Tentes from Athens, and Sugarbaker and Stuart from Washington, DC all focus on HIPEC with gemcitabine to help control local recurrence and PM in patients with resected pancreas cancer. The high incidence of early local-regional progression following pancreas cancer resection causes extensive morbidity and interferes with possible benefits of systemic chemotherapy. The Spanish group presents their clinical trial data showing no unexpected morbidity and mortality if HIPEC gemcitabine is added to a pancreatico-duodenal resection (1). Tentes and Sugarbaker present similar safety data regarding HIPEC gemcitabine (2,3). Mature but non-randomized data regarding reduced local-regional treatment failures were presented by Tentes (10.3%) and by Sugarbaker (0%). Sugarbaker and Stuart presented pharmacokinetic data strongly supporting HIPEC gemcitabine as a treatment to suppress the high likelihood of local-regional treatment failure in resected pancreas cancer. Also, 6 months of NIPEC gemcitabine through an intraperitoneal port was well tolerated. These authors suggest HIPEC and NIPEC gemcitabine can be included in multimodality strategies to treat resected pancreas cancer. Yamada and coworkers provide this Focused Issue data on a multi-institutional study from 10 different Japanese universities (4). In two different protocols of 33 and 46 patients, combined intraperitoneal paclitaxel and systemic chemotherapy were administered until unacceptable toxicity, disease progression or conversion surgery that occurred in 16 of the 79 patients (20.3%). The “super responders” who had the benefit of conversion surgery showed an overall survival of 32.5 months. These authors concluded that repeated doses of combined intraperitoneal paclitaxel and systemic chemotherapy showed efficacy and was tolerable.

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