ACPMP PSOGI 2018 SUMMARY
The ACPMP Research Foundation was proud to sponsor and attend the 11th Workshop on Peritoneal Surface Malignancy in Paris, France on September 9-11, 2018, represented by President Jerry Lewandowski and Communications and Development Manager Lauren Smith. This is the preeminent international event related to peritoneal metastases such as PMP and is organized by the Peritoneal Surface Oncology Group International (PSOGI), which promotes research, education and innovations in patient care. PSOGI’s first biennial event was held in 1998 at Basingstoke, UK and had 20 attendees. This year’s event broke the previous attendance record with over 900 participants from countries around the world. With our participation this year, ACPMP has now participated in the last five PSOGI conferences.
ACPMP provided scholarships to the event that enabled 29 medical professionals from twelve different countries to attend this premier event to present their research and discuss the latest research on the understanding, diagnosis and treatment of appendix cancer, pseudomyxoma peritonei and other peritoneal surface malignancies.
Our participation also allowed us to spend time with our fellow patient groups, particularly our friends at PMP Pals who were represented by a large international contingent.
From a scientific standpoint, many exciting research findings were presented and debated.
Drug Development: Mucin-Dissolving Bromelain
Dr. David Morris and research officer Sarah Valle from St. George Hospital in Australia, 2016 ACPMP research grant recipients, presented on their progress treating patients with a combination of bromelain (an enzyme from pineapples) and n-acetylcysteine (used in acetaminophen overdose) to dissolve the mucin produced in connection with PMP. The team is very encouraged by their results so far in dissolving the mucin in PMP patients. Due in part to ACPMP's research grant, their research is now in human clinical trials in Australia and they are working on expanding the trials to Europe and the United States. Their research was the subject of a lot of excitement and discussion at the conference.
Recurrence of PMP after CRS/HIPEC
The French have a robust clinical and research network that extends across a number of centers in the country. They presented research based on their national patient database related to PMP recurrence titled “Recurrence of pseudomyxoma peritonei after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.” In the presentation, they observed that (1) about a quarter of PMP recurred, and (2) recurrences were earlier with high grade cancer or patients who underwent preoperative chemotherapy. They also concluded that post-operative surveillance should include long term follow-up because about 1/8 of recurrences were discovered 5 years or more after surgery. However, it was also noted that overall survival of patients with a recurrence was still very good. You can find the published journal article on this research here.
Classification System for PMP
The new classification system for peritoneal pseudomyxoma (PMP) agreed upon by pathologists at the PSOGI 2016 meeting was discussed. The three-tier system (low grade, high grade, and high grade with signet ring cells) simplifies the naming convention and diagnostic criteria. But the interpretation of overlapping features of the tumor cells and identification of signet ring cells are still challenging. The goal of pathologists is to improve the accuracy of how they define these diagnostic groups so that the clinical decision making can be made based on the pathology of the tumors – with the end goal of improving patient outcomes.
Goblet Cell Carcinoid Tumors
Goblet cell carcinoid tumors were also discussed extensively, given that their distinct nature is very confusing - right down to the very name of this tumor (although it contains the word “carcinoid” in the name, this tumor behaves more like an adenocarcinoma). It was proposed that goblet cell carcinoids should be renamed to mitigate this confusion; however, considering the name has already changed many times, the majority of those in attendance felt that it shouldn’t be changed again to avoid further confusion.
The Approach to Low Grade Appendiceal Mucinous Neoplasms
Attendees continued the long-running debate about the best clinical approach for low grade appendiceal mucinous neoplasms (“LAMN” or what has historically sometimes been called “DPAM”): surveillance, or CRS with HIPEC? This is a big question that impacts many patients. The experts agreed that meeting with a surgical oncologist is extremely important for all PMP patients, and expert pathology review is critical. Research shows that the rates of recurrence vary depending on (1) whether any cells escaped outside of the appendix, and (2) whether those cells were cancerous or only mucinous, and concluded that with cancerous cells outside of the appendix there is a higher percentage of recurrence, versus when only mucin was found outside of the appendix. The criteria for what constitutes LAMN was also discussed, and largely the conclusion can be thought of in terms of what the cells are not: if there are no high-grade mucinous neoplasms (HAMN), invasive cells (adenocarcinoma), or goblet or signet ring cells, the pathology is likely LAMN.
PRODIGE 7 Colon Cancer Trial Controversy
The results of the PRODIGE 7 colon cancer clinical trial occupied a good amount of the conference time and generated significant debate and feedback. By way of background, the PRODIGE 7 trial involves patients with advanced metastatic colorectal cancer and randomized them into two groups: one group received cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin, and the other group received only cytoreductive surgery. The study has been carefully watched and its results are highly anticipated, because there have been relatively few randomized clinical trials related to the use of HIPEC to treat diseases that involve peritoneal surface malignancies. This past summer, the study’s investigators released some results from PRODIGE 7 at the annual American Society of Clinical Oncology (ASCO) meeting in Chicago.
Data from the study showed that patients in the non-HIPEC and HIPEC arms had no statistically significant difference in overall survival (OS), which suggests that HIPEC did not affect overall survival for those colon cancer patients. There was a statistically significant improvement in overall survival for patients in the HIPEC arm when the focus was narrowed to look at just patients with a medium amount of tumor (PCI scores between 11 and 15), but the sample sizes were small. It is important to note that this trial involved colorectal cancer and not appendix cancer or pseudomyxoma peritonei (for which CRS/HIPEC is the accepted standard of care). However, it is still a very significant study because the results are likely to affect general attitudes about HIPEC in the medical community. One doctor at the conference from Turkey noted that the Turkish government has already responded to the results of the PRODIGE 7 trial by not approving CRS and HIPEC for colorectal cancer patients with a high or low PCI score. Other specialists expressed concern that the study supports the notion that a high-quality surgery is important to overall survival, but given the results, some patients may not get referred to the right center to get that high-quality surgery (or potentially any surgery at all). The PRODIGE 7 trial may stay open for another year, but the debate about its findings will likely continue much longer.
PIPAC or Pressurized Intraperitoneal Aerosol Chemotherapy
The conference included an extensive discussion on PIPAC, or pressurized intraperitoneal aerosol chemotherapy, as a less invasive alternative to HIPEC. The survival data from the PIPAC studies presented was encouraging and warrants further clinical studies. Research presented by doctors from France noted that PIPAC with low dose cisplatin and doxorubicin is safe and feasible in combination with systemic chemotherapy. Research was also presented on the results of animal models that studied PIPAC, noting that small animal models are required to study antitumor efficacy and that the rat tumor model of PIPAC was successfully established and we should be seeing more data coming out
Prehabilitation Before CRS/HIPEC
Another topic discussed was the positive impact of “prehabilitation” on patients undergoing CRS/HIPEC. According to this research, rehab prior to surgery results in better tolerance of surgery and facilitates recovery. Involved in this prehabilitation process is analysis of nutritional status and risk of malnutrition, rehabilitation medical assessment—respiratory and physical, blood work—assessment of the risk of bone marrow toxicity, psycho-oncology (acceptance with the patient and family), and finally, making sure all nurses, doctors, etc. stay involved in patient care post-surgery. As most of us know, getting or staying in shape and addressing the other physical, mental and emotional challenges that come along with a diagnosis of cancer are very important to the patient’s overall well-being; it was good to see the focus on how these factors affect recovery from surgery.
Overall, PSOGI 2018 was an incredible exchange of findings, ideas and debates. We were happy to support and participate in the conference and to help almost 30 clinicians attend it as well. Looking forward to PSOGI 2020 in Beijing, China!