Regional Cancer Therapies 2019: ACPMP Recap

The Appendix Cancer / Pseudomyxoma Peritonei Research Foundation (ACPMP) sponsored and participated in the 14th Annual International Symposium on Regional Cancer Therapies, presented by the Society of Surgical Oncology, which took place from February 16-18, 2019 at the Arizona Grand Resort in Phoenix, AZ. 

ACPMP expanded our investment in this exciting event by providing funding for three travel scholarships enabling young physicians to present their research. 

The event was planned and executed by the fantastic staff of the Society of Surgical Oncology and included nearly 200 participants, including many young physicians and researchers. 

During the event, ACPMP held the first in-person meeting of the ACPMP Medical Advisory Board, enabling us to thank Dr. Laura Lambert, Dr. Andrew Lowy, Dr. Armando Sardi and Dr. Kostas Votanopoulos for their long tenure and steadfast support and welcome new members Dr. Joseph Misdraji and Dr. Bradley Switzer.  We were also able to congratulate Dr. Lambert on recently being named Chair of the ACPMP MAB.

Karolyn Lewandowski, COO & General Counsel of ACPMP, presented an overview of ACPMP’s history and current programs at the Sunday evening session, which was followed by spirited dinner with our friends & colleagues from PMP Pals.

The presentations spanned across many different topics, including the following:

Genetic markers:  As part of the evolving 21st century field of precision medicine, there is increasing scientific and medical interest in the study of genetic markers.  This research is directed at discovering new therapies that may be more effective in patients with certain tumor mutations.  Notably, many tumor mutations, to date, are of unidentified significance.  There is a significant need for prospective molecular profiling and analysis of demographics and patient reported outcomes.   There is broader scientific recognition of the need for the study of genetic markers in appendiceal tumors specifically rather than aggregating more broadly with colorectal cancer.  Patient registries, clinical trials, and sample tissue repositories are recognized as important tools to further this research.

In addition to identifying new treatments, other research into genetic markers is being done to better understand the ability of certain mutations to better predict disease behavior.  There is now scientific recognition of the need for more prospective studies with uniformly classified tumors based on consensus guidelines.  The outcomes from these types of studies may, in turn, drive selected treatments for patients.  For example, if a patient’s tumor histology is low grade, but it is behaving more akin to high grade, then genetic sequencing may be used to adjust the recommended treatment accordingly.

Imaging:  In addition to the clinical research and testing of new therapies to treat AC/PMP, there is also exciting companion research on the medical device side.  For example, one of the presenters summarized research of a peptide that penetrates tumor-specific tissue. The peptide targets blood vessels of the tumor.  This technology is being further explored with the objective of it being used to detect tumors in the body that may not otherwise be visible with conventional imaging or by the naked eye during surgery.  While studies have been limited, to date, to those in mice, this imaging technology has been found to be capable of detecting very small tumors.  If this technology is demonstrated to function this way in human studies, it may be adopted as an important novel tool to enhance surgical outcomes.

Evidence-Based Perioperative Practices:  These presentations focused on establishing evidence-based CRS/HIPEC operative practices (ie., perioperative practices) to facilitate improved patient outcomes by reducing risk of associated comorbidities.  There are current challenges with establishing consensus on such practices, particularly given the vast differences (i.e., heterogeneity) of the patient population.  For example, each individual patient varies with respect to his or her pre-operative performance status, disease histology, prior treatments and surgeries undergone, and tumor burden and location.  Examples of perioperative considerations for which there is a drive toward evidence-based practices include analgesia, fluid management, nutrition, tubes and drains).  The thinking is that establishing evidence-based perioperative practices will, in turn, help reduce the number of patients who need to be placed into intensive care for a period of time following CRS/HIPEC, facilitate IV fluid management, minimize the need for blood transfusions, and standardize increasing the flow rate of HIPEC as a means to maintain the target HIPEC temperature rather than decreasing the temperature (and potentially adversely impacting the effect of HIPEC) to mitigate cardiac risk. 

Predicting Ability to Achieve Complete Cytoreduction:  There were some presentations and lively debate about the utility of various imaging and other scoring to predict the surgical ability to achieve a complete cytoreduction.    There was considerable debate about the value of a patient’s PCI (peritoneal cancer index) in predicting a complete cytoreduction.  Some of the attendees opined that a PCI of 15 or greater is associated with greater odds of an incomplete cytoreduction.  On the other hand, there were many that vigorously pushed back on that point of view.  The latter camp argued that it is not so much the PCI score in the abstract, but rather more of a combination of several weighted factors, including histology, areas of disease, and the PCI.   All recognized the role that the level of disease burden on the small bowel/mesentery may play in the ability to achieve a complete cytoreduction.  In terms of the preferred imaging modality for pre-surgical assessment of the small bowel, some physicians favored perfusion MRI and others advocated exploratory laprascopy.

Pathology/Terminology: Some of the presentations focused on the ongoing lack of expertise among pathologists in assessing AC/PMP tumors.  The persistence of grey zones, including, for example, areas of increased atypia in otherwise predominantly low grade disease, were discussed.  As noted at other conferences in prior years, it is fairly typical for high-volume centers to downgrade the pathology from that initially reviewed at community hospitals or other less experienced institutions.   The current fairly high rate of discordance in pathology reporting between centers tends to result in both under-treatment in some cases and, in others over-treatment, depending on actual histology.

ACPMP was proud to once again support this exciting event, and we look forward to continuing our support in the future.