The Clinical And Basic Reaserch Of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) On Gastric Cancer With Malignant Ascites

Part one:The clinical research about hyperthermic intraperitoneal chemotherapy (HIPEC) on gastric cancer with malignant ascites.Objective:1. To explore the impact of HIPEC in patients with respiratory, circulatory and other physiological functions with the BR-TRG-I type body cavity perfusion treatment system.2. To investigate the measurement, feasibility and clinic effect of laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of gastric cancer with malignant ascites from peritoneal carcinomatosis.3. To investigate the measurement, feasibility and clinic effect of B ultrasound guided hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of malignant ascites from peritoneal carcinomatosis.Materials and Methods:1. Clinical data:25patients with malignant tumors in our hospital, all patients were diagnosed by pathological examination confirmed serious cardiovascular and cerebrovascular diseases and bleeding tendency.7cases of gastric cancer resection, palliative resection in4cases, radical resection of colorectal cancer5cases, palliative resection in2cases, ovarian cancer in complete cytoreductive surgery for five cases, incomplete cytoreductive surgery two cases.2. HIPEC methods:5-Fu1500mg and saline3000-5000ml to join the special bag for HIPEC, and add volume normal saline to the abdominal cavity filled with perfusion fluid. Switched on the equipment, set the intraperitoneal hyperthermic perfusion chemotherapy in the treatment temperature43℃, with the treatment time of60min, infusion rate of500ml/min. Solution naturally leads out after the HIPEC. Monitoring the temperature in the inlet, outlet of the HIPEC Pipeline and the body surface, rectum, and tympanic on the patients at each time point of HIPEC0min,15min,30min,45min,60min. Monitoring the blood pressure, heart rate, vital signs such as respiration, oxygen saturation on each corresponding time, analysis the impact of43℃temperature HIPEC treatment to the patients with body surface, rectal, tympanic membrane temperature and vital signs.3. The clinical data of the laparoscopic-assisted HIPEC group:Of the18patients in this study, there were7men and9women. There were9primary cases of gastric cancer and9cases of postoperative gastric cancer, which were diagnosed by laparotomy, gastric fiberoptic endoscopy, serum tumor markers (CEA and CA199) and ascite cytology. Ultrasonic B and laparoscopic examinations displayed4000-9000mL seroperitoneum in all the patients.12patients had no apparent palliation was found after repeated abdominal puncture drainage,12patients had numerous free cancer cells within the ascites,2cases presented obvious bloody ascites, and1case presented chyle-like ascites.4. Laparoscopic-assisted HIPEC technique and methods:After endotracheal anesthesia, a transverse cut (10mm long) was performed at the belly,5mm below the umbilicus. The seroperitoneum was extracted as completely as possible; artificial pneumoperitoneum was established via an open procedure with a pressure of13mmHg (1mmHg=0.133kPa); a10-mm Trocar was inserted into the abdominal cavity via the working port. Thereafter, the laparoscope (10mm and30°) was inserted via the10mm Trocar to examine the abdominal viscera and tumors. The site, size and clinical stages of tumors were examined laparoscopically. Patients with peritoneal diffusive seeding and unresectable tumors were advised to receive laparoscope assisted HIPEC. In the process of laparoscope-assisted HIPEC, three new ports were prepared under the guidance of a laparoscope. On the right side, the second and third ports (both10mm long) were prepared at the cross-point of the midclavicular line and transverse surfaces, with two finger spaces above and below the umbilicus, respectively. On the left side, the fourth port (10mm long) was prepared at the cross-point of the mid-clavicular line and transverse surface, with two finger spaces below the umbilicus. Thereafter, under the guidance of laparoscope. a10mm Trocar was inserted into the abdominal cavity via the working port. Two perfusion catheters were placed in the right superior abdominal cavity via the third and fourth working ports, respectively. One drainage catheter was placed in the Douglas’ cavity of the lowest place in the pelvic cavity via the second working port. Then, the laparoscope was placed in the inferior abdomen and the Trocar was inserted. Subsequently, the laparoscope was pulled out, and the perfusion catheter was placed in the Douglas’ cavity of the lowest place in the pelvic cavity under the guidance of the Trocar.5. Clinical data of the B ultrasound-guided group:18cases of patients with abdominal malignancy (1case of gastric,4cases of diffuse gastric cancer postoperative peritoneal metastasis,1case of ovarian cancer,4patients ovarian cancer after surgery,1cases of colon cancer,4cases of colon cancer peritoneal diffuse metastasis,1case of the pancreascarcinoma,1case of hepatocellular carcinoma after liver transplantation in peritoneal metastasis, and1case of gastrointestinal stromal tumor after surgery). Diagnosis of the primary disease by laparotomy, imaging, fiber endoscopy. serum tumor markers checked. All patients have a large number of malignant ascites inspected with imaging studies. B-ultrasound assessment the amount of ascites was3500-9000ml.6. B ultrasound-guided HIPEC technique and methods:The basis intravenous anesthesia was given for the supine patient, B-ultrasonic examination to determine the amount of ascites. conventional prepped and draped, B-ultrasound guided in the left upper quadrant, right upper quadrant, left lower quadrant, right lower abdomen to check, select the ascites deep enough abdominal wall as the puncture point, and avoid the original abdominal incision site. Left lower quadrant, right lower quadrant puncture point placed on the perfusion tube to the orientation of the left upper quadrant, right upper quadrant; the left upper quadrant, right upper quadrant puncture point to place the drainage tube to the orientation to the left lower quadrant, right lower quadrant. At the puncture site for a1-cm transverse incision after0.5%lidocaine local anesthesia,1cm in diameter laparoscopic Trocar puncture into the abdominal cavity, adjust the angle of the Trocar into the abdominal cavity when seen the ascites outflow, the perfusion tube (0.8cm in inner diameter, outer diameter1.0cm, length120cm) were placed to the left upper quadrant, right upper quadrant with the guide of Trocar, the drainage tube put to the left lower quadrant, right lower quadrant, into the length about40-80cm. If the ascites was not enough, we can take the advantage of the position to accumulate the ascites in the left lower quadrant options, after poured into the appropriate amount of saline to the abdominal cavity after abdominal bulge, and then select the other puncture sites for catheter insertion.Results:1. HIPEC process in patients with body surface, rectal, tympanic temperature and vital signs monitoring values such as shown in Table1. The axillary, tympanic membrane, rectal average temperature of the patients rise0.9℃,0.7℃,0.9℃Before and after HIPEC, which showed that the treatment temperature of43℃for60min,500ml/min infusion rate HIPEC, can cause patients body temperature slightly elevated, but were within the normal range; The blood pressure, heart rate, respiration, blood oxygen saturation values were within the normal range before and during the treatment, which suggests that this therapy had no significant effect to the patient blood pressure, heart rate, respiratory, oxygen saturation and other vital signs.2. The laparoscopic-assisted HIPEC group:After the first laparoscopeassisted HIPEC, the daily amount of ascite outflow was100-300ml. After the first day, ascite outflow gradually decreased. A week later, daily outflow was5-30ml. During the period from two weeks after laparoscope-assisted HIPEC to the end of follow-up, clinical CR of ascites and related symptoms were achieved in15of the18treated patients (83.3%), and PR was achieved in3patients (16.7%). Thus the objective remission rate (ORR=CR+PR) was100%. The Karnofsky mark indicating patient quality of life was60-90, which was increased significantly in comparison with before laparoscope-assisted HIPEC (P<0.01). The general status of patients improved after the third laparoscope-assisted HIPEC. Mental status, appetite and body weight improved, and symptoms of anemia were obviously alleviated. Thus, satisfactory initial clinical efficacy has been achieved in these patients treated by laparoscope-assisted HIPEC.3. The B ultrasound-guided group:The operations of18patients were carried out smoothly, B ultrasound-guided placement of perfusion and drainage tube an average of20to45min, the average discharge pipe for35min. Patients with ascites after the first HIPEC on the next day ascites releas was generally100to300ml, then gradually declined, a week later ascites leads to generally5to30ml/d. After the review of18cases in two weeks to the end of follow-up, the CR in17cases (94.4%); the PR in1case (5.6%), the total efficiency of100%(CR+PR18cases). HIPEC treatment in patients with KPS score increased by10to30percent, the median rose20percent, general status, mental status improved, to improve appetite, weight gain, anemia and symptom relief, short-term clinical results were satisfactory.Part two:The basic research of hyperthermic intraperitoneal chemotherapy (HIPEC) on gastric cancer with malignant ascites.Objectives:1. To investigate the expression changes of microRNA (miRNA) in the blood of advanced gastric cancer before and after HIPEC, establish the distinctive circulating miRNA spectrum related to gastric cancer with the treatment of HIPEC.Materials and Methods:1. This study had collected five advanced gastric cancer patients’ serum and ascite before and after HIPEC from January2010to December2011. All patients were confirmed by pathology and the clinical stages were all stage Ⅳ. The blood samples were drawn with empty stomach and then centrifugated. Plasma was aspirated and then frozened under-80℃condition.2ml plasma’s RNA from each group was extracted by mirVana PARIS kit. After the saturation evaluation and the quality control, the total RNA of each group was examined by Exiqon MicroRNA low density assay respectively. The result was analyzed by SDS2.3software.Results:1. Two hundred and seventy miRNAs were detected in the two groups before and after HIPEC totally. According to the judgment standard analysis,169miRNAs were upregulated including19miRNAs upregulated more than3times such as hsa-miR-218-2-3p, hsa-miR-135a-5p, hsa-miR-377-5p, hsa-miR-409-3p and hsa-miR-4326.101miRNAs were downregulted including14miRNAs downregulated significantly such as hsa-let-7a-5p, hsa-let-7b-5p, hsa-let-7c and hsa-miR-96-5p.Conclusions:Conclusions of part one:1. Treatment temperature of43℃for60min,500ml/min infusion rate of HIPEC with the BR-TRG-I type body cavity perfusion treatment system, had no significant effect to the patient blood pressure, heart rate, respiratory, oxygen saturation and other vital signs, clinical application is safety and feasible.2. Laparoscope-assisted HIPEC could explore the tumor in the abdominal cavity with the help of laparoscope, which can fully apply the advantages of minimally invasive surgical techniques, confirmed and then given HIPEC for patients whose cancer cell extensive peritoneal metastasis, is not suitable for tumor resection. HIPEC is a safe and easy and effective treatment for clinical non-resected gastric cancer patients with refractory ascites, with good prospects for clinical application.3. B ultrasound-guided HIPEC has non-invasive, and the advantages of specific diagnosis for malignant ascites, with less trauma, less pain, and postoperative recovery faster, more effective, low-cost advantages, etc. It has good prospects for clinical application.Conclusions of part two:1. Patients with gastric cancer given the therapy of HIPEC can cause the upregulation and downregulation of multiple miRNAs, which implied the dysfunction of miRNA might lead to the abnormal expression targeted gene and played an important role betweeen gastric cancer and HIPEC. Further study of these abnormal expression of miRNA is expected to find the target genes and of the regulation of gastric cancer signals transduction pathways; miRNA microarray technology is an effective high-throughput detection methods.