Moving Fast and Moving Slow

The Ninth International Symposium on Regional Therapies at Steamboat Springs, Colorado brought forth some of the finest research occurring in the management of advanced malignancies. We are pleased to present some of this work in the Annals of Surgical Oncology. Although it is difficult to do justice to the perseverance of the teams, the investigation of the scientists, and the sacrifices of our patients in a few pages, we hope to provide you with a snapshot of a rapidly changing field. Delivering cytotoxic therapy in a proinflammatory healing state after an operation requires the development of a precise framework— the hallmark of regional therapies. Advancement of care has required rapid intuitive thinking and development of surgical concepts that have allowed us to apply selective regional therapies to patients more widely than ever before. It is estimated that more than 1,300 cytoreductive procedures and hyperthermic intraperitoneal chemotherapy (HIPEC) procedures were performed in the United States in 2012, and the numbers are increasing. The rapid pace of these advances has brought with it careful investigation of the aspects of care, focusing on oncological outcomes, safety, and patient-centered metrics. These developments have been associated with the growth of new centers both locally and internationally, thereby improving access to care. The articles from the Symposium explore the application of aggressive surgical resection in the setting of chemoperfusion. Randle et al. studied 108 patients from a prospective database of 1,067 patients who underwent hepatic resection concomitantly with cytoreductive surgery (CRS) and HIPEC. After establishing two groups—one with patients who underwent surface resection alone versus the other in which the patients were subjected to parenchymal resection—they found that the perioperative morbidity and mortality rates were similar. The overall survival for the group with colorectal cancer and peritoneal and hepatic metastases was 21.2 months. In a separate analysis, the authors examined 89 patients with diaphragmatic involvement who underwent CRS and HIPEC. In contrast to their previous report, the authors found that morbidity associated with the surgery was seen at a significantly higher rate among those undergoing diaphragmatic resection, especially in patients who required resection of fewer than five organs. Distribution of peritoneal disease often leads to involvement of the splenic hilum, necessitating distal pancreatectomy. Doud et al. reported on 63 patients who underwent distal pancreatectomy with a 30 % major morbidity rate and a significantly longer hospital stay than those that did not. Further adding to the evidence regarding the risks of a distal pancreatectomy, Downs-Canner et al. compared patients undergoing distal pancreatectomy with and without intraperitoneal chemotherapy. They found that although the number of patients developing pancreatic fistulas was similar the morbidity associated with the fistulas was greater. In addition, the development of complications came at an oncological cost. Patients with fistulas had earlier recurrence of their disease. Nunez et al. looked at another surgical issue: whether abdominal wall resection and reconstruction carry a higher postoperative morbidity rate. Often, port-site excision or reexcision of the abdominal wall is necessary for oncological cytoreduction. The morbidity rate was 33 % in those undergoing port-site excisions, 21 % in those undergoing primary fascial closure, and 41 % in those undergoing reconstructive surgery. Society of Surgical Oncology 2015