Highly Specialised Services. Peritoneal Oncology Service. Report September 2015

Transcription

1 Highly Specialised Services Peritoneal Oncology Service Report September 2015 The Christie NHS Foundation Trust Wilmslow Road Withington Manchester M20 4BX

2 Contents Highly Specialised Services... 1 Introduction... 1 Staff... 3 Research and Education... 4 Patient and Public Engagement... 7 Activity... 8 Section 1: Referral Activity... 8 Section 2: Assessments and Treatment Quality Section 3: Length of stay, Op times and CC scores Section 4: Complications Section 5: Survival Appendices I Procedure Activity (Including Private Patients) Appendices II Outcomes Appendices III Outcomes by disease group Section IV ESSO Agenda... 26

3 Introduction Since its inception in 2002, the Peritoneal Oncology Service (POS) has grown from year to year. (p9 section 1 referrals Fig 1 and 2) More recently in we received 198 referrals (148 for appendiceal tumours and 50 for peritoneal metastases of colorectal origin (PMCR)). In this increased to 288 (186 appendix/ 102 PMCR); and from April 2015 we have received 169 referrals (112 Appendix/ 57 PMCR). Similarly the numbers of patients operated on have increased from 93 in to 145 in Since April 2015 we have already performed 78 procedures. In total, we have now performed 613 cytoreductions in appendiceal tumours and 151 such procedures in patients with PMCR (Fig 1, 2). We have prospectively monitored outcomes and have low mortality and complication rates alongside internationally comparable survival, details of which are outlined in this report. Due to the expansion of the service we have increased the workforce to support patient flow. Mr Omer Aziz was appointed in May 2014 as the 6 th consultant surgeon. His expertise in laparoscopic surgery has augmented the existing team and has allowed us to expand our minimal access service for peritoneal tumours. Mr Selvasekar and Mr Aziz have now performed 36 laparoscopic cytoreductions and HIPEC for patients with low volume, early stage disease which represents the largest cohort of patients worldwide undergoing this technique. Scott Brown and Margaret Butler joined us in July 2013 and July 2014 respectively as two additional Clinical Nurse Specialists to complement Rebecca Halstead s experience in this role. The 3 CNS s cover the entire unit s activities and provide a vital support mechanism to the patients. They are the organisational force behind the now weekly Multi-Disciplinary Team meetings and the patients investigations and clinic visits. In addition, Rebecca Halstead not only runs the telephone follow-up service but also performs her own Nurse-led telephone clinic for patients on watch and wait surveillance and for those who are post 5 years follow-up. Grant Punnett was appointed as the Unit s Data Manager in June 2013 and is responsible for the upkeep of the prospective database started in 2002 and organises the quarterly morbidity and mortality meetings. With regard to our perfusion service, we now have 4 trained perfusion practitioners who can all provide HIPEC independently with Rachel Aziz heading this group as the HIPEC service manager. We replaced our 2 older perfusion machines this year with 3 new Rand machines to ensure that we are using the most modern equipment adding to our training capabilities in this field. As recognition of the work of the unit in the area of PMCR, we were awarded Cancer Care Team of the Year by the British Medical Journal Group and MacMillan in May Our academic profile has been recognised with the appointment of Andrew Renehan as Professor of Cancer Studies and Surgery, University of Manchester in June 2013 and Sarah O Dwyer as Clinical Professor of Surgery, University of Manchester in July The report outlines the continued efforts of the team in exploring new approaches to evaluation of current and novel treatments (p4) In October 2015 we hosted the first UK course and Advanced Workshop on Peritoneal Surface Malignancy in conjunction with the European Society of Surgical Oncology (ESSO). The course attracted faculty from 10 countries and delegates from 17 countries as far as Canada and Australia. The content included Keynote addresses, lectures, a mock MDT, video based education and live operating sessions (appendix V). Our links with ESSO has inaugurated the unit as a recognised European training centre for Fellowships 1

4 in peritoneal malignancy: we currently have two registered fellows on this programme one from Greece and one from Jordan. We have recently finished redesigning and producing our website which sits within the Christie s site. This now contains up to date information for clinicians and patients. It contains a google map to assist the patient and their family with a virtual tour through the department and videos including examples of patient experiences of the service; a wide range of content is available at With regard to the future, we have recently submitted a business plan to accommodate the development of the peritoneal service in tune with NHS England commissioning for PMCR. This includes the appointment of a dedicated service manager, an additional CNS and Consultant Surgeon. Sarah O Dwyer continues to advise the Clinical Reference Group for Specialised Colorectal Services in regard to peritoneal malignancy. In 2013 she became Chair of the Peritoneal Surface Maligancy Sub Committee for The Association of Coloproctology of Great Britain and Ireland. The committee meets 2-3 times each year to achieve clinical consensus for the management of these conditions. Through this group the potential expansion of treatment centres for colorectal peritoneal metastases and Commissioning through evaluation for mesothelioma is being discussed. In his role of Clinical Lead for the Interventional Procedure Unit, Malcolm Wilson is leading the 7.6m development of day-case services in the trust. It is anticipated that this project will commence in February 2016 to be operational by April This will free up operating theatre and outpatient facilities to allow further expansion of the POS alongside other surgical activities in the Trust. Malcolm Wilson MD FRCS October

5 Staff Name Prof ST O Dwyer Mr MS Wilson Mr PE Fulford Prof AG Renehan Mr CR Selvasekar Mr O Aziz Mr R Deshpande Dr MP Saunders Dr R Kochhar Dr V Kasipandian Dr B Chakrabarty Rebecca Halstead Margaret Butler Scott Brown Rachel Aziz Nancy Flynn-Chadwick Andy Colclough Rachelle Wood Grant Punnett Rosanne Meronti Job Title Consultant Surgeon/Lead Clinician Consultant Surgeon Consultant Surgeon Professor in Cancer Studies and Surgery, Honorary Consultant Consultant Surgeon Consultant Surgeon Consultant Hepatobiliary Surgeon Consultant Oncologist Lead Consultant Radiologist Lead Consultant Anaesthetist Lead Consultant Histopathologist Clinical Nurse Specialist Clinical Nurse Specialist Clinical Nurse Specialist HIPEC Service Manager HIPEC Perfusionist HIPEC Perfusionist HIPEC Perfusionist Data Manager MDT Co-ordinator 3

6 Research and Education The research activities continue along two broad work streams: clinical studies and trials; and basic science research. In 2014/2015, from our prospective clinical databases, we presented data in five abstracts at the Peritoneal Surface Oncology Group International (PSOGI), Amsterdam, October 2014; and two abstracts at the Digestive Disease Federation Conference, London, June We led on two publications during this period one as a letter in the Journal of Clinical Oncology on the evolution of treatment of peritoneal tumour treatment (lead: Professor O Dwyer) (1); and one as a first paper on the use of laparoscopic cytoreductive surgery in the setting of risk reducing treatment in very early appendiceal mucinous tumours (lead: Mr Selvasekar) (2). Importantly, during this period, we were awarded funding from the Bowel Disease Research Foundation to fund a prospective project titled Development of an IDEAL framework to standardise the complex intervention of cytoreductive surgery for colorectal peritoneal metastases: a necessary step to phase III trials (lead: Professor Renehan). This is a combined project with the Basingstoke Peritoneal Malignancy Institute, which will start in January In 2014, we finished a decade long collaboration in Pseudomyxoma Peritonei (PMP) basic science research with the retirement of Professor Peter Stern at the Cancer Research UK Manchester Institute, CRUK MI (on the Christie campus). At its completion, we published a first in the world paper on the immortalisation of PMP cell lines (3). We are now establishing a new collaboration with Dr John Brognard, in CRUK MI, taking forward this work with laboratory studies on gene expression and their mechanisms in PMP, using the novel PMP cell lines (lead: Professor Renehan). Involvement in two international research activities is noteworthy. 1), Manchester is part of a European Horizon (H2020) programme grant application, known as Cure4PM: lead Professor Renehan. 2), Manchester is part of the International Rare Cancer Initiative (IRCI) in peritoneal malignancies (leads Professor Renehan, Dr Saunders). From an educational perspective the team has been active internationally In 2013 we were central to the First INDO-UK Oncology Summit in Chennai, India. Lectures and workshops were run by the POS team in conjunction with The Christie School of Oncology. In 2014 Mr Selvasekar co-ordinated a two day programme specifically dealing with POS which included a joint MDT by teleconference with the Chennai team and a demonstration operating session transmitted live to the auditorium in Chennai. The team have given a number of lectures and presentations and hosted visiting surgeons and trainees from India, Egypt, Germany and Jordan Publications : References 1. O'Dwyer S, Verwaal VJ, Sugarbaker PH. Evolution of Treatments for Peritoneal Metastases From Colorectal Cancer. J Clin Oncol 2015;33(18): Fish R, Selvasekar C, Crichton P, Wilson M, Fulford P, Renehan A, et al. Risk-reducing laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for low-grade appendiceal mucinous neoplasm: early outcomes and technique. Surg Endosc 2014;28(1):

7 3. Roberts DL, O'Dwyer ST, Stern PL, Renehan AG. Global gene expression in pseudomyxoma peritonei, with parallel development of two immortalized cell lines. Oncotarget 2015;6(13): Appendiceal Goblet Cell Carcinoids: Management Considerations from a Reference Peritoneal Tumour Service Centre and ENETS Centre of Excellence Neuroendocrinology Oct 2015 (DOI: / ) Posters Minimal Access Cytoreductive Surgery and Hyperthermic intraperitoneal chemotherapy for at risk low-grade appendiceal mucinous neoplasms: 3 year experience. Peritoneal Oncology Surface Malignancies Summit: 9-11 October 2014 Elective 2-stage cytoreduction and hyperthermic intraperitoneal chemotherapy in selected patients with widespread, high volume pseudomyxoma peritonei. Peritoneal Oncology Surface Malignancies Summit: 9-11 October 2014 Clinico-pathological classification of mucinous neoplasms of appendiceal origin combining primary lesion and disseminated features. Peritoneal Oncology Surface Malignancies Summit: 9-11 October 2014 Dysregulated Wnt and Notch Pathways at Gene and Protein Levels in Pseudomyxoma Peritonei. Peritoneal Oncology Surface Malignancies Summit: 9-11 October 2014 Presentations North Manchester Hospital FRCS course, January 2013 HIPEC and how it works INDO-UK Oncology Summit, Chennai, Sept 2013 Cytoreduction and HIPEC Postoperative management and complications How to publish a research paper Improving outcomes in peritoneal metastases from colon cancer Peritoneal Oncology Surface Malignancies Summit, Amsterdam, October 2014 Clinico-Pathologic Study of Goblet Cell Carcinoid of the Appendix and outcomes following Cytoreductive surgery and Hyperthermic Intra-peritoneal Chemotherapy. International Guidelines for management of peritoneal surface malignancy Peritoneal Disease Chennai, India, November 2014 Primary peritoneal cancer live operating The role of the CNS in a peritoneal service The Peritoneal Service MDT Setting up a peritoneal Service 5

8 International Guidelines for peritoneal malignancy Peritoneal Disease Workshop Basingstoke, December 2014 Peritoneal Metastases in colorectal cancer European developments in Peritoneal Maligancy Surgical management of appendiceal carcinoid tumours MAHSC Conference Manchester January 2015 Telephone follow up for a national peritoneal service Nottingham Cancer Network, August 2015 Peritoneal Metastases in colorectal cancer. Chemotherapy in the management of PMP ESSO Advanced Course in Peritoneal Malignancy, Manchester October, 2015 Nutrition and enhanced recovery in PSM Standardised recording of mortality and morbidity Surgical techniques : RUQ, MAS Presentation and outcomes of appendiceal neoplasia 6

9 Patient and Public Engagement A patient survivorship group has been generated following requests from patients and their families. In December 2015 the first formal meeting will take place supported by the Clinical Nurse Specialists Rebecca Halstead and Margaret Butler. This will be aimed at patients within the Peritoneal Tumour Service and will allow opportunities to meet one another/support each other, ask the team questions and engage with the complimentary therapies team. The expectation is to have an annual Afternoon Tea and meeting with an agenda led by the patients themselves. Over the last 18 months there have been a number of events hosted by patients and their families including, coffee mornings, a bake off and a vintage tea party. Whilst these events raise money donated to the PMP research and patient support fund they also allow fellowship, support and camaraderie. The redesign of the Web site was centred around improving access for patient and families to a virtual tour of the facilities that they are likely to come across through their patient journey. We have included video vignettes of patient experiences to help demystify the treatments of these rare conditions. We will be undertaking a service user experience survey in 2016 which will include patients/families/ supporters and professionals to identify areas for improvements 7

10 Activity Section 1: Referral Activity Specialist Commissioning (Appendix) Referrals Q30 - NORTH EAST Q31 - NORTH WEST Q32 - YORKSHIRE & THE HUMBER Q33 - EAST MIDLANDS Q34 - WEST MIDLANDS Q35 - EAST OF ENGLAND Q36 - LONDON Q37 - SOUTH EAST COAST Q38 - SOUTH CENTRAL Q39 - SOUTH WEST ENGLAND - NOT KNOWN W01 - WALES NORTHERN IRELAND SCOTLAND OTHER GB OTHER TOTAL PMCR Referrals Q30 - NORTH EAST Q31 - NORTH WEST Q32 - YORKSHIRE & THE HUMBER Q33 - EAST MIDLANDS Q34 - WEST MIDLANDS Q35 - EAST OF ENGLAND Q36 - LONDON Q37 - SOUTH EAST COAST Q38 - SOUTH CENTRAL Q39 - SOUTH WEST ENGLAND - NOT KNOWN W01 - WALES NORTHERN IRELAND SCOTLAND OTHER GB OTHER TOTAL

11 UK distribution of Specialist Commissioning (Appendix) Referrals UK distribution of PMCR referrals 9

12 Specialist Commissioning (Appendix) Demographics Age Median - Male: Median - Female: Range: N = Gender Male Female Total PMCR Demographics Age Median - Male: Median - Female: Range: N = Gender Male Female Total

13 Section 2: Assessments and Treatment Figure 1: Appendix tumours Cases and Operations Source data in Appendices I Figure 2: PMCR - Cases and Operations Source data in Appendices I 11

14 Specialist Commissioning (Appendix) Assessment/Follow Up Activity (Q1 & Q2) First Assessment IP First Assessment OP Re Assessment IP Re Assessment OP Follow Ups Telephone Follow Ups Chemo Appointments Total PMCR Assessment/Follow Up Activity (Q1 & Q2) First Assessment IP First Assessment OP Re Assessment IP Re Assessment OP Follow Ups Chemo Appointments Total

15 Quality Section 3: Length of stay, Op times and CC scores. Operation times Cytoreduction Major Debulk Median Op Time Range Op Time Median Op Time Range Op Time (Q1 & Q2) Hospital Stay Level 2 CCU Stay Level 2 Level 2 Level 2 Level 2 Total CCU Total CCU Total CCU Total CCU Stay Stay Stay Stay Stay Stay Stay Stay Total Stay (Q1 & Q2) Level 2 CCU Total Stay Stay Median Range

16 CC Scores All cases Source data in Appendices II CC Scores Appendix tumours Source data in Appendices III CC Scores PMCR Source data in Appendices III 14

17 Section 4: Complications Complications Unit Overview (to April 2015, n = 726) n % No Complications Minor Complications (NCI grade 1-2) Major Complications (NCI grade 3-4) Peri-Operative (30 Day) Mortality Complications Appendix Pathologies Overview (to April 2015, n = 562) n % No Complications Minor Complications (NCI grade 1-2) Major Complications (NCI grade 3-4) Peri-Operative (30 Day) Mortality Complications PMCR Overview (to April 2015, n = 125) n % No Complications Minor Complications (NCI grade 1-2) Major Complications (NCI grade 3-4) Peri-Operative (30 Day) Mortality

18 Complication rates for past 5 years Minor Complications* Major Complications** Peri-Operative (30 Day) Mortality Cases n % n % n % Total * Defined as Grade 1 or 2 NCI Common Terminology Criteria for Adverse Events (v4.0) ** Defined as Grade 3 or 4 NCI Common Terminology Criteria for Adverse Events (v4.0) Laparoscopic Cytoreduction & HIPEC - overview Cases Median Hospital Stay Median CCU Stay Median PCI Score PCI Range Median Op Time (Q1 & Q2) Total Laparoscopic Cytoreduction & HIPEC Complications n % No Complications Minor Complications (NCI grade 1-2) Major Complications (NCI grade 3-4) Peri Operative (30 Day) Death

19 0 Survival (%) Survival (%) Service Report September 2015 Section 5: Survival PMP Survival - Cytoreduction Vs Debulk Cytoreduction +/- HIPEC Debulking Procedure Time (Months) Number at risk Cytoreduction +/- HIPEC Debulking Procedure Appendix Ca - Cytoreduction Vs Debulk Cytoreduction +/- HIPEC Debulking Procedure Number at risk Cytoreduction +/- HIPEC Debulking Procedure Time (Months)

20 0 Survival (%) Service Report September 2015 PMCR Survival - Cytoreduction Vs Debulk Cytoreduction +/- HIPEC Debulking Procedure Time (Months) Number at risk Cytoreduction +/- HIPEC Debulking Procedure

21 Appendices I Procedure Activity (Including Private Patients) All Procedure Activity by year Major Debulk Cytoreduction Total (Q1 & Q2) Total Appendix Procedure Activity by year Undergone Cyto/Debulk Confirmed Cases (6 months) Total

22 PMCR Procedure Activity by year Undergone Cyto/Debulks Confirmed Cases (6 months) Total

23 Appendices II Outcomes All n % Patients 1759 Undergone Cyto/Debulk Cytoreduction & HIPEC Debulking Procedure Total Procedures 804 PCI Median 12 PCI Range 0-39 CC0 Count CC1 Count CC2 Count CC3 Count CC Score Missing

24 Appendices III Outcomes by disease group PMP n % Patients 584 Undergone Cyto/Debulk Cytoreduction & HIPEC Debulking Procedure Total Procedures 384 PCI Median 20 PCI Range 0-39 CC0 Count CC1 Count CC2 Count CC3 Count CC Score Missing PMCR n % Patients 374 Undergone Cyto/Debulk Cytoreduction & HIPEC Debulking Procedure Total Procedures 151 PCI Median 8 PCI Range 0-39 CC0 Count CC1 Count CC2 Count CC3 Count CC Score Missing

25 LAMN 2 n % Patients 129 Undergone Cyto/Debulk Cytoreduction & HIPEC Debulking Procedure Total Procedures 63 PCI Median 0 PCI Range 0-15 CC0 Count CC1 Count CC2 Count CC3 Count CC Score Missing Appendix Adenocarcinoma (incl MCP - High n % Grade) Patients 224 Undergone Cyto/Debulk Cytoreduction & HIPEC Debulking Procedure Total Procedures 125 PCI Median 9 PCI Range 0-39 CC0 Count CC1 Count CC2 Count 10 8 CC3 Count CC Score Missing

26 LAMN 1 n % Patients 93 Undergone Cyto/Debulk Cytoreduction & HIPEC 4 80 Debulking Procedure 0 20 Total Procedures 4 PCI Median 20 PCI Range Mar-16 CC0 Count CC1 Count 0 0 CC2 Count 0 0 CC3 Count 0 0 CC Score Missing 0 0 Adenocarcinoma ex Goblet Cell Carcinoid n % Patients 33 Undergone Cyto/Debulk Cytoreduction & HIPEC Debulking Procedure 1 5 Total Procedures 20 PCI Median 6 PCI Range 0-26 CC0 Count CC1 Count 2 10 CC2 Count 3 15 CC3 Count 1 5 CC Score Missing

27 Goblet Cell Carcinoid n % Patients 32 Undergone Cyto/Debulk Cytoreduction & HIPEC Debulking Procedure Total Procedures 17 PCI Median 1 PCI Range 0-9 CC0 Count CC1 Count 0 0 CC2 Count 0 0 CC3 Count 0 0 CC Score Missing Others n % Patients 278 Undergone Cyto/Debulk Cytoreduction & HIPEC Debulking Procedure Total Procedures 40 PCI Median 11 PCI Range 0-39 CC0 Count CC1 Count CC2 Count CC3 Count 6 15 CC Score Missing

28 Section IV ESSO Agenda Programme Peritoneal_Manchester final WORD - rb.pdf 27