Advancing Treatment Outcomes for Peritoneal Surface Malignancies in Low- and Middle-Income Countries: Insights from the First Multicenter Study in North Africa

Our plain-English summary of Advancing Treatment Outcomes for Peritoneal Surface Malignancies in Low- and Middle-Income Countries: Insights from the First Multicenter Study in North Africa, by A. Souadka, H. Habbat, A. Makni, et al (Cancers, 2025).

The study

• Authors: A. Souadka, H. Habbat, A. Makni, M. Abid, Z. El Mouatassim, A. Daghfous, Z. Korjani, W. Rebai, M. Ayadi, W.H. Messai, M.A. Majbar, A. Benkabbou, R. Mohsine, A. Souadka
• Journal: Cancers
• Published: 2025;17(13)
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Peritoneal surface malignancies (PSM) are aggressive cancers with limited treatment access in low- and middle-income countries (LMICs). While cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have improved survival outcomes globally, their feasibility in LMICs remains underexplored. This first multicenter study in North Africa evaluates the implementation and outcomes of CRS with or without HIPEC in resource-limited settings. Methods: A retrospective cohort study of 391 patients with PSM (colorectal cancer, pseudomyxoma peritonei, ovarian cancer, gastric cancer, or mesothelioma) treated with CRS ± HIPEC between 2014 and 2020 at four tertiary centers in Morocco, Tunisia, and Algeria. Primary outcomes included overall survival (OS), disease-free survival (DFS), and severe postoperative morbidity (Clavien-Dindo ≥ IIIa). Cox regression was used to identify independent prognostic factors. Results: Among 391 patients, complete cytoreduction (CC-0/1) was achieved in 88%, and HIPEC was performed in 39%. Severe morbidity occurred in 22%, with HIPEC, spleno-pancreatectomy, and incomplete cytoreduction (CC-2) identified as significant risk factors. The median OS was 68 months, with 1- and 5-year survival rates of 97% and 56%, respectively. Patients undergoing CRS + HIPEC had significantly longer OS than CRS alone (70 vs. 64 months, p = 0.016), though DFS was not significantly different between groups. Independent predictors of improved OS included HIPEC, CC score, PCI, and primary tumor type. Conclusions: This first North African multicenter study establishes the feasibility and efficacy of CRS and HIPEC in LMICs, achieving survival outcomes comparable to high-income settings. The findings support expanding advanced PSM treatment programs in resource-limited settings, emphasizing structured training and multidisciplinary collaboration to improve access and outcomes.

In plain English

This retrospective cohort study reviewed 391 patients treated between January 2014 and December 2020 at centers in Rabat (Morocco), Tunis (Tunisia) and Batna (Algeria) for peritoneal surface malignancies, which are cancers that arise in or spread to the lining of the abdomen. All patients had cytoreductive surgery, and 39% also received heated chemotherapy circulated through the abdomen (HIPEC). Most had colorectal cancer (168) or pseudomyxoma peritonei (144). Only 7 had mesothelioma, and 2 of them died during follow-up. The article does not discuss asbestos. In 88% of patients, surgeons left no visible disease or only nodules smaller than 2.5 mm. Severe complications occurred in 22.3% (87 patients), and 5.6% (22) died after surgery. Median overall survival was 68 months, and 56% of patients were alive at 5 years. Patients who received HIPEC had a median survival of 70 months, compared with 64 months for surgery alone. HIPEC was not significantly linked to disease-free survival, and it was linked to more severe complications. The authors concluded that the treatment is feasible and effective in low- and middle-income countries. They noted that the retrospective design is subject to selection bias.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective multicenter cohort study of surgical treatment outcomes
• Who was studied: 391 patients with peritoneal surface malignancies, which the article describes as tumors arising in the peritoneum (such as peritoneal mesothelioma) or spreading there from other cancers. They were selected from 954 patients presented at multidisciplinary meetings and treated January 2014 to December 2020 in Rabat, Morocco (186), Batna, Algeria (105) and Tunis, Tunisia (100). Primary tumors: colorectal cancer 168, pseudomyxoma peritonei 144, ovarian cancer 47, gastric cancer 25, mesothelioma 7
• Exposure: Not an asbestos exposure study. The 'exposure' compared was treatment: cytoreductive surgery with or without HIPEC (oxaliplatin-based for most tumor types, cisplatin-based for ovarian cancer). Asbestos and fiber types are not mentioned.
• Main results:
  • Among all 391 patients, complete cytoreduction (CC-0/1) was achieved in 88% and HIPEC was performed in 39%
  • Complications occurred in 42.2% (165 patients), severe complications in 22.3% (87), and the mortality rate was 5.6% (22)
  • Independent predictors of severe complications: ASA score 2 or more (OR 2.228, 95% CI 1.309–3.793), spleno-pancreatectomy (OR 3.803, 95% CI 1.765–8.197), incomplete cytoreduction CC-2 (OR 3.830, 95% CI 1.765–8.297) and HIPEC (OR 2.364, 95% CI 1.369–4.080)
  • For the whole cohort, median overall survival was 68 months, and 1-, 5- and 7-year survival rates were 97%, 56% and 37%
  • Median overall survival was 70 months with CRS plus HIPEC vs 64 months with CRS alone (p = 0.016). In multivariate analysis, HIPEC was associated with a survival benefit (HR 0.649, p = 0.037)
  • HIPEC did not significantly affect disease-free survival. Median disease-free survival for the cohort was 48 months
  • In multivariate analysis of overall survival, compared with colorectal cancer, gastric cancer was associated with worse survival (HR 4.738) and pseudomyxoma peritonei with better survival (HR 0.283). PCI 1–6 was linked to better survival (HR 0.225), and incomplete cytoreduction CC-2 to worse survival (HR 3.235)
  • Of the 7 mesothelioma patients, 2 died (overall survival events) and 3 had recurrence or death (disease-free survival events). They received no systemic neoadjuvant therapy
• The authors' conclusion: The authors concluded that CRS and HIPEC are feasible and effective in low- and middle-income countries, with survival outcomes comparable to high-income settings. They also concluded that HIPEC's impact on disease-free survival varied by tumor type.
• Limitations the authors state:
  • The retrospective design is subject to selection bias and to variability in data collection across centers
  • Differences in HIPEC protocols, patient selection criteria and access to adjuvant therapy may have influenced survival
  • No long-term quality-of-life data

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Cohort Study, Colorectal Cancer, Ovarian Cancer, Stomach Cancer, Mesothelioma, Overall Survival.

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• Feasibility and outcomes of cytoreductive surgery and HIPEC for peritoneal surface malignancies in low- and middle-income countries: a single-center experience of 232 cases — S. Deo, M. Ray, et al. (2021)
• Building an Efficient Peritoneal Surface Malignancies Program Despite the Lower-Middle-Income Barriers: Ukraine Experience — V. Kopetskyi, M. Antoniv, et al. (2024)
• An Approach to Overcome the Limitations of Surveillance of Asbestos Related Diseases in Low- and Middle-Income Countries: What We Learned from the Sibaté Study in Colombia — J.P. Ramos-Bonilla, M. Giraldo, et al. (2023)
• Postoperative outcomes of laparoscopic vs open cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of peritoneal surface malignancies — G. Passot, N. Bakrin, et al. (2014)
• Dose-Dependent Effect of Red Blood Cells Transfusion on Perioperative and Long-Term Outcomes in Peritoneal Surface Malignancies Treated with Cytoreduction and HIPEC — E. Nizri, S. Kusamura, et al. (2018)
• Analysis of Treatment Strategies and Outcomes in Malignant Peritoneal Mesothelioma: Insights From a Multi-Center Study — S. Yaşar, F. Yılmaz, et al. (2024)

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