CRS/HIPEC with Major Organ Resection in Peritoneal Mesothelioma Does not Impact Major Complications or Overall Survival: A Retrospective Cohort Study of the US HIPEC Collaborative

Our plain-English summary of CRS/HIPEC with Major Organ Resection in Peritoneal Mesothelioma Does not Impact Major Complications or Overall Survival: A Retrospective Cohort Study of the US HIPEC Collaborative, by D. Roife, B.D. Powers, M.Y. Zaidi, et al (Annals of Surgical Oncology, 2020).

The study

• Authors: D. Roife, B.D. Powers, M.Y. Zaidi, C.A. Staley, J.M. Cloyd, A. Ahmed, T. Grotz, J. Leiting, K. Fournier, A.J. Lee, J. Veerapong, J.M. Baumgartner, C. Clarke, S.H. Patel, R.J. Hendrix, L. Lambert, D.E. Abbott, C. Pokrzywa, B. Lee, A. Blakely, J. Greer, F.M. Johnston, D. Laskowitz, S. Dessureault, S.P. Dineen
• Journal: Annals of Surgical Oncology
• Published: 2020;27(13):4996-5004
• Cited by: 13 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: CRS/HIPEC is thought to confer a survival advantage for patients with malignant peritoneal mesothelioma (MPM). However, the impact of nonperitoneal organ resection is not clearly defined. We evaluated the impact of major organ resection (MOR) on postoperative outcomes and overall survival (OS).

Patients And Methods: The US HIPEC collaborative database (2000-2017) was reviewed for MPM patients who underwent CRS/HIPEC. MOR was defined as total or partial resection of diaphragm, stomach, spleen, pancreas, small bowel, colon, rectum, kidney, ureter, bladder, and/or uterus. MOR was categorized as 0, 1, or 2+ organs.

Results: A total of 174 patients were identified. Median PCI was 16 (3-39). The distribution of patients with MOR-0, MOR-1, and MOR-2+ was 94, 45, and 35 patients, respectively. MOR-1 and MOR-2+ groups had a higher frequency of any complication compared with MOR-0 (57.8%, 74.3%, and 48.9%, respectively, p = 0.035), but Clavien 3/4 complications were similar. Median length of stay was slightly higher in the MOR-1 and MOR-2+ groups (10 and 11 days) compared with the MOR-0 cohort (9 days, p = 0.005). Incomplete cytoreduction, ASA class 4, and male gender were associated with increased mortality on unadjusted analysis; however, their impact on OS was attenuated on multivariable analysis. MOR was not associated with OS based on these data (MOR-1: HR 1.67, 95% CI 0.59-4.74; MOR-2+ : HR 0.77, 95% CI 0.22-2.69).

Conclusions: MOR was not associated with an increase in major complications or worse OS in patients undergoing CRS/HIPEC for MPM and should be considered, if necessary, to achieve complete cytoreduction for MPM patients.

In plain English

This retrospective cohort study examined 174 patients from the US HIPEC Collaborative database (12 centers) with peritoneal mesothelioma treated with cytoreductive surgery, with or without heated abdominal chemotherapy (CRS/HIPEC), in 2000–2017. In 94 patients no major organ was resected; 45 had total or partial resection of one organ, 35 of two or more. Any complication was more frequent with organ resection (48.9%, 57.8% and 74.3%, p = 0.035), but serious complications requiring intervention were not significantly different. Median hospital stay was 9, 10 and 11 days. Among 141 patients analyzed for survival, median overall survival was 130, 56 and 93 months, not a significant difference. After adjustment, organ resection was not associated with survival (one organ: HR 1.67, 95% CI 0.59–4.74; two or more: HR 0.77, 95% CI 0.22–2.69). Asbestos exposure was recorded as present in 7 patients and unknown in 78. Its unadjusted hazard ratio for death, 1.06 (0.76–1.49), was not significant. The authors concluded organ resection appears safe and should be considered when needed for complete cytoreduction. They noted that with only 39 deaths the study may have been underpowered.

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 cohort study using a multi-institutional database
• Who was studied: 174 patients with peritoneal mesothelioma, including well-differentiated papillary (WDPM) and malignant (MPM) types, treated with CRS with or without HIPEC from 2000 to 2017 at centers in the US HIPEC Collaborative (a dataset of over 2300 patients from 12 academic medical centers). Urgent and palliative cases were excluded, as were patients missing survival data. Survival analysis excluded 12 multicystic and 19 papillary patients, leaving 141.
• Exposure: Major organ resection (MOR) during CRS/HIPEC. This was defined as total or partial removal of the diaphragm, stomach, spleen, pancreas, small bowel, colon, rectum, kidney, ureter, bladder and/or uterus, grouped as 0, 1, or 2 or more organs. A history of asbestos exposure was also recorded as a patient characteristic. No fiber types or doses were given.
• Main results:
  • 94 patients (54%) had peritoneal resections only (no MOR). 45 (25.9%) had one organ totally or partially resected, and 35 (20.1%) had two or more.
  • Any complication occurred in 57.8% (one organ), 74.3% (two or more) and 48.9% (no MOR), p = 0.035. MOR was not associated with Clavien–Dindo grade 3/4 complications requiring intervention (p = 0.29) or with 90-day readmission (p = 0.44).
  • Median length of stay was 10 days (one organ) and 11 days (two or more) versus 9 days (no MOR), p = 0.005. MOR also increased blood loss, operating time and ICU stay.
  • Among the 141 patients in the survival analysis, median overall survival was 86 months. It was 130 months with no MOR, 56 months with one organ and 93 months with two or more, a difference that was not statistically significant (p = 0.499). There were 39 deaths among all 174 patients.
  • In the adjusted (multivariable) analysis, MOR was not associated with overall survival: one organ HR 1.67 (95% CI 0.59–4.74); two or more organs HR 0.77 (95% CI 0.22–2.69). No factor was associated with survival after adjustment.
  • Asbestos exposure was recorded as present in 7 of 174 patients (4.0%), absent in 89 and unknown in 78 (44.8%). In unadjusted analysis its hazard ratio for death was 1.06 (95% CI 0.76–1.49, p = 0.721), which was not statistically significant.
• The authors' conclusion: The authors concluded that their study suggests major organ resections are safe during CRS/HIPEC for malignant peritoneal mesothelioma, and that their data support considering MOR if needed to achieve complete cytoreduction.
• Limitations the authors state:
  • Only 39 deaths occurred, so the authors could not exclude that the study was underpowered to detect a difference.
  • Some variables were missing from the database, including histologic subtype for 60 (35%) patients.
  • The peritoneal cancer index (PCI) was left out of the multivariable model because too much data was missing.
  • There were too few diaphragm resections to draw clinical conclusions about them.

Topics

Medical terms in this study, explained in our Lexicon: HIPEC, Peritoneal Mesothelioma, Overall Survival, Cohort Study, Diaphragm, Cytoreductive Surgery.

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• Two-Stage Cytoreductive Surgery and Intraperitoneal Chemotherapy for Diffuse Malignant Peritoneal Mesothelioma: Predictors of Overall Survival in an Intention-to-Treat Series — J.C. Leinwand, R.N. Taub, et al. (2020)
• Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for limited peritoneal metastasis. The PSOGI international collaborative registry — A. Arjona-Sanchez, O. Aziz, et al. (2021)
• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)
• The Safety of Iterative Cytoreductive Surgery and HIPEC for Peritoneal Carcinomatosis: A High Volume Center Prospectively Maintained Database Analysis — E. Bekhor, J. Carr, et al. (2020)
• Long-term results of laparoscopic cytoreductive surgery and HIPEC for the curative treatment of low-grade pseudomyxoma peritonei and multicystic mesothelioma — F. Mercier, G. Jeremie, et al. (2020)

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