Current clinical practices of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)

Our plain-English summary of Current clinical practices of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), by M. Acs, M. Babucke, M. Jusufi, et al (Innovative Surgical Sciences, 2024).

The study

• Authors: M. Acs, M. Babucke, M. Jusufi, Z. Kaposztas, P. Slowik, M. Hornung, H.J. Schlitt, I. Panczel, J. Hevesi, J. Herzberg, T. Strate, P. Piso
• Journal: Innovative Surgical Sciences
• Published: 2024;9(1):3-15
• Type of article: Review
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Treatment of peritoneal surface malignancies makes physicians face demanding and new-fangled problems, as there are many uncertain aspects considering the outcomes of affected patients' prognoses. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are associated with favorable long-term outcomes in carefully selected patients with peritoneal metastases (PM). We aim to summarize the current results about the initial malignancies and their peritoneal spreads. The current literature has been scrutinized, and studies between 2016 and 2022 were included wherein long-term, progression-free (PFS), and overall survival (OS) data were considered relevant information. Medline, Embase, and Google Scholar have been the main sources. Hereby, we cover all the primer malignancies: gastric, ovarian, and colorectal cancers with peritoneal metastases (PM), malignant peritoneal mesothelioma, and pseudomyxoma peritonei. Examining the advances in the current peer-reviewed literature about the indications of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), target groups, risk factors, and other influencing elements, we intend to provide a complex state-of-the-art report, establishing the relevant aspects of that emerging treatment method.

© 2024 the author(s), published by De Gruyter, Berlin/Boston.

In plain English

This article was a narrative review, not a new study of patients. The authors searched Medline, Embase and Google Scholar for studies published between 2016 and 2022 on two treatments used together. Cytoreductive surgery (CRS) is an operation to remove all visible tumor in the abdomen. Hyperthermic intraperitoneal chemotherapy (HIPEC) is heated chemotherapy delivered directly into the abdomen. The review covered cancer that had spread to the abdominal lining from colorectal, gastric and ovarian cancer, as well as malignant peritoneal mesothelioma and pseudomyxoma peritonei. The article did not discuss asbestos exposure. For malignant peritoneal mesothelioma, the review noted that no randomized trials had been done, and it summarized registry studies. In a US database study of 1,514 patients, median overall survival was 61 months with CRS plus HIPEC and 6 months with observation. A Dutch registry study of 566 patients found surgery and HIPEC were each independently associated with better survival. Other cited studies linked higher platelet counts and higher tumor stage with shorter survival. The authors concluded that complete removal of visible tumor was of paramount importance for survival in all tumor types. They also concluded that the role of HIPEC remained controversial, and in mesothelioma unclear.

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: Narrative literature review of published studies on CRS and HIPEC
• Who was studied: Published studies of patients with peritoneal metastases from gastric, ovarian and colorectal cancer, malignant peritoneal mesothelioma, and pseudomyxoma peritonei; sources were Medline, Embase and Google Scholar
• Main results:
  • The review reported that in a Dutch Cancer Registry study of 566 malignant peritoneal mesothelioma patients (1993 to 2016), better survival was independently associated with surgery (HR 0.33; 95% CI 0.23 to 0.48) and HIPEC (HR 0.33; 95% CI 0.21 to 0.55)
  • The review reported that in a US National Cancer Data Base study of 1,514 malignant peritoneal mesothelioma patients, median overall survival was 6 months (observation), 17 months (chemotherapy only), 21 months (CRS alone), 52 months (CRS plus chemotherapy) and 61 months (CRS plus HIPEC)
  • The review reported that in a cited staging system for malignant peritoneal mesothelioma, 5-year overall survival was 87%, 53% and 29% for stages I, II and III
  • The review reported that in a cited study of malignant peritoneal mesothelioma, median survival was 13 months for patients with high preoperative platelet counts and 58 months for those with normal counts
  • The review reported that in a large retrospective study of 2,149 patients undergoing CRS and HIPEC, major (grade 3 and 4) complications occurred in 19.3% and 30-day postoperative hospital mortality was 2.3%
• The authors' conclusion: The authors concluded that complete macroscopic cytoreduction is of paramount importance for survival in all tumor types, while the impact of HIPEC remains controversial (and, for malignant peritoneal mesothelioma, unclear)
• Limitations the authors state:
  • The authors noted that, because malignant peritoneal mesothelioma is rare, no randomized trials had been conducted
  • The authors noted that HIPEC methods (technique, drug doses, timing, duration) vary widely between centers, which makes results hard to compare

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Overall Survival, Colorectal Cancer, Peritoneal Mesothelioma.

Related studies

• Adjuvant dendritic cell based immunotherapy (DCBI) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal mesothelioma, a phase II single centre open-label clinical trial: rationale and design of the MESOPEC trial — N.L. de Boer, J.P. van Kooten, et al. (2019)
• Indications for hyperthermic intraperitoneal chemotherapy with cytoreductive surgery: a clinical practice guideline — R.C. Auer, D. Sivajohanathan, et al. (2020)
• Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality — K.I. Votanopoulos, N.A. Newman, et al. (2013)
• Cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for children, adolescents, and young adults: the first 50 cases — A. Hayes-Jordan, H. Green, et al. (2015)
• The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — S. Kusamura, P.A. Torres Mesa, et al. (2016)
• Multicystic peritoneal mesothelioma: outcomes and patho-biological features in a multi-institutional series treated by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — D. Baratti, M. Vaira, et al. (2010)

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