Cytoreductive surgery and heated intraperitoneal chemotherapy for peritoneal carcinomatosis from rare etiologies

Our plain-English summary of Cytoreductive surgery and heated intraperitoneal chemotherapy for peritoneal carcinomatosis from rare etiologies, by M. Mah, L.A. Mack, S. Hurton, et al (American Journal of Surgery, 2019).

The study

• Authors: M. Mah, L.A. Mack, S. Hurton, A. Bouchard-Fortier
• Journal: American Journal of Surgery
• Published: 2019;217(5):923-927
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Cytoreductive surgery and heated intraperitoneal chemotherapy (CRS/HIPEC) are commonly used in the treatment of peritoneal carcinomatosis (PC) originating from colorectal, appendiceal and ovarian cancers. It is unclear what benefit CRS/HIPEC might have for PC from uncommon etiologies, therefore we sought to describe local practice patterns and evaluate overall survival (OS).

Methods: All patients who had CRS/HIPEC between 2000 and 2016 were identified using our institutional cancer database. Patients with appendiceal, colorectal, and ovarian pathologies were excluded. Kaplan-Meier curves were used to estimate and demonstrate 5-year OS. Cox regression analysis was performed to determine factors associated with OS.

Results: Of all patients treated with CRS/HIPEC at our institution, 38 were treated for PC of rare origin. Etiologies included 23 patients with mesothelioma, 8 with primary peritoneal carcinoma, 4 with small bowel tumours and 3 with gastric cancer. Median OS of 35.4, 20.8, 25.4, and 20.2 months were obtained for each group respectively. 5-year OS for each pathology was 8.7%, 0.0%, 25.0%, and 33.3% respectively with corresponding mean PCI of 31.3, 23.6, 21.5, and 12.7. No independent prognostic factors were significant on Cox regression analysis. Median length of stay was 19 days. Readmission rate within 30 days of discharge was 7.9%. Rate of Grade III/IV complications was 34.2%. No thirty-day mortality.

Conclusion: Survivals beyond 20 months can be obtained with the use of CRS/HIPEC for rare PC etiologies aligning with results of other groups. CRS/HIPEC in well-selected patients demonstrates a clinical benefit and this could be confirmed with a multi-institutional study.

Copyright © 2019 Elsevier Inc. All rights reserved.

In plain English

This single-centre retrospective cohort study, at Foothills Medical Centre in Calgary, Canada, reviewed patients who had cytoreductive surgery (removing visible tumour) plus heated abdominal chemotherapy (HIPEC) between 2000 and 2016. All had cancer spread on the abdominal lining from uncommon sources. Of 38 patients included, 23 had mesothelioma, 8 primary peritoneal cancer, 4 small bowel tumours and 3 gastric cancer. Median overall survival was 35.4 months (mesothelioma), 20.8 (primary peritoneal), 25.4 (small bowel) and 20.2 (gastric). Kaplan-Meier estimates of five-year survival were 8.7%, 0.0%, 25.0% and 33.3% respectively; no primary peritoneal patient had yet been followed five years, so their 0.0% was an estimate, not an observed outcome. None of the factors tested, including age, sex and extent of disease, was a statistically significant independent predictor of survival. Serious (grade III or IV) complications affected 34.2% of patients; none died within 30 days. The authors concluded the treatment was technically feasible, with acceptable risks, at an expert centre for selected patients. They noted the small, highly selected sample and only 12 confirmed deaths. The article does not discuss asbestos.

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: Single-centre retrospective cohort study (review of an institutional database and patient records)
• Who was studied: 38 patients (24 female, 14 male; median age 56) treated at Foothills Medical Centre, Calgary, Alberta, Canada, between January 2000 and December 2016, with peritoneal carcinomatosis from causes other than colorectal, appendiceal or ovarian cancer: 23 mesothelioma, 8 primary peritoneal, 4 small bowel, 3 gastric. Follow-up ended April 2018.
• Exposure: The study examined a treatment, not an asbestos exposure: cytoreductive surgery plus heated intraperitoneal chemotherapy. Mesothelioma patients received doxorubicin and cisplatin, plus early postoperative intraperitoneal paclitaxel (EPIC). Asbestos or fiber exposure is not addressed.
• Main results:
  • Of the 38 patients included, 23 had mesothelioma, 8 primary peritoneal cancer, 4 small bowel tumours and 3 gastric cancer.
  • Median overall survival was 35.4 months (mesothelioma), 20.8 months (primary peritoneal), 25.4 months (small bowel) and 20.2 months (gastric).
  • Five-year overall survival, estimated by the Kaplan-Meier method, was 8.7% (mesothelioma), 0.0% (primary peritoneal), 25.0% (small bowel) and 33.3% (gastric).
  • For the primary peritoneal group, no patient had been followed for five years; the 0% figure was a Kaplan-Meier curve estimate. The authors gave a 2-year overall survival of 37.5% for this group.
  • Mean Peritoneal Carcinomatosis Index (extent of disease) was 31.3 (mesothelioma), 23.6 (primary peritoneal), 21.5 (small bowel) and 12.7 (gastric).
  • No visible tumour was left after surgery (CCR score of zero) in 56.5% of mesothelioma patients, 87.5% of primary peritoneal patients, and 100% of gastric and small bowel patients.
  • Median overall survival for all 38 patients together was 26.4 months.
  • In Cox regression, none of age at surgery, gender, PCI, CCR or site of primary lesion was a statistically significant independent prognostic factor for survival.
  • Across all patients, mean and median hospital stay were 22.6 and 19 days, 7.9% were readmitted within 30 days, 34.2% had Clavien-Dindo grade III/IV complications, and none died within 30 days.
• The authors' conclusion: The authors concluded that CRS/HIPEC for peritoneal carcinomatosis of rare origin is technically feasible, with acceptable perioperative morbidity and mortality, when performed at an expert centre for appropriately selected patients. They said studies comparing it with systemic chemotherapy, best done across several institutions, may help confirm an overall clinical benefit.
• Limitations the authors state:
  • Retrospective design, single centre, small sample size, mixed tumour types and missing data.
  • Only 12 patients were confirmed to have died; the other 26 were censored or lost to follow-up, some with last appointments more than 24 months earlier.
  • Patients were a highly selected group representing only a subset of people with peritoneal carcinomatosis from rare sources.
  • The primary peritoneal patients had surgery between 2012 and 2016 and could not be followed long enough for 5-year data.
  • Only three gastric cancer patients were included, making comparison with other studies difficult.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, Chemotherapy, HIPEC, Ovarian Cancer, Overall Survival, Kaplan-Meier Curve, Mesothelioma, Primary Peritoneal Carcinoma.

Related studies

• Peritoneal metastases from small bowel cancer: Results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in The Netherlands — T.R. van Oudheusden, V.E. Lemmens, et al. (2015)
• Learning curve for cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis — Y. Huang, N.A. Alzahrani, et al. (2017)
• 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)
• Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent or progressive diffuse malignant peritoneal mesothelioma: clinicopathologic characteristics and survival outcome — C. Ihemelandu, L. Bijelic, et al. (2015)
• Is Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Justified for Biphasic Variants of Peritoneal Mesothelioma? Outcomes from the Peritoneal Surface Oncology Group International Registry — K.I. Votanopoulos, P. Sugarbaker, et al. (2018)
• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)

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