Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: long-term results at St George Hospital, Australia

Our plain-English summary of Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: long-term results at St George Hospital, Australia, by N. Alzahrani, J.S. Ferguson, S.J. Valle, et al (ANZ Journal of Surgery, 2016).

The study

• Authors: N. Alzahrani, J.S. Ferguson, S.J. Valle, W. Liauw, T. Chua, D.L. Morris
• Journal: ANZ Journal of Surgery
• Published: 2016;86(11):937-941
• Cited by: 34 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Peritoneal carcinomatosis (PC) results from the secondary spread of many intraabdominal tumour types, such as colorectal malignancy (colorectal cancer, CRC), disseminated peritoneal adenomucinosis (DPAM), appendiceal cancer, ovarian carcinoma, sarcoma or from the occurrence of primary peritoneal disease such as peritoneal mesothelioma. The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has seen improvements in survival in selected cases of these cancers.

Methods: Between 1996 and 2014, a prospective database of 675 patients was created for the peritonectomy unit at our hospital. In total, 827 peritonectomy procedures (including redo CRS) were performed for the major subgroups of PC: DPAM 220; appendiceal cancer (peritoneal mucinous adenocarcinoma (PMCA)) 191; CRC 234; diffuse malignant peritoneal mesothelioma (DMPM) 73 and others 109. There were 152 redo-peritonectomy procedures within the total mentioned earlier (CRC 26; DPAM 58; DMPM 18; appendix 40; other 10).

Results: The 5-year survivals for DPAM and PMCA were 80% and 42% respectively. The 5-year survivals for appendiceal cancer with peritoneal cancer index (PCI) <10, 10-20 and >20 were 60, 57 and 37% respectively (P = 0.09). The 2- and 5-year survivals for CRC were 56 and 24% respectively. The 5-year survivals for PCI 0-5, 6-10, 11-15 and >15 were 59, 15, 7 and 0% respectively (P = 0.000). The 5-year survival for DMPM with PCI < 10, 10-20 and >20 were 100, 55 and 39% respectively (P = 0.01).

Conclusion: CRS in combination with HIPEC provides a chance of long-term survival in selected cases of PC when compared with systemic therapy alone.

© 2015 Royal Australasian College of Surgeons.

In plain English

This article reported results from one surgical unit at St George Hospital in Sydney, Australia. The unit treated cancers that had spread across the lining of the abdomen (the peritoneum) with cytoreductive surgery, which removes visible tumour, combined with heated chemotherapy washed through the abdomen during the operation (HIPEC). The authors looked back at a database of 675 patients who had 827 operations between 1996 and 2014. The groups included 56 patients with diffuse malignant peritoneal mesothelioma, along with patients with appendix, colorectal and other cancers. The study did not examine asbestos exposure. For the mesothelioma patients, median survival was 63 months. 68% were alive at 2 years and 57% at 5 years. Five-year survival in this group was lower when disease was more widespread: 100%, 55% and 39% as the peritoneal cancer index rose. Across all 827 operations, 10 patients (1.21%) died within 30 days. The authors concluded that their survival results were consistent with the published literature. They also concluded that the combined treatment offers selected patients a chance of long-term survival when compared with systemic therapy alone.

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 review of patients treated by one surgical unit, using a database kept prospectively and analysed retrospectively
• Who was studied: 675 patients who had 827 peritonectomy procedures, 152 of them repeat operations, at the peritonectomy unit of St George Hospital, Sydney, Australia, 1996 to 2014. Procedures by disease: disseminated peritoneal adenomucinosis (DPAM) 220; appendiceal cancer (peritoneal mucinous adenocarcinoma) 191; colorectal cancer 234; diffuse malignant peritoneal mesothelioma (DMPM) 73; others 109. The DMPM group was 56 patients with a mean age of 50 (25 female, 31 male).
• Exposure: Asbestos exposure was not studied. The study examined a treatment: cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC). For DMPM, the HIPEC protocol was cisplatin 100 mg/m2 plus mitomycin C 12.5 mg/m2 for 90 minutes.
• Main results:
  • Diffuse malignant peritoneal mesothelioma (DMPM) patients: median survival 63 months; 2-year survival 68%; 5-year survival 57%
  • DMPM patients by extent of disease: 5-year survival was 100% for peritoneal cancer index (PCI) below 10, 55% for PCI 10 to 20, and 39% for PCI above 20 (P = 0.01). Table 1 lists 11, 24 and 21 patients in these groups, counting first operations only.
  • In DMPM patients, the factors linked to poorer survival were lymph node involvement, sarcomatoid type, incomplete cytoreduction, not receiving HIPEC, and male gender
  • Other groups: 5-year survival was 80% for DPAM and 42% for peritoneal mucinous adenocarcinoma (PMCA). For colorectal cancer, median survival was 28 months, with 2-year survival of 56% and 5-year survival of 24%.
  • Repeat (redo) operations: across all 152 redo procedures, survival was 75% at 2 years and 56% at 5 years. For mesothelioma, 5-year survival after a redo operation was 50%.
  • Complications across all 827 procedures: no deaths during surgery. 30-day mortality was 1.21% (10 of 827), with 17 deaths in hospital in total. 110 cases needed a return to theatre (42 of them for significant bleeding), and there were 47 pancreatic leaks.
• The authors' conclusion: The authors concluded that survival in their DPAM, PMCA, colorectal cancer and DMPM groups was consistent with the available literature. They concluded that cytoreductive surgery with HIPEC provides a significant chance of long-term survival in selected patients when compared with systemic therapy alone, and that low morbidity and mortality are achievable in centres with a highly experienced multidisciplinary team.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Colorectal Cancer, Carcinoma, Sarcoma, Peritoneal Mesothelioma, Adenocarcinoma, Peritoneal Cancer Index (PCI).

Related studies

• Evaluation of the cost-effectiveness of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (peritonectomy) at the St George Hospital peritoneal surface malignancy program — T.C. Chua, S. Martin, et al. (2010)
• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)
• Long-term Survival and Propensity Score Matched Outcomes of Bilateral vs. Unilateral Diaphragm Interventions in Cytoreductive Surgery plus Intra-peritoneal Chemotherapy — B. Singh, G. Singh, et al. (2018)
• 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)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)
• Long-term survival outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy: Single-institutional experience with 1225 cases — L.S. Kyang, N.A. Alzahrani, et al. (2019)

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