Cytoreductive surgery with selective versus complete parietal peritonectomy followed by hyperthermic intraperitoneal chemotherapy in patients with diffuse malignant peritoneal mesothelioma: a controlled study

Our plain-English summary of Cytoreductive surgery with selective versus complete parietal peritonectomy followed by hyperthermic intraperitoneal chemotherapy in patients with diffuse malignant peritoneal mesothelioma: a controlled study, by D. Baratti, S. Kusamura, A.D. Cabras, et al (Annals of Surgical Oncology, 2012).

The study

• Authors: D. Baratti, S. Kusamura, A.D. Cabras, M. Deraco
• Journal: Annals of Surgical Oncology
• Published: 2012;19(5):1416-24
• Cited by: 60 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Combined treatment involving peritonectomy procedures, multivisceral resections, and hyperthermic intraperitoneal chemotherapy (HIPEC) has reportedly resulted in survival benefit for peritoneal surface malignancies, including diffuse malignant peritoneal mesothelioma (DMPM). Many unanswered questions remain regarding the surgical options in the management of DMPM. The aim of this case–control study was to assess the impact of the type and extent of parietal peritonectomy on survival and operative outcomes.

Methods: Thirty patients with DMPM undergoing selective parietal peritonectomy (SPP) of macroscopically involved regions, and 30 matched patients undergoing routine complete parietal peritonectomy (CPP), regardless of disease distribution, were retrospectively identified from a prospective database.

Results: Groups were comparable for all characteristics, except for a higher proportion of patients treated before July 2003 and undergoing preoperative systemic chemotherapy in the SPP group. Median follow-up was 86.2 months in the SPP group and 50.3 months in the CPP group. Median overall survival was 29.6 months in the SPP group and not reached in the CPP group; 5-year overall survival was 40.0% and 63.9%, respectively (P = 0.0269). At multivariate analysis, CPP versus SPP was recognized as an independent predictor of better prognosis, along with complete cytoreduction, negative lymph nodes, epithelial histology, and lower MIB-1 labelling index. Morbidity and reoperation rates were not different between groups. No operative mortality occurred. In 12 of 24 patients undergoing CPP, pathologic examination detected disease involvement on parietal surfaces with no evident tumor at surgical exploration.

Conclusions: CPP improved survival in patients with DMPM undergoing combined treatment. This information may contribute to standardize surgical options for DMPM and other peritoneal malignancies.

In plain English

This study from the Istituto Nazionale Tumori in Milan, Italy, compared two ways of operating on patients with diffuse malignant peritoneal mesothelioma, a cancer of the abdominal lining. All patients had surgery to remove tumor followed by heated chemotherapy (cisplatin plus doxorubicin) circulated through the abdomen. The study looked back at records of 30 patients who had only visibly diseased areas of the lining removed (selective) and 30 matched patients who had all six areas removed regardless of visible disease (complete). The article does not discuss asbestos exposure. Five-year overall survival was 40.0% in the selective group and 63.9% in the complete group (P = 0.0269). In combined analysis, complete removal was an independent factor for better survival. Serious complications did not differ significantly between groups, and no patient died from the operation. In 12 of 24 complete-group patients, tumor would have been missed in lining that looked normal at surgery. The authors noted the study was retrospective. They concluded that complete removal may improve survival and that prospective studies are needed.

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 case-matched (case-control) comparison drawn from a prospective database
• Who was studied: Patients with diffuse malignant peritoneal mesothelioma operated on by the same surgical team in Milan, Italy, from August 1996 to May 2011 (136 consecutive peritoneal mesothelioma patients in total). From these, 30 patients who had selective parietal peritonectomy were compared with 30 matched patients who had complete parietal peritonectomy. Matching used histology, completeness of cytoreduction, lymph node and metastasis status, peritoneal cancer index, age and sex.
• Exposure: Not an asbestos exposure study. The comparison was between two surgical approaches, both followed by closed-abdomen heated intraperitoneal chemotherapy (HIPEC) with cisplatin (45 mg/L) plus doxorubicin (15 mg/L) for 90 minutes. Selective parietal peritonectomy removed only lining regions with visible disease. Complete parietal peritonectomy removed all six regions, including normal-looking surfaces.
• Main results:
  • Median overall survival was 29.6 months (95% CI 9.6–49.6) in the selective group and was not reached in the complete group. Five-year overall survival was 40.0% (selective) and 63.9% (complete), P = 0.0269.
  • In multivariate analysis, complete versus selective peritonectomy was an independent factor for better overall survival (Table 3 hazard ratio for peritonectomy 0.46, 95% CI 0.21–0.99, P = 0.048). The other independent factors were completeness of cytoreduction, epithelial histology, nodal status (borderline significance) and MIB-1 positive cells above 10%.
  • Median progression-free survival was 14.4 months (95% CI 5.3–23.4) in the selective group and was not reached in the complete group. Five-year progression-free survival was 24.9% (selective) and 54.3% (complete), P = 0.0334. At multivariate analysis, longer progression-free survival correlated with complete peritonectomy (HR 0.18; 95% CI 0.06–0.56; P = 0.002).
  • Complete peritonectomy was associated with better survival in patients with macroscopically complete (CCR-0, P = 0.039) and near-complete (CCR-1) cytoreduction. It was not associated with better survival in those with suboptimal (CCR-2) cytoreduction (P = 0.449).
  • Overall grade 3–5 adverse events occurred in 15 of 30 selective-group patients and 8 of 30 complete-group patients (P = 0.110, not statistically significant). Reoperations were 5 versus 2 (P = 0.424). No operative mortality occurred.
  • Complete peritonectomy was associated with longer operative time: mean 599.7 versus 519.5 minutes for selective, P = 0.012. It was also associated with shorter hospital stay: mean 19.7 versus 27.3 for selective, P = 0.035.
  • In the complete group, 19 of 35 parietal surface specimens with no visible tumor at surgery showed microscopic (12) or macroscopic (7) disease on pathology. In 12 of 24 patients with accurate pathologic data, residual disease would have gone unnoticed with a selective approach.
• The authors' conclusion: The authors concluded that this retrospective comparison suggests complete parietal peritonectomy may improve survival in patients with diffuse malignant peritoneal mesothelioma undergoing cytoreduction and HIPEC. They stated that future prospective studies are needed to confirm the findings.
• Limitations the authors state:
  • The authors acknowledged that the study is retrospective.
  • More selective-group patients were treated in the early years of the study period. A surgical learning curve may have helped the more recently treated complete group, although treatment period was not significant in the survival analysis.
  • More selective-group patients had received systemic chemotherapy before referral, which could have induced resistance to HIPEC. However, prior chemotherapy did not correlate with survival in the analyses.
  • Even the most extensive parietal peritonectomy cannot remove residual tumor on crucial visceral sites, which may result in recurrence.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma, Peritoneal mesothelioma.

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Peritoneal Mesothelioma, Chemotherapy, Median Overall Survival, Overall Survival, Multivariate Analysis, Prognosis.

Related studies

• 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 peritoneal metastases — T.C. Chua, L.E. Quinn, et al. (2013)
• Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for malignant peritoneal mesothelioma: mitomycin versus cisplatin — A.U. Blackham, P. Shen, et al. (2010)
• Conversion to Complete Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Malignant Peritoneal Mesothelioma After Bidirectional Chemotherapy — F. Le Roy, M. Gelli, et al. (2017)
• 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)
• 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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