Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)

Our plain-English summary of Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), by G.H.C. Tan, C.S. Chia, S.H. Tan, et al (International Journal of Clinical Oncology, 2018).

The study

• Authors: G.H.C. Tan, C.S. Chia, S.H. Tan, K.C. Soo, M.C.C. Teo
• Journal: International Journal of Clinical Oncology
• Published: 2018;23(5):989-998
• Cited by: 10 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are used in the management of selected peritoneal malignancies. While most patients achieve long-term disease-free survival, there remains a group with early recurrence (ER). We aim to investigate the clinical factors associated with ER.

Methods: A retrospective review of a prospectively maintained database of CRS-HIPEC patients treated between April 2001 and Feb 2016 was performed. ER was defined as recurrence within 12 months of CRS-HIPEC. Patients were stratified according to time to recurrence and only patients with at least 12-month follow-up were included. Perioperative factors were investigated, and subgroup analyses of colorectal, ovarian and appendiceal groups were performed.

Results: Of the 144 patients included, 30.6% were colorectal, 36.8% ovarian and primary peritoneal, 24.3% appendiceal, 2.1% mesothelioma and 6.3% were of other origins. Thirty-nine patients (27%) suffered ER. Univariable and multivariable analyses revealed that primary tumour type (p = 0.02) and post-CRS adjuvant treatment (p = 0.04) were associated with ER. Appendiceal patients had a lower odds of ER compared to colorectal patients [OR = 0.15 (0.043-0.502) p < 0.002]. Patients who received post-CRS adjuvant treatment had a lower odds of ER than patients without adjuvant treatment [OR = 0.32; (0.128-0.818) p = 0.02].

Conclusion: There remains a 27% risk of ER after CRS-HIPEC. Better patient selection and the administration of adjuvant chemotherapy may help to reduce ER.

In plain English

This study from the National Cancer Centre Singapore reviewed a prospectively kept database of patients treated with cytoreductive surgery (removing visible tumour inside the abdomen) followed by heated chemotherapy circulated through the abdomen (HIPEC), between April 2001 and February 2016. Of 215 procedures, 144 patients with optimal tumour removal and at least 12 months of follow-up were included. Most had colorectal, ovarian or primary peritoneal, or appendiceal cancer. Three (2.1%) had mesothelioma. Asbestos exposure was not studied. Early recurrence (cancer returning within 12 months) occurred in 39 patients (27%). After adjustment, appendiceal patients had lower odds of early recurrence than colorectal patients (odds ratio 0.15; 95% CI 0.043 to 0.502). Patients given chemotherapy after surgery had lower odds than those not given it (odds ratio 0.32; 95% CI 0.128 to 0.818). The mesothelioma result was not statistically significant. Median survival was 27 months with early recurrence and 100 months without, though the discussion gives different figures. The authors concluded that early recurrence is primarily determined by tumour type and that adjuvant chemotherapy may improve results. They named the mix of cancer types and small numbers as limitations.

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 review of a prospectively maintained database of consecutive patients at a single institution
• Who was studied: 144 patients (of 215 CRS/HIPEC procedures) at the National Cancer Centre Singapore, treated April 2001 to February 2016, with optimal cytoreduction and at least 12 months of follow-up. 30.6% colorectal, 36.8% ovarian and primary peritoneal, 24.3% appendiceal, 2.1% mesothelioma, 6.3% other origins.
• Exposure: No asbestos exposure was studied. The study examined treatment with cytoreductive surgery plus HIPEC (mitomycin C for colorectal and appendiceal cases; cisplatin for ovarian, primary peritoneal and mesothelioma cases) and clinical factors such as tumour type and post-surgery adjuvant treatment.
• Main results:
  • 39 of 144 patients (27%) had recurrence within 12 months of CRS-HIPEC.
  • In the multivariable analysis, appendiceal patients had lower odds of early recurrence than colorectal patients (adjusted OR = 0.15; 95% CI 0.043 to 0.502; P = 0.002).
  • Patients who received post-surgery adjuvant treatment had lower odds of early recurrence than those without it (adjusted OR = 0.32; 95% CI 0.128 to 0.818; P = 0.02).
  • For the 3 mesothelioma patients compared with colorectal patients, the adjusted odds ratio for early recurrence was 0.52 (95% CI 0.043 to 6.288), with P value 0.6, not statistically significant.
  • Median overall survival was 27 months (95% CI 17 to 70) in the early recurrence group and 100 months in the group without early recurrence.
  • In the colorectal subgroup, 18 of 44 patients (40.9%) had early recurrence. Adjuvant treatment was associated with lower odds of early recurrence (OR = 0.19; 95% CI 0.046 to 0.764; P = 0.01).
  • In the ovarian/primary peritoneal subgroup, 12 of 53 patients (22.6%) had early recurrence, and no factor was significantly associated with it on univariable analysis.
  • Post-operative complications, raised tumour markers, incomplete cytoreduction and blood loss were not found to be associated with early recurrence.
• The authors' conclusion: The authors concluded that early recurrence can occur after CRS-HIPEC and is primarily determined by tumour histological type, and that improved results may be obtained by adding adjuvant chemotherapy after CRS and HIPEC.
• Limitations the authors state:
  • The different primary cancer types in the patient group were named as the main limitation.
  • Small numbers of patients and events may explain why some factors reported elsewhere were not found to be associated with early recurrence.
  • Multivariable analysis was not done for the ovarian/primary peritoneal subgroup because there were too few early recurrences.
  • RAS status, a prognostic factor in metastatic colorectal cancer, could not be included.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Disease-Free Survival, Mesothelioma, Chemotherapy.

Related studies

• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)
• 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)
• 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)
• 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)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in Asian patients: 100 consecutive patients in a single institution — M.C. Teo, G.H. Tan, et al. (2013)
• Iterative procedures combining cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for isolated peritoneal recurrence — M. Vaira, M. Robella, et al. (2014)

Browse more research in International Journal of Clinical Oncology, or return to medical research.