Efficacy of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in the management of malignant ascites

Our plain-English summary of Efficacy of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in the management of malignant ascites, by R.W. Randle, K.R. Swett, D.S. Swords, et al (Annals of Surgical Oncology, 2014).

The study

• Authors: R.W. Randle, K.R. Swett, D.S. Swords, P. Shen, J.H. Stewart, E.A. Levine, K.I. Votanopoulos
• Journal: Annals of Surgical Oncology
• Published: 2014;21(5):1474-9
• Cited by: 65 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: In peritoneal surface disease, accumulation of malignant ascites represents a difficult problem to treat, with adverse impact on quality of life. The role of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in controlling malignant ascites is not well defined.

Methods: A retrospective analysis of a prospectively maintained database of 1,000 procedures was performed. Type of malignancy, resolution of ascites, duration and agent of chemoperfusion, performance status, resection status, morbidity, mortality, and survival were reviewed.

Results: Ascites was found in 299 patients (310 procedures) either before or during exploration. A total of 142 (46 %) procedures were performed for appendiceal primary disease, 53 (17 %) colorectal, 20 (6 %) gastric, 45 (15 %) mesothelioma, and 26 (8 %) ovarian. A total of 288 (93 %) patients had resolution of ascites by 3 months' follow-up. In patients with ascites, complete cytoreduction was obtained in 15 versus 59 % when ascites was not present (p < 0.001). In the group of patients who had their ascites controlled, 243 of 288 (84 %) had resection with residual macroscopic disease (R2 status). Twenty-two patients (7 %) had persistent ascites at 3 months' follow-up, 19 (86 %) of whom had an R2 resection. Univariate analysis revealed that type of primary disease, resection status, duration or agent of chemoperfusion, and performance status did not predict failure.

Conclusions: CRS-HIPEC is effective in controlling ascites in 93 % of patients with malignant ascites, even when a complete cytoreduction is not feasible. Ascites is predictive of incomplete cytoreduction and worse overall survival. Although complete cytoreduction remains the goal of this procedure, HIPEC can provide palliative value in selected patients with malignant ascites.

In plain English

This was a retrospective review of a prospectively kept database of 1,000 procedures combining cytoreductive surgery with heated chemotherapy washed through the abdomen (CRS-HIPEC), done from 1992 to 2012. The authors studied the 310 procedures, in 299 patients, where malignant ascites (cancer-related abdominal fluid) was found. Mesothelioma was the primary disease in 45 (15%) of these procedures. The study did not examine asbestos exposure. Ascites resolved by the 3-month check in 288 (93%) of the 310 cases. Success did not differ between complete and incomplete tumor removal (p = 1.00). Complete removal of visible tumor was achieved in 15% of procedures with ascites, versus 59% (403 of 680) without ascites. Among patients whose primary cancer was not low grade appendiceal and whose tumor removal was incomplete, median survival was 5.6 months, compared with 37 months after complete removal. Major complications occurred in 25% (79 of 310). The authors concluded that CRS-HIPEC can control malignant ascites in most patients even when cytoreduction is incomplete. They argued against using it purely for palliation in non-low-grade-appendiceal disease.

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 analysis of a prospectively maintained surgical database (case series of treated patients)
• Who was studied: 310 of 1,000 CRS-HIPEC procedures, performed in 299 patients, in which malignant ascites was documented on preoperative CT or during surgery, 1992 to 2012. Primary diseases by procedure were appendiceal 142 (46%), colorectal 53 (17%), gastric 20 (6%), mesothelioma 45 (15%), ovarian 26 (8%) and other 34 (11%). The authors are at Wake Forest University, Winston-Salem, NC.
• Exposure: Not an asbestos exposure study. The factor studied was treatment by cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy. The drug was chosen by tumor type, mostly mitomycin C (258 of 310 procedures), and perfusion lasted 60 to 120 minutes.
• Main results:
  • Ascites resolved in 288 (93%) of the 310 cases at 3 months; 84% of these successes had incomplete macroscopic resection (R2).
  • Ascites failed to resolve in 22 (7%) cases, 86% of which were R2 resections.
  • Success rate did not differ between complete and incomplete resection (p = 1.00). Type of primary tumor (p = 0.19), duration (p = 0.85) or agent (p = 0.34) of chemoperfusion, and ECOG performance status (p = 0.81) did not predict failure.
  • Among the 45 mesothelioma procedures, 39 were in the success group and 6 in the failure group (6 of 22 failures, 27%). Type of primary disease overall did not predict failure.
  • Complete macroscopic resection (R0/R1) was achieved in 15% of procedures with malignant ascites, compared with 59% (403 of 680) of procedures without malignant ascites (p less than 0.001).
  • The ascites score could be calculated in 129 (42%) cases. In these, each 1-point increase in the score was linked to higher odds of incomplete resection (OR 1.33, 95% CI 1.14 to 1.55). In 77 scored patients with low grade appendiceal primaries, the OR was 2.04 (95% CI 1.26 to 3.30, p = 0.003).
  • For patients with malignant ascites from non-low-grade-appendiceal primaries, median overall survival was 37 months with complete resection versus 5.6 months with R2 resection (p less than 0.001).
  • In low grade appendiceal disease, median survival was 85.1 months (R0/R1) versus 69.3 months (R2); this difference was not statistically significant (p = 0.33).
  • Higher ascites scores were associated with worse overall survival in all scored patients (HR 1.1, 95% CI 1.02 to 1.21, p = 0.02).
  • Of the 310 procedures, 111 (36%) had minor complications and 79 (25%) had major complications. Mortality was 5.8% at 30 days and 10.6% at 90 days.
• The authors' conclusion: The authors concluded that CRS-HIPEC can control malignant ascites in most patients with incomplete cytoreduction. They found ascites to be a strong predictor of not achieving complete cytoreduction, and suggested the ascites score may help select patients. For non-low-grade-appendiceal patients in whom complete cytoreduction seems impossible, they favored palliative laparoscopic HIPEC without CRS.
• Limitations the authors state:
  • The ascites score could be calculated in only 129 (42%) cases, because the others lacked an accessible preoperative CT or a detailed enough operative report.
  • The link between ascites score and survival in low grade appendiceal disease was only marginally statistically significant.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Ascites, Quality of Life, Performance Status, Mesothelioma, Overall Survival, Palliative Care.

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)
• 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)
• 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 with intraperitoneal hyperthermic chemotherapy for malignant peritoneal mesothelioma: mitomycin versus cisplatin — A.U. Blackham, P. Shen, et al. (2010)

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