Elevated brain natriuretic peptide (BNP) is an early marker for patients at risk for complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC)

Our plain-English summary of Elevated brain natriuretic peptide (BNP) is an early marker for patients at risk for complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC), by S.B. Fisher, S. Rafeeq, K. Hess, et al (Journal of Surgical Oncology, 2018).

The study

• Authors: S.B. Fisher, S. Rafeeq, K. Hess, T.E. Grotz, P. Mansfield, R. Royal, B. Badgwell, J. Fleming, K. Fournier, G.N. Mann
• Journal: Journal of Surgical Oncology
• Published: 2018;117(4):685-691
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Elevated BNP is associated with adverse cardiac outcomes after noncardiac surgery. We assessed BNP values as markers of perioperative fluid status and their correlation with major/cardiopulmonary (CP) complications following CRS + HIPEC.

Methods: Fluid balance, BNP levels, and morbidity data were collected for all patients undergoing CRS + HIPEC between 6/2014 and 2/2016.

Results: One hundred and twenty-nine patients underwent CRS + HIPEC for appendiceal adenocarcinoma (n = 99), mesothelioma (n = 16), and colon cancer (n = 14). Less than 10% had CP comorbidities. The median PCI was 14 (range 4-39); 89% underwent CC0/1 resection (n = 115). Median blood loss (EBL) was 497 mL (50-2700). Major complications (Clavien III-V) occurred in 16 (12%), CP in 17 (13%), and major/CP in 24 (18%). Thirty-day mortality occurred in 2 (1.5%). Elevated BNP on POD1 correlated with increased risk of major/CP complications (OR 2.2, P = 0.052). This was most pronounced in the 25 patients receiving cisplatin: for each 100 unit increase in POD1 BNP the OR for major/CP complication was 7.4 versus 1.2 for the remaining patients, P = 0.083. Multivariate analysis identified increased EBL (OR 4.1 P = 0.011) and a trend toward increased BNP on POD1 (OR for each 100 unit increase 2.0, P = 0.10) as risk factors for major/CP complications.

Conclusions: Postoperative BNP measurement after CRS + HIPEC may guide postoperative fluid resuscitation and facilitate identification of patients at risk for major and/or cardiopulmonary complications.

© 2017 Wiley Periodicals, Inc.

In plain English

This retrospective study covered 129 patients who had cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) at MD Anderson Cancer Center, June 2014 to February 2016. Most had appendiceal cancer (99); 16 had mesothelioma and 14 colorectal cancer. The article does not discuss asbestos exposure. The authors asked whether postoperative brain natriuretic peptide (BNP) levels tracked fluid balance and complications. Daily BNP showed no significant relationship with fluid balance. Major or cardiopulmonary complications occurred in 24 patients (18.6%). Higher BNP on the first day after surgery was linked to these complications: odds ratio 2.2 per 100-unit rise (1.0 to 5.0, P = 0.052). Of 15 patients with first-day BNP above 139 pg/mL, 6 (40%) had such complications, versus 18 of 111 (16%) with lower values. In multivariate analysis, first-day BNP's adjusted odds ratio was 2.0 per 100-unit rise (0.9 to 4.6, P = 0.10), which the authors called a trend. Estimated blood loss had an adjusted odds ratio of 4.1 per five-fold increase (1.4 to 12.0, P = 0.011). The authors called elevated first-day BNP a potential risk factor needing larger prospective study.

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 study of consecutive patients at one cancer center (described by the authors as an initial exploratory, hypothesis-generating study)
• Who was studied: 129 consecutive patients undergoing CRS + HIPEC at MD Anderson Cancer Center, Houston, Texas, June 1, 2014 to February 1, 2016: appendiceal cancer 99 (76.7%), mesothelioma 16 (12.4%), colorectal cancer 14 (10.9%)
• Exposure: Not an asbestos exposure study. The factor studied was serial postoperative BNP levels, mainly on postoperative day 1, analyzed per 100-unit change. HIPEC drugs were mitomycin C (mostly for appendiceal cancer), oxaliplatin (colon cancer) and cisplatin (mesothelioma).
• Main results:
  • Of the 129 patients, major complications (Clavien grades III-V) occurred in 16 (12.4%), cardiopulmonary complications in 17 (13.2%), and either major or cardiopulmonary complications in 24 (18.6%). Two patients (1.6%) died within 30 days.
  • Daily BNP measurements did not show a significant relationship with fluid balance.
  • All patients: odds ratio for major/cardiopulmonary complications for each 100-unit increase in day-1 BNP was 2.2 (1.0, 5.0), P = 0.052.
  • Patients with day-1 BNP above 139 pg/mL: 6 of 15 (40%) developed major/cardiopulmonary complications. Patients with lower values: 18 of 111 (16%). P = 0.043.
  • Complication rates did not differ significantly by chemotherapy agent: 18.1% mitomycin C, 25.0% cisplatin, 9.0% oxaliplatin (P = 0.52).
  • For each 100-unit increase in day-1 BNP, the odds ratio was 7.1 (1.4, 39) in cisplatin patients, compared with 1.2 (0.4, 3.7) in patients receiving mitomycin C or oxaliplatin (P = 0.083).
  • Patients needing more than 3 days of diuretics were most likely to have major/cardiopulmonary complications: odds ratio 2.0 (1.3, 3.1), P = 0.0019.
  • In the multivariate model, day-1 BNP had an adjusted odds ratio of 2.0 (0.9, 4.6) per 100-unit increase, P = 0.10.
  • In the multivariate model for major/cardiopulmonary complications, estimated blood loss had an adjusted odds ratio of 4.1 (1.4, 12.0) for a five-fold increase, P = 0.011.
• The authors' conclusion: The authors identified elevated BNP on the first postoperative day as a potential risk factor for major or cardiopulmonary complications, and said this should be evaluated prospectively in a larger population.
• Limitations the authors state:
  • Exploratory study limited by sample size and its retrospective nature
  • Preoperative BNP and measures of preoperative cardiac performance were not available
  • True fluid balance is hard to measure retrospectively, and errors in recorded fluid volumes may explain the failure to detect changes in volume status
  • Clinicians used BNP to guide care day to day, which may have blunted any relationship between BNP, fluid balance and complications
  • The small number of events made it impossible to tell whether BNP relates to cardiopulmonary complications or to major complications alone

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Adenocarcinoma, Mesothelioma, Colorectal Cancer, Cisplatin, Multivariate Analysis.

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• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, 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)
• Interval between cytoreductions as a marker of tumor biology in selecting patients for repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy — I.T. Konstantinidis, E.A. Levine, et al. (2017)
• Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy (HIPEC) by Minimally Invasive Approach, an Initial Experience — A. Arjona-Sanchez, S. Rufian-Peña, et al. (2018)
• 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)

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