Indications for hyperthermic intraperitoneal chemotherapy with cytoreductive surgery: a clinical practice guideline

Our plain-English summary of Indications for hyperthermic intraperitoneal chemotherapy with cytoreductive surgery: a clinical practice guideline, by R.C. Auer, D. Sivajohanathan, J. Biagi, et al (Current Oncology, 2020).

The study

• Authors: R.C. Auer, D. Sivajohanathan, J. Biagi, J. Conner, E. Kennedy, T. May
• Journal: Current Oncology
• Published: 2020;27(3):146-154
• Cited by: 28 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objective: The purpose of the present review was to provide evidence-based guidance about the provision of cytoreductive surgery (crs) with hyperthermic intraperitoneal chemotherapy (hipec) in the treatment of peritoneal cancers.

Methods: The guideline was developed by the Program in Evidence-Based Care together with the Surgical Oncology Program at Ontario Health (Cancer Care Ontario) through a systematic review of relevant literature, patient- and caregiver-specific consultation, and internal and external reviews.

Results: Recommendation 1a: For patients with newly diagnosed stage iii primary epithelial ovarian or fallopian tube carcinoma, or primary peritoneal carcinoma, hipec should be considered for those with at least stable disease after neoadjuvant chemotherapy at the time that interval crs (if complete) or optimal cytoreduction is achieved. Recommendation 1b: There is insufficient evidence to recommend the addition of hipec when primary crs is performed for patients with newly diagnosed advanced primary epithelial ovarian or fallopian tube carcinoma, or primary peritoneal carcinoma, outside of a clinical trial. Recommendation 2: There is insufficient evidence to recommend hipec with crs in patients with recurrent ovarian cancer outside the context of a clinical trial. Recommendation 3: There is insufficient evidence to recommend hipec with crs in patients with peritoneal colorectal carcinomatosis outside the context of a clinical trial. Recommendation 4: There is insufficient evidence to recommend hipec with crs for the prevention of peritoneal carcinomatosis in colorectal cancer outside the context of a clinical trial; however, hipec using oxaliplatin is not recommended. Recommendation 5: There is insufficient evidence to recommend hipec with crs for the treatment of gastric peritoneal carcinomatosis outside the context of a clinical trial. Recommendation 6: There is insufficient evidence to recommend hipec with crs for the prevention of gastric peritoneal carcinomatosis outside the context of a clinical trial. Recommendation 7: There is insufficient evidence to recommend hipec with crs as a standard of care in patients with malignant peritoneal mesothelioma; however, patients should be referred to hipec specialty centres for assessment for treatment as part of an ongoing research protocol. Recommendation 8: There is insufficient evidence to recommend hipec with crs as a standard of care in patients with disseminated mucinous neoplasm in the appendix; however, patients should be referred to hipec specialty centres for assessment for treatment as part of an ongoing research protocol.

2020 Multimed Inc.

In plain English

This article was a clinical practice guideline from Ontario Health (Cancer Care Ontario), not a new study of patients. The authors based it on a systematic review, published separately, that covered randomized trials and also non-randomized studies, along with patient and expert review. It covered heated chemotherapy placed in the abdomen (HIPEC) given together with surgery to remove tumour. It applied to adults with mesothelioma or with appendiceal, colorectal, gastric, ovarian or primary peritoneal cancers. It did not study asbestos exposure. For malignant peritoneal mesothelioma, the authors found no randomized or comparative studies. They found only one retrospective cohort study of 1547 patients, and they rated the certainty of that evidence very low. In that study, chemotherapy alone, surgery alone, or observation was associated with poorer overall survival than surgery plus HIPEC. Survival did not differ significantly from surgery plus chemotherapy. The authors concluded the evidence was insufficient to recommend the treatment as standard care for peritoneal mesothelioma. They advised that patients be referred to specialty centres for assessment for treatment as part of an ongoing research protocol.

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: Clinical practice guideline developed from a systematic review of randomized controlled trials and non-randomized studies, with patient and caregiver consultation and internal and external review
• Who was studied: Guideline target population: adults aged 18 or older with mesothelioma or with appendiceal (including appendiceal mucinous neoplasms), colorectal, gastric, ovarian, or primary peritoneal carcinoma; evidence drawn from published trials and cohort studies
• Exposure: Treatment studied: hyperthermic intraperitoneal chemotherapy (HIPEC) with cytoreductive surgery (CRS); asbestos exposure was not studied
• Main results:
  • For peritoneal mesothelioma, no randomized or comparative studies had compared CRS plus HIPEC with other management
  • The only mesothelioma evidence was one retrospective cohort study of 1547 patients
  • In that cohort study, patients receiving chemotherapy alone, CRS alone, or observation were independently associated with poorer overall survival than the CRS plus HIPEC group (p less than 0.001)
  • In that cohort study, overall survival did not differ significantly between CRS plus HIPEC and CRS plus chemotherapy (p = 0.397)
• The authors' conclusion: The authors concluded there was insufficient evidence to recommend HIPEC with CRS as standard of care for malignant peritoneal mesothelioma. They recommended that patients be referred to HIPEC specialty centres for assessment for treatment as part of an ongoing research protocol.
• Limitations the authors state:
  • The authors rated the certainty of the mesothelioma evidence as very low
  • Some trial evidence was available only as abstracts, which the authors judged insufficient for definitive recommendations
  • For colorectal cancer, the control arms of both trials did not reflect current practice
  • The gastric cancer trials were in Asian populations, which limits how far the results apply to others

Topics

Medical terms in this study, explained in our Lexicon: HIPEC, Cytoreductive Surgery, Systematic Review, Carcinoma, Primary Peritoneal Carcinoma, Neoadjuvant Chemotherapy, Clinical Trial, Ovarian Cancer.

Related studies

• Unresectable peritoneal metastasis treated by pressurized intraperitoneal aerosol chemotherapy (PIPAC) leading to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy — M. Alyami, F. Mercier, et al. (2021)
• Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for limited peritoneal metastasis. The PSOGI international collaborative registry — A. Arjona-Sanchez, O. Aziz, et al. (2021)
• The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis: a systematic review including evidence from Japan — T. Kitai (2021)
• Two-Stage Cytoreductive Surgery and Intraperitoneal Chemotherapy for Diffuse Malignant Peritoneal Mesothelioma: Predictors of Overall Survival in an Intention-to-Treat Series — J.C. Leinwand, R.N. Taub, et al. (2020)
• Adjuvant dendritic cell based immunotherapy (DCBI) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal mesothelioma, a phase II single centre open-label clinical trial: rationale and design of the MESOPEC trial — N.L. de Boer, J.P. van Kooten, et al. (2019)
• Urological approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a clinical care center — C.G. Trujillo, C. Domínguez, et al. (2018)

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