Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent peritoneal metastases

Our plain-English summary of Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent peritoneal metastases, by T.C. Chua, L.E. Quinn, J. Zhao, et al (Journal of Surgical Oncology, 2013).

The study

• Authors: T.C. Chua, L.E. Quinn, J. Zhao, D.L. Morris
• Journal: Journal of Surgical Oncology
• Published: 2013;108(2):81-8
• Cited by: 36 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) achieves disease control within the peritoneum but recurrences occur. This study examines the outcomes of iterative CRS (iCRS) HIPEC for treatment of recurrent peritoneal metastases.

Methods: Patients who underwent iCRS in a single tertiary referral center were identified from a prospective database. Safety analysis was performed and clinicopathological variables were analyzed to assess factors predictive of major morbidity and survival.

Results: The demographics of patients who underwent primary cytoreductive surgery (pCRS) (n = 466) and iCRS (n = 79) were balanced between groups. pCRS was shown to require more blood transfusion (P = 0.019) and albumin use (P = 0.013). The mortality and major complication rates were comparable (1.2% vs. 0%; P = 0.600, and 42% vs. 41%; P = 0.806). Residual pneumothorax occurred more frequently after pCRS (12% vs. 4%; P = 0.030). Factors associated with major complications after iCRS include use of HIPEC (P = 0.042) and length of hospital stay (P = 0.024). The overall median survival was 48 months and 5-year survival was 34%. By cancer type, the 3-year survival was 0%, 74%, 80%, and 72% for colorectal, appendiceal pseudomyxoma, peritoneal mesothelioma, and appendix cancer, respectively. Independent predictors of survival include age (P = 0.049), interval between pCRS and iCRS (P = 0.008), small bowel resection (P < 0.001), and use of HIPEC (P = 0.005).

Conclusion: Iterative CRS achieved further peritoneal disease control without adverse effects on morbidity. Patients with appendiceal tumors and peritoneal mesothelioma appear to benefit most after iCRS. Intraoperative HIPEC remains important in the repetoire of managing these patients.

Copyright © 2013 Wiley Periodicals, Inc.

In plain English

This study from St George Hospital in Sydney, Australia, looked back at patients whose cancer returned in the abdominal lining (peritoneum) after a first operation to remove visible tumor, usually combined with heated chemotherapy into the abdomen (HIPEC). Between January 2000 and March 2012, 79 such patients had repeat surgery; 9 had peritoneal mesothelioma. The article does not discuss asbestos. No treatment-related deaths (deaths within 30 days of surgery) were recorded after repeat surgery. Major complications followed 41% of repeat operations, compared with 42% of 466 first operations. Overall, 34% of repeat-surgery patients were alive at five years. Among the 9 peritoneal mesothelioma patients, median survival was 57 months (95% confidence interval 32.0 to 82.1), and 3-year and 5-year survival were 80% and 27%. HIPEC use at repeat surgery was linked to both more major complications and longer survival. The authors concluded that repeat surgery did not worsen surgical outcomes and that patients with appendiceal tumors and peritoneal mesothelioma appeared to benefit. They noted that the appendix cancer (15 patients) and peritoneal mesothelioma (9 patients) groups were small and that larger studies were 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 analysis of a single center's prospectively maintained database (12 years of experience), comparing repeat (iterative) cytoreductive surgery with first (primary) cytoreductive surgery
• Who was studied: 79 patients (40 women, 39 men; median age 53) who had repeat cytoreductive surgery for recurrent peritoneal metastases at St George Hospital, Sydney, Australia, between January 2000 and March 2012. Their cancers were colorectal cancer (11), appendiceal pseudomyxoma (39), mucinous appendix cancer (15), peritoneal mesothelioma (9), small bowel adenocarcinoma (2), ovarian cancer (2) and hepatocellular carcinoma (1). They were compared with 466 primary operations.
• Exposure: Not an asbestos exposure study; asbestos is not mentioned. The treatment studied was repeat cytoreductive surgery, with or without HIPEC. For peritoneal mesothelioma the heated chemotherapy used cisplatin and doxorubicin.
• Main results:
  • Treatment-related mortality was defined as death within 30 days of surgery. Of 545 procedures there were six such deaths (mortality 1.1%), all in the primary surgery group (1.2% vs. 0% after repeat surgery).
  • Major complications occurred in 197 patients (42%) after primary surgery and 32 patients (41%) after repeat surgery
  • Residual pneumothorax was more common after primary surgery (12%) than after repeat surgery (4%)
  • After repeat surgery, independent predictors of major complications were use of HIPEC (OR 8.7, 95% CI 1.1 to 69.7) and length of hospital stay (OR 1.1, 95% CI 1.0 to 1.2)
  • For all 79 repeat-surgery patients, median survival was 48 months (95% CI 38.1 to 57.9); 1-, 3- and 5-year survival were 92%, 60% and 34%
  • For the 9 peritoneal mesothelioma patients, median survival was 57 months (95% CI 32.0 to 82.1); 3- and 5-year survival were 80% and 27%
  • For colorectal cancer patients, median survival was 23 months, with 1- and 3-year survival of 90% and 0%. For appendiceal pseudomyxoma, 3- and 5-year survival were 74% and 53%. For appendix cancer, median survival was 48 months, with 3- and 5-year survival of 72% and 29%.
  • Independent predictors of survival after repeat surgery were age over 65 (HR 2.8, 95% CI 1.00 to 7.85), interval beyond 18 months between the operations (HR 0.1, 95% CI 0.02 to 0.55), more than one small bowel resection (HR 8.6, 95% CI 2.6 to 28.3) and use of HIPEC (HR 0.26, 95% CI 0.10 to 0.67)
• The authors' conclusion: The authors concluded that repeat cytoreductive surgery did not contribute to adverse surgical outcomes and that patients with appendiceal tumors and peritoneal mesothelioma appeared to benefit from it
• Limitations the authors state:
  • The numbers of appendix cancer (15) and peritoneal mesothelioma (9) patients were small
  • Longer follow-up, a larger cohort and comparison with modern systemic chemotherapy are needed
  • Repeat surgery was performed in highly selected patients

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Peritoneum, Pneumothorax, Median Survival, Peritoneal Mesothelioma, Bowel Resection.

Related studies

• Iterative procedures combining cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for isolated peritoneal recurrence — M. Vaira, M. Robella, et al. (2014)
• Quality of life after cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy: a prospective study of 216 patients — G. Passot, N. Bakrin, et al. (2014)
• Repeat cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent diffuse malignant peritoneal mesothelioma — Y. Huang, N.A. Alzahrani, 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)
• Outcomes of repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal surface malignancy — K.I. Votanopoulos, C. Ihemelandu, et al. (2012)
• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)

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