Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent or progressive diffuse malignant peritoneal mesothelioma: clinicopathologic characteristics and survival outcome

Our plain-English summary of Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent or progressive diffuse malignant peritoneal mesothelioma: clinicopathologic characteristics and survival outcome, by C. Ihemelandu, L. Bijelic, P.H. Sugarbaker (Annals of Surgical Oncology, 2015).

The study

• Authors: C. Ihemelandu, L. Bijelic, P.H. Sugarbaker
• Journal: Annals of Surgical Oncology
• Published: 2015;22(5):1680-5
• Cited by: 39 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Diffuse malignant peritoneal mesothelioma (DMPM) is an aggressive disease for which cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been used with remarkable survival benefits. Our aim was to analyze the clinicopathologic characteristics and prognosis of recurrent DMPM managed with iterative CRS and HIPEC.

Methods: A retrospective analysis of a prospectively maintained database for all patients treated for DMPM from 1989 to 2012.

Results: Of 205 consecutive CRS and HIPEC procedures, 44 (21.5 %) patients underwent an iterative procedure-22 (50.0 %) males versus 22 (50.0 %) females. Mean age at recurrence was 51.5 years. There was no 30-day mortality following an iterative procedure, and the grade III-V morbidity was 2.3 %. The median overall survival of patients undergoing an iterative CRS and HIPEC was 54 months versus 77 months following an initial CRS and HIPEC (p = 0.96). Patients undergoing an iterative surgery had a 3- and 5-year survival of 61 and 46 %, respectively, versus 60 and 52 % following an initial CRS and HIPEC. Amongst the iterative group, the achieved complete cytoreduction (CC) score was 15.9, 18.2, 22.7, and 43.2 % for CC0, CC1, CC2 and CC3, respectively, versus 3.1, 43.5, 28.6 and 24.8 %, respectively, following initial CRS (p = 0.000). Significant predictors of an improved survival in multivariate analysis were an epithelioid subtype, female sex, complete or near CC (CC0 or CC1), HIPEC regimen utilized, absence of postoperative complication, and age at diagnosis.

Conclusion: Iterative CRS and HIPEC can be performed safely and appear to have benefits with this group of patients showing an improved median survival.

In plain English

The authors reviewed a database of patients with diffuse malignant peritoneal mesothelioma (cancer of the abdominal lining) treated at the Washington Cancer Institute between 1989 and 2012. Treatment combined cytoreductive surgery with heated chemotherapy in the abdomen (HIPEC), though not every operation included HIPEC. Of 205 procedures in 161 patients, 44 were repeat operations for disease that returned or grew. The article did not report asbestos exposure. After repeat surgery no patient died within 30 days, and 2.3% had serious complications, against 17.4% after first surgery. Median survival was 54 months after repeat surgery and 77 months after first surgery, a difference that was not statistically significant (p = 0.96). Five-year survival was 46% and 52%, respectively. Repeat operations were more often rated CC3, the least complete tumor removal (43.2% against 24.8%), and 36.4% were done without HIPEC. Recurrence was not an independent predictor of worse survival. The authors concluded that in selected patients repeat surgery with HIPEC can be done safely and appears to have benefits. They noted that the study was retrospective, from one institution, and open to selection bias.

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 database (single institution)
• Who was studied: 161 patients with histologically proven diffuse malignant peritoneal mesothelioma who had 205 cytoreductive procedures at the Washington Cancer Institute, Washington, DC, USA, between 1989 and 2012
• Exposure: No asbestos or fiber exposure is reported. The study compared repeat (iterative) cytoreductive surgery and HIPEC with initial cytoreductive surgery and HIPEC. HIPEC was not given in some operations in either group.
• Main results:
  • 44 of the 205 procedures (21.5%) were iterative (repeat) cytoreductive surgery and HIPEC
  • There were no 30-day deaths after repeat procedures. Grade III to V complications occurred in 2.3% of the repeat group and 17.4% of the initial-surgery group.
  • Median overall survival was 54 months after repeat surgery and 77 months after initial surgery (p = 0.96)
  • 3- and 5-year overall survival was 60% and 52% in the initial group, and 61% and 46% in the repeat group
  • A CC3 cytoreduction was achieved in 43.2% of the repeat group and 24.8% of the initial group
  • HIPEC was not used in 36.4% of the repeat group and 6.8% of the initial group
  • Median time from initial to next surgery was 12.5 months
  • Among patients with a CC3 cytoreduction, median survival was 28 months after repeat surgery and 13 months after initial surgery
  • In multivariate analysis, the factors independently associated with improved survival were epithelioid subtype, female sex, complete or near-complete cytoreduction (CC0 or CC1), HIPEC regimen, absence of postoperative complication, and age at diagnosis
  • Recurrence was not an independent predictor of worse survival
• The authors' conclusion: The authors concluded that, in selected patients, iterative cytoreductive surgery and HIPEC can be performed safely and appears to have benefits, with this group showing an improved median survival
• Limitations the authors state:
  • The study was retrospective, which makes it difficult to control bias and confounders and to establish cause and effect
  • The study came from a single institution, with patients selected on clinical experience over 23 years, so selection bias is part of the outcomes
  • Survival of the repeat-surgery patients without reoperation cannot be known

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma, Peritoneal mesothelioma.

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Peritoneal Mesothelioma, Prognosis, Median Overall Survival, Multivariate Analysis, Epithelioid, Median Survival.

Related studies

• 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)
• 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)
• Is Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Justified for Biphasic Variants of Peritoneal Mesothelioma? Outcomes from the Peritoneal Surface Oncology Group International Registry — K.I. Votanopoulos, P. Sugarbaker, et al. (2018)
• Conversion to Complete Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Malignant Peritoneal Mesothelioma After Bidirectional Chemotherapy — F. Le Roy, M. Gelli, et al. (2017)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)

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