Laparoscopy is Safe and Accurate to Evaluate Peritoneal Surface Metastasis Prior to Cytoreductive Surgery

Our plain-English summary of Laparoscopy is Safe and Accurate to Evaluate Peritoneal Surface Metastasis Prior to Cytoreductive Surgery, by R.A. Marmor, K.J. Kelly, A.M. Lowy, et al (Annals of Surgical Oncology, 2016).

The study

• Authors: R.A. Marmor, K.J. Kelly, A.M. Lowy, J.M. Baumgartner
• Journal: Annals of Surgical Oncology
• Published: 2016;23(5):1461-7
• Cited by: 58 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Completeness of cytoreduction is a significant predictor of long-term outcome after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Imaging has limited sensitivity to identify peritoneal metastases and therefore predict whether complete cytoreduction is possible. We reviewed our experience using laparoscopy to determine candidates for complete cytoreduction and HIPEC.

Methods: This single-center, retrospective study examined patients from 2007 to 2014 who underwent laparoscopy to determine complete cytoreduction (CC-0/1)/HIPEC candidacy. Preoperative, intraoperative, and postoperative data were collected.

Results: A total of 145 laparoscopies were performed on 141 patients, 72 (51.1 %) of whom were female, with a median age of 53 years (range 20-79). The primary site was appendiceal in 67 (47.5 %) patients, colorectal in 43 (30.5 %), mesothelioma in 17 (12.1 %), unknown in 9 (6.4 %), small bowel in 3 (2.1 %), gastric in 1, and ovarian in 1 (0.7 % each). Overall, 115 (81.6 %) patients had prior abdominal surgery, 111 (76.6 %) had evidence of disease on imaging, and 117 (80.7 %) underwent prior chemotherapy, with a median of 5.9 weeks between the last treatment and laparoscopy (0.9-498.9 weeks). Four (2.8 %) intraoperative complications were observed (one liver laceration, two enterotomies, and one air embolus), and nine (6.2 %) postoperative complications [four (2.8 %) Clavien grade (CG) I, three (2.8 %) CG II, one (0.7 %) CG III (return to operating room) and one (0.7 %) CG IV (transient ischemic attack)]. Forty-eight patients deemed candidates by laparoscopy underwent CRS/HIPEC (positive predictive value 82.8 %).

Conclusion: Diagnostic laparoscopy is a safe, feasible, and accurate staging tool in patients with suspected peritoneal metastases being considered for CRS.

In plain English

This single-center retrospective study, from the University of California, San Diego, reviewed 145 diagnostic laparoscopies (keyhole surgery to look inside the abdomen) done on 141 patients with suspected cancer involving the abdominal lining (peritoneum). The aim was to judge whether each patient could have complete cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC). Seventeen patients had peritoneal mesothelioma. Their results were not reported separately, and asbestos exposure was not studied. Three laparoscopies were nondiagnostic. Of 63 patients judged candidates for complete cytoreduction, 58 went on to surgery and 48 achieved complete cytoreduction, a positive predictive value of 82.9%. Among patients with no disease on imaging, 76.5% had visible disease at laparoscopy. There were four intraoperative complications (2.75%) and nine postoperative complications (6.20%). The authors concluded that laparoscopy is a safe, feasible and effective screening tool for predicting complete cytoreduction. They noted several limitations: the retrospective, single-institution design, no adequate comparison group, and no way to determine the negative predictive value.

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, single-institution cohort study
• Who was studied: 141 patients (145 laparoscopies) at the University of California, San Diego, 2008 to 2014 per the Methods, being considered for CRS/HIPEC. Primary sites were appendix 67 (47.5%), colorectal 43 (30.5%), peritoneum (mesothelioma) 17 (12.1%), unknown 9 (6.4%), small bowel 3 (2.1%), gastric 1 (0.7%) and ovary 1 (0.7%).
• Exposure: No asbestos or fiber exposure was studied. The procedure examined was diagnostic laparoscopy, done as an outpatient procedure separate from planned CRS/HIPEC.
• Main results:
  • 3 of 145 laparoscopies (2.06%) were nondiagnostic.
  • 129 patients (88.9%) had visible disease at laparoscopy. 13 (8.9%) had no evidence of carcinomatosis.
  • Of the 63 patients judged candidates for complete cytoreduction, 5 (7.93%) were found at open surgery to have disease too extensive for complete cytoreduction.
  • Of the candidates who underwent CRS/HIPEC, 42 (79.2%) had CC-0, 6 (11.3%) had CC-1 and 5 (9.43%) had CC-2 cytoreduction.
  • Positive predictive value of laparoscopy for complete cytoreduction was 82.9%: 48 patients achieved complete cytoreduction among 58 laparoscopy-judged candidates who underwent surgery.
  • Among the 34 patients without imaging evidence of disease, 76.5% had visible disease at laparoscopy. 34.6% of those with visible disease were not candidates for complete cytoreduction.
  • Four intraoperative complications (2.75%) occurred among the 145 laparoscopies: one liver laceration, two enterotomies and one air embolus.
  • Nine postoperative complications (6.20%) occurred, including one Clavien grade IV complication (a transient ischemic attack).
  • 140 laparoscopies (96.5%) were performed as outpatient procedures.
• The authors' conclusion: The authors concluded that laparoscopy is a safe, feasible and effective screening tool for predicting the likelihood of complete cytoreduction in patients being considered for CRS/HIPEC.
• Limitations the authors state:
  • Retrospective design and single-institution experience.
  • There was no adequate comparison group of patients who had only preoperative imaging.
  • The negative predictive value could not be determined, because patients judged not to be candidates were typically not offered open surgery.

Topics

Medical terms in this study, explained in our Lexicon: Metastasis, Cytoreductive Surgery, HIPEC, Mesothelioma, Chemotherapy, Diagnostic Laparoscopy, Staging.

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)
• 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)
• Postoperative outcomes of laparoscopic vs open cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of peritoneal surface malignancies — G. Passot, N. Bakrin, et al. (2014)
• 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)
• Value of laparoscopy before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis — L.H. Iversen, P.C. Rasmussen, et al. (2013)

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