Learning curve for cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis

Our plain-English summary of Learning curve for cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis, by Y. Huang, N.A. Alzahrani, W. Liauw, et al (ANZ Journal of Surgery, 2017).

The study

• Authors: Y. Huang, N.A. Alzahrani, W. Liauw, D.L. Morris
• Journal: ANZ Journal of Surgery
• Published: 2017;87(1-2):49-54
• Cited by: 11 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Combined cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) has been considered as a standard approach for peritoneal surface malignancy. This study aims to assess the learning curve of this combined approach.

Methods: Prospectively collected data of our first 800 consecutive patients treated by CRS and PIC between January 1996 and July 2014 were retrospectively reviewed. Eight hundred patients were divided into two groups and eight groups for comparison. A significant difference was defined as P < 0.05.

Results: A significant increase in the rate of the completeness of cytoreduction (CC) score-0 from 74.0% to 83.0% was seen with a reduction in rates of other CC scores. Also, there was a decreasing trend in mean blood transfusion units. The rate of viscus perforation, fistula formation and small bowel obstruction was significantly lower in the recent 400 patients. However, there was a significant increase in the incidence of deep venous thrombosis and pulmonary embolism. There was an improvement in the 5-year survival rate for patients with colorectal cancer, pseudomyxoma peritonei and mesothelioma.

Conclusion: Our findings demonstrate a learning curve associated with the combined approach of CRS and PIC. With adequate experience, CRS and PIC can be safely performed with acceptable mortality and morbidity.

© 2015 Royal Australasian College of Surgeons.

In plain English

This study reviewed records, collected as treatment happened, of the first 800 patients with cancer spread across the abdominal lining (peritoneal carcinomatosis) treated by one surgical team at St George Hospital, Sydney, between January 1996 and July 2014 with cytoreductive surgery plus chemotherapy delivered into the abdomen. They included 71 patients with peritoneal mesothelioma; asbestos exposure was not studied. Comparing the first and second 400 patients, surgery leaving no visible cancer rose from 74.0% to 83.0%. Blood transfusion, bowel perforation, fistula, bowel obstruction and fluid around the lungs (pleural effusion) were significantly lower in the later group, while blood clots in veins or lungs rose from 1.5% to 9.3%. Hospital mortality was 2.8% versus 1.5%; this did not differ significantly across the eight groups. Five-year survival for mesothelioma patients was 53% in the fourth group of 100 versus 40% in the first, not statistically significant (P = 0.620); colorectal and pseudomyxoma differences were also not significant. The authors concluded there is a learning curve and that, with experience, the treatment can be performed with acceptable mortality and morbidity.

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 prospectively collected data (single-centre surgical case series), comparing consecutive groups of patients over time to assess a learning curve
• Who was studied: The first 800 consecutive patients with peritoneal carcinomatosis treated by the same surgical team at St George Hospital, Sydney, Australia, January 1996 to July 2014. Diagnoses: colorectal cancer 229, pseudomyxoma peritonei 238, peritoneal mesothelioma 71, appendiceal carcinoma 178, other peritoneal neoplasms 94. Patients were split into eight groups of 100 and into two groups of 400.
• Exposure: No asbestos or fiber exposure was studied. The comparison was between earlier and later patients receiving cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC). For peritoneal mesothelioma, the heated intraperitoneal chemotherapy was cisplatin (100 mg/m2) and mitomycin (12.5 mg/m2) given over 90 minutes.
• Main results:
  • The rate of complete cytoreduction with no visible residual cancer (CC-0) rose from 74.0% in the first 400 patients to 83.0% in the second 400. The authors described this as a significant increase.
  • Overall hospital mortality was 2.1% (17 of 800 patients).
  • Hospital mortality was 2.8% in the first 400 patients and 1.5% in the second 400 patients. Across the eight groups of 100, hospital deaths ranged from 4 to 1 per group, with P = 0.652, which is not below the study's 0.05 significance threshold.
  • Mean blood transfusion was 5.9 units in the first 400 patients versus 4.8 units in the second 400 patients, a significant difference.
  • Comparing the first 400 with the second 400 patients, there were significantly fewer viscus perforations (20, 5.0%, versus 4, 1.0%), fistulas (62, 15.5%, versus 30, 7.5%) and small bowel obstructions (24, 6.0%, versus 5, 1.3%) in the later group.
  • Pleural effusion was significantly less common in the second 400 patients (91, 22.8%) than in the first 400 patients (137, 34.3%).
  • Deep venous thrombosis or pulmonary embolism rose significantly, from 6 patients (1.5%) in the first 400 to 37 patients (9.3%) in the second 400. The authors thought this was probably due to more liberal use of CT pulmonary angiograms, and reported that no patient died of pulmonary embolism.
  • Across the eight groups, the rate of grade 4 (life-threatening) complications declined from 21% to 14%. Grade 3 complications showed an increasing trend.
  • Among patients with mesothelioma, 5-year survival was 53% in group IV versus 40% in group I. This difference was not statistically significant (P = 0.620).
  • Five-year survival comparisons for the other cancers were also not statistically significant. For colorectal cancer it was 31% in group IV versus 16% in group I (P = 0.145). For pseudomyxoma peritonei it was 94% in group IV versus 64% in group I (P = 0.321).
• The authors' conclusion: The authors concluded that their findings demonstrate a learning curve for combined CRS and PIC, and that with adequate experience the treatment can be performed safely with acceptable mortality and morbidity.
• Limitations the authors state:
  • The authors stated that, because of their methodology, they could not define the point at which the learning curve peaked.
  • Five-year survival was compared mainly between group I and group IV because the other groups had insufficient follow-up.
  • The authors stated that it is very difficult to determine which factors produced the improved outcomes.
  • Patient selection changed over the years, for example the PCI limit for colorectal cancer was lowered from 20 to 15 in 2012. The authors said this contributed to the differences in PCI and diagnoses and to the improved results.
  • The authors suggested the rise in grade 3 complications could reflect more scanning, higher-PCI referrals and more complex cases being taken on in later years.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, Chemotherapy, Completeness of Cytoreduction (CC) Score, Colorectal Cancer, Mesothelioma.

Related studies

• Institutional learning curve of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for peritoneal malignancies — P.M. Polanco, Y. Ding, et al. (2015)
• Long-term survival outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy: Single-institutional experience with 1225 cases — L.S. Kyang, N.A. Alzahrani, et al. (2019)
• Cytoreductive surgery and heated intraperitoneal chemotherapy for peritoneal carcinomatosis from rare etiologies — M. Mah, L.A. Mack, et al. (2019)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: long-term results at St George Hospital, Australia — N. Alzahrani, J.S. Ferguson, et al. (2016)
• Long term survival and perioperative propensity score matched outcomes of diaphragmatic resections compared to stripping in cytoreductive surgery + intra-peritoneal chemotherapy — B. Singh, G. Singh, et al. (2020)
• Evolution of locoregional treatment for peritoneal carcinomatosis: single-center experience of 308 procedures of cytoreductive surgery and perioperative intraperitoneal chemotherapy — T.C. Chua, W. Liauw, et al. (2011)

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