Long-term results of laparoscopic cytoreductive surgery and HIPEC for the curative treatment of low-grade pseudomyxoma peritonei and multicystic mesothelioma

Our plain-English summary of Long-term results of laparoscopic cytoreductive surgery and HIPEC for the curative treatment of low-grade pseudomyxoma peritonei and multicystic mesothelioma, by F. Mercier, G. Jeremie, M. Alyami, et al (Surgical Endoscopy, 2020).

The study

• Authors: F. Mercier, G. Jeremie, M. Alyami, V. Delphine, K. Vahan, R. Pascal, I. Sylvie, P. Guillaume, G. Olivier
• Journal: Surgical Endoscopy
• Published: 2020;34(11):4916-4923
• Cited by: 20 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provide long-term survival for low-grade pseudomyxoma peritonei (PMP) and multicystic peritoneal mesothelioma (MM). Feasibility of laparoscopic CRS-HIPEC has been reported for selected patients but data regarding long-term outcomes are missing to assess the oncological interest. This study aimed to report long-term outcomes for low-grade PMP and MM treated by laparoscopic approach.

Methods: From a prospectively maintained CRS-HIPEC database, all patients who underwent laparoscopic CRS-HIPEC with curative intent were analyzed. Selection criteria for laparoscopic approach were low-grade PMP or MM, with pathological confirmation prior to CRS-HIPEC, ASA 2, age < 75 years, no extrap-eritoneal disease, Peritoneal Cancer Index (PCI) < 10, and a limited history of abdominal surgery.

Results: Between March 2009 and June 2017, 43 patients were scheduled for laparoscopic CRS and HIPEC. Laparoscopic CRS and HIPEC was completed (LSC) in 32 patients and 11 patients were converted to open surgery (CONV). Median age was 44.5 years (17.13-71.4) in the LSC group and 54.9 years (22.5-70.5) in the CONV group (p = 0.086). Median BMI was not different between groups, 21.2 and 23.9 for LSC and CONV groups, respectively (p = 0.267). There were 21 and 11 patients in the LSC group, and 8 and 3 in the CONV group, with PMP and MM, respectively (p = 0.794). Median PCI was 2.5 (0-9) and 7 (1-15) in the LSC and CONV groups, respectively (p = 0.004). There was no difference in the completeness of cytoreduction score (p = 0.256). After a median follow-up of 31.6 months (95% CI 19.3-36.4), 2 patients in the LSC group and 2 patients in the CONV group presented with peritoneal recurrence.

Conclusion: For selected patients with low aggressive peritoneal disease, laparoscopic CRS-HIPEC provides interesting long-term outcomes.

In plain English

This study reviewed patients from one French center's prospectively maintained database. It examined patients with low-grade pseudomyxoma peritonei or multicystic peritoneal mesothelioma who were scheduled for tumor-removal surgery (cytoreductive surgery) plus heated chemotherapy inside the abdomen (HIPEC) by laparoscopy (keyhole surgery). Of 92 patients who had a first cytoreductive surgery with HIPEC for these diseases between March 2009 and June 2017, 43 were planned for the laparoscopic approach. It was completed laparoscopically in 32, and 11 were converted to open surgery. Multicystic mesothelioma accounted for 11 patients in the laparoscopic group and 3 in the converted group. After a median follow-up of 31.6 months (95% CI 19.3 to 36.4), all patients were alive and 4 had a recurrence, 2 in each group. One of these was a patient with multicystic mesothelioma in the converted group. Five-year disease-free survival was 91.04% in the laparoscopic group and 62.5% in the converted group. The authors concluded that results appeared favorable in this highly selected population but need confirmation in larger cohorts with longer follow-up. They noted that follow-up was limited for such slow-growing tumors. The article does not discuss asbestos.

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 institutional database at a single surgical center, comparing patients whose laparoscopic surgery was completed with those converted to open surgery
• Who was studied: Patients treated with curative intent for low-grade pseudomyxoma peritonei or multicystic peritoneal mesothelioma at a center in Lyon, France, between March 2009 and June 2017. Of 92 such patients, 43 were considered for laparoscopic surgery. Of these, 32 were completed laparoscopically (21 with pseudomyxoma, 11 with multicystic mesothelioma). The other 11 were converted to open surgery (8 with pseudomyxoma, 3 with multicystic mesothelioma).
• Exposure: No asbestos exposure is reported. The study examined a treatment: cytoreductive surgery followed by HIPEC, started laparoscopically. For multicystic mesothelioma, HIPEC lasted 90 minutes using cisplatin and doxorubicin.
• Main results:
  • Of the 43 patients planned for laparoscopic surgery, 32 (74.4%) had it completed laparoscopically. The other 11 were converted to open surgery, mainly because of technical difficulties related to the extent or location of disease.
  • The laparoscopic group had 21 patients with pseudomyxoma peritonei and 11 with multicystic mesothelioma. The converted group had 8 and 3 respectively (p = 0.794).
  • Median Peritoneal Cancer Index (extent of disease) was 2.5 (range 0 to 9) in the laparoscopic group and 7 (range 1 to 15) in the converted group (p = 0.004).
  • Median follow-up was 31.6 months (95% CI 19.3 to 36.4). All patients were alive at follow-up. Four patients had a recurrence, 2 in the laparoscopic group and 2 in the converted group.
  • In the converted group, one patient with multicystic mesothelioma had a recurrence 20 months after the first surgery and underwent a second open cytoreductive surgery with HIPEC.
  • One- and 5-year overall survival was 100% in both groups. One- and 5-year disease-free survival was 100% and 91.04% in the laparoscopic group. In the converted group it was 100% and 62.5%.
  • Median hospital stay was 11 days (range 6 to 18) in the laparoscopic group and 13 days (range 10 to 19) in the converted group, which the authors reported as statistically longer (p = 0.041).
• The authors' conclusion: The authors concluded that their short-term results appeared favorable in this highly selected patient population. They stated that definitive conclusions need confirmation with larger cohorts and longer follow-up.
• Limitations the authors state:
  • The study was retrospective, had a limited sample size, was subject to inclusion bias, and had missing data, which may have affected the survival analysis.
  • Follow-up was relatively short for such slow-growing tumors, which can recur late, sometimes after 10 years.
  • Larger cohorts and longer follow-up are needed to detect potential late recurrences.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Multicystic Mesothelioma (MCM), Peritoneal Mesothelioma, Peritoneal Cancer Index (PCI).

Related studies

• Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for limited peritoneal metastasis. The PSOGI international collaborative registry — A. Arjona-Sanchez, O. Aziz, et al. (2021)
• Overall survival of pseudomyxoma peritonei and peritoneal mesothelioma patients after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy can be predicted by computed tomography quantified sarcopenia — A. Galan, P. Rousset, et al. (2018)
• Multicystic mesothelioma: Operative and long-term outcomes with cytoreductive surgery and hyperthermic intra peritoneal chemotherapy — E. Nizri, D. Baratti, et al. (2018)
• 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)
• 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 Intraperitoneal Hyperthermic Chemotherapy (HIPEC) by Minimally Invasive Approach, an Initial Experience — A. Arjona-Sanchez, S. Rufian-Peña, et al. (2018)

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