Multicentric initial experience with the use of the pressurized intraperitoneal aerosol chemotherapy (PIPAC) in the management of unresectable peritoneal carcinomatosis

Our plain-English summary of Multicentric initial experience with the use of the pressurized intraperitoneal aerosol chemotherapy (PIPAC) in the management of unresectable peritoneal carcinomatosis, by M. Alyami, J. Gagniere, O. Sgarbura, et al (European Journal of Surgical Oncology, 2017).

The study

• Authors: M. Alyami, J. Gagniere, O. Sgarbura, D. Cabelguenne, L. Villeneuve, D. Pezet, F. Quenet, O. Glehen, N. Bakrin, G. Passot
• Journal: European Journal of Surgical Oncology
• Published: 2017;43(11):2178-2183
• Cited by: 87 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: PIPAC is a recent approach for intraperitoneal chemotherapy with promising results for patients with peritoneal carcinomatosis (PC). We aimed to evaluate the postoperative outcome of PIPAC in patients with non-resectable PC during our initial experience of the technique.

Methods: All patients who underwent PIPAC for non-resectable PC in three centers were analyzed regarding postoperative outcomes.

Results: Seventy-three patients underwent 164 PIPAC. PC was from colorectal, gastric, ovarian, malignant mesothelioma, pseudomyxoma peritonei or other origins in 20, 26, 13, 8, 1 and 5 patients respectively. Forty-five (62%), 31 (42%), 8 (11%), 6 (8%), 1 (1%) patients underwent a second, third, fourth, fifth, and sixth PIPAC respectively. At the time of the first PIPAC, the median PCI was 17 (1-39), 57 patients presented with symptomatic PC (pain: 33; ascites: 35; transit disorder like diarrhea and constipation: 11). PCI improved in 64.5% of patients, 63.5% of patients presented with complete disappearance of symptoms. Major complications occurred as the outcome of 16 PIPAC (9.7%) and 5 (6.8%) patients died within 30 days of the PIPAC procedure. Rate of mortality and major complications 40% and 62% respectively occurred in first 20 treated patients. For 64 (88%) patients, systemic chemotherapy was associated with PIPAC and could be administered after PIPAC with a median delay of 14 days (2-28).

Conclusions: Implementing a PIPAC program in association with systemic chemotherapy is feasible and is associated with a risk of postoperative morbidity, even in teams highly experienced in PC management and requires a learning curve in patient selection.

Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

In plain English

This study reviewed the first year of pressurized intraperitoneal aerosol chemotherapy (PIPAC), chemotherapy sprayed into the abdomen as a pressurized mist during keyhole surgery, at three French hospitals. From December 2015 to December 2016, 73 patients with unremovable peritoneal carcinomatosis (cancer spread in the abdominal lining) had 164 PIPAC procedures. Eight had malignant mesothelioma; the rest had gastric, colorectal, ovarian or other cancers. The article does not discuss asbestos or report mesothelioma patients separately. Major complications followed 16 procedures (9.7%), and 5 patients (6.8%) died within 30 days. Of deaths and major complications, 40% and 62% respectively occurred in the first 20 patients. A disease-extent score reportedly fell in 32 (64.5%) patients at the third cycle, yet only 31 had a third cycle, so this figure is unclear. The authors reported complete symptom disappearance in 63.5% of 57 symptomatic patients, but their results give separate per-symptom rates after the third cycle, so the timing is unclear. The authors concluded that starting PIPAC carries complication risks even for experienced teams. They did not measure quality of life or follow patients long term.

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 case series drawn from a prospectively maintained database at three centers
• Who was studied: 73 patients with non-resectable peritoneal carcinomatosis treated with PIPAC between December 2015 and December 2016 at 3 French tertiary university hospitals. PC origin was colorectal (20), gastric (26), ovarian (13), malignant mesothelioma (8), pseudomyxoma peritonei (1) and other (5).
• Exposure: The treatment studied was PIPAC: chemotherapy given as a pressurized aerosol into the abdomen. The drugs were cisplatin followed by doxorubicin, oxaliplatin alone, or mitomycin C alone. Asbestos exposure is not studied or mentioned.
• Main results:
  • Among the 73 patients, PC origin was colorectal, gastric, ovarian, malignant mesothelioma, pseudomyxoma peritonei or other in 20, 26, 13, 8, 1 and 5 patients respectively.
  • 45 patients (62%) had a second PIPAC, 31 (42%) a third, 8 (11%) a fourth, 6 (8%) a fifth and 1 (1%) a sixth.
  • At the first PIPAC, the median Peritoneal Cancer Index (PCI, a score of disease extent) was 19 (range 1 to 39).
  • Major complications (CTCAE grade III or IV) within 30 days followed 16 of 164 PIPAC procedures (9.7%), and 5 patients (6.8%) died within 30 days.
  • Of the 5 deaths, 2 were from disease progression, 1 from aspiration pneumonia during general anesthesia and 2 from intestinal obstruction after a PIPAC cycle.
  • Of the deaths and of the major complications, 40% and 62% respectively occurred in the first 20 patients treated.
  • The article reports that PCI decreased in 32 (64.5%) patients at the third PIPAC cycle. This conflicts with its own report that only 31 patients had a third PIPAC, and the denominator behind 64.5% is not stated.
  • Among patients with symptoms before treatment, complete disappearance after the 3rd PIPAC was reported in 21 (63.3%) with pain, 21 (60%) with ascites and 5 (45.5%) with transit disorders.
  • In the discussion, the authors state that 63.5% of the 57 patients with preoperative PC-related symptoms had complete disappearance of symptoms. The timing and the denominator behind this overall figure are not explained, and only 31 patients had a third PIPAC.
  • All 64 patients who had systemic chemotherapy with PIPAC restarted it after PIPAC, with a median delay of 14 days (range 4 to 28).
  • Six patients went on to cytoreductive surgery and HIPEC after their disease responded and was judged resectable: 5 after 3 PIPAC cycles and 1 after 6.
• The authors' conclusion: The authors concluded that implementing a PIPAC program carries a risk of postoperative complications even in teams highly experienced in managing peritoneal carcinomatosis.
• Limitations the authors state:
  • The patient group was mixed with respect to cancer origin, number of previous chemotherapy lines and chemo-sensitivity.
  • Quality of life was not evaluated.
  • There was no long-term follow-up.

Topics

Medical terms in this study, explained in our Lexicon: Chemotherapy, Unresectable, Malignant Mesothelioma, Ascites.

Related studies

• Multicenter comprehensive methodological and technical analysis of 832 pressurized intraperitoneal aerosol chemotherapy (PIPAC) interventions performed in 349 patients for peritoneal carcinomatosis treatment: An international survey study — M. Nowacki, M. Alyami, et al. (2018)
• Unresectable peritoneal metastasis treated by pressurized intraperitoneal aerosol chemotherapy (PIPAC) leading to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy — M. Alyami, F. Mercier, et al. (2021)
• Quality of life of patients with end-stage peritoneal metastasis treated with Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) — K. Odendahl, W. Solass, et al. (2015)
• Oxaliplatin use in pressurized intraperitoneal aerosol chemotherapy (PIPAC) is safe and effective: A multicenter study — O. Sgarbura, M. Hübner, et al. (2019)
• Pressurised intraperitoneal aerosol chemotherapy: rationale, evidence, and potential indications — M. Alyami, M. Hübner, et al. (2019)
• What made hyperthermic intraperitoneal chemotherapy an effective curative treatment for peritoneal surface malignancy: A 25-year experience with 1,125 procedures — G. Passot, D. Vaudoyer, et al. (2016)

Browse more research in European Journal of Surgical Oncology, or return to medical research.