Outcomes of repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal surface malignancy

Our plain-English summary of Outcomes of repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal surface malignancy, by K.I. Votanopoulos, C. Ihemelandu, P. Shen, et al (Journal of the American College of Surgeons, 2012).

The study

• Authors: K.I. Votanopoulos, C. Ihemelandu, P. Shen, J.H. Stewart, G.B. Russell, E.A. Levine
• Journal: Journal of the American College of Surgeons
• Published: 2012;215(3):412-7
• Cited by: 66 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has improved the survival of patients with peritoneal surface malignancy. On recurrence, a repeat CRS/HIPEC is a treatment option.

Study Design: A retrospective analysis of 868 CRS/HIPEC procedures was performed. Type of primary, functional status, completion of resection, hospitalization, morbidity, mortality, and survival were reviewed.

Results: Sixty-two patients (7.7%) underwent a second CRS/HIPEC, including 33 patients with appendiceal primaries, 8 ovarian, 7 mesotheliomas, 4 colon cancers, and 10 various malignancies. Median follow-up was 60.8 months. Median overall survival in months was 85.3 for appendiceal cancer, 52.9 for mesothelioma, 60.1 for ovarian, and 137.4 for colon cancer. R1 resection was achieved in 43.5% after both procedures. Median survival after the second cytoreduction was 52.1 months for appendiceal cancer, 21.8 for mesothelioma, 53.9 for ovarian, and 55.7 for colon cancer. Median survival was 55.7 months for R1 resection, 20.3 months for R2a resection, and 15.5 months for R2b-R2c. Median ICU and hospital stay was 1 and 7.5 days, respectively. The 30-day morbidity after the second CRS/HIPEC was 48.4% and mortality was 3.2%. In multivariate analysis, the R status of the second CRS/HIPEC (p = 0.013) and the interval between the 2 procedures (p = 0.009) were significant in predicting improved survival.

Conclusions: In experienced tertiary centers and for selected patients, a repeat CRS/HIPEC procedure has morbidity and mortality similar to the initial cytoreduction. Survival depends primarily on the completion of the repeat cytoreduction and favorable biology of the tumor.

Published by Elsevier Inc.

In plain English

This study looked back at patients treated at one institution from 1993 to 2010. Each had cancer in the lining of the abdomen (the peritoneum) that came back after an operation called cytoreductive surgery with heated chemotherapy (CRS/HIPEC). Sixty-two patients, a highly selected group drawn from 868 treated with CRS/HIPEC, had a second such operation. Seven of them had malignant mesothelioma. The article does not discuss asbestos.

After the repeat operation, median survival was 32.2 months for all 62 patients and 21.8 months for the mesothelioma patients. Patients left with no visible tumor (R0/R1) lived a median of 55.7 months. Patients left with visible tumor lived a median of 20.3 months (R2a) and 15.5 months (R2b to R2c). Two patients (3.2%) died within 30 days.

In the statistical analysis, two things were linked to longer survival: how completely tumor was removed in the second operation, and the time between the two operations. The authors concluded that, for selected patients in experienced centers, a repeat operation carried complication and death rates similar to the first. They noted the study was retrospective, came from one institution, and included patient 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 of CRS/HIPEC procedures at a single institution (surgical outcomes study)
• Who was studied: 62 patients who had 66 repeat CRS/HIPEC procedures for cancer recurring in the abdominal lining, 1993 to 2010, at one institution. They were a highly selected subset of the 868 who had CRS/HIPEC. Primary tumors: 33 appendiceal, 8 ovarian, 7 malignant mesothelioma, 4 colon/colorectal, 10 other types. Mean age was 46.4 years.
• Exposure: Not an asbestos exposure study. What was studied was a treatment: a second (repeat) cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for recurrent peritoneal disease. No fiber type or asbestos exposure is mentioned.
• Main results:
  • Median overall survival after the repeat CRS/HIPEC was 32.2 months for all 62 patients.
  • Median survival after the second CRS/HIPEC differed by type of tumor: 52.1 months for appendiceal cancer, 21.8 months for mesothelioma (7 patients), 53.9 months for ovarian cancer and 55.7 months for colon cancer.
  • Median overall survival counted from the first procedure was 52.9 months for mesothelioma, 60.1 months for ovarian cancer and 137.4 months for colon cancer (85.3 months for appendiceal cancer).
  • After the second procedure, patients left with no visible tumor (R0/R1) had a median survival of 55.7 months. This compared with 20.3 months for R2a and 15.5 months for R2b to R2c. The authors called the difference significant.
  • For all 62 patients, overall survival after the repeat procedure was 78.7% at 1 year, 48.6% at 3 years and 31.6% at 5 years.
  • Two patients (3.2%) died within 30 days of the repeat procedure.
  • Postoperative complications occurred in 43.5% (27 patients) according to the results section. The abstract and Table 2 give a different figure (see text problems).
  • Median hospital stay after the repeat procedure was 7.5 days, with a range of 4 to 49 days.
  • In multivariate analysis, two factors predicted improved survival: completeness of resection at the second procedure (p 0.013) and the interval between the two procedures (p 0.009).
  • In the same analysis, two factors were not significant predictors of overall survival: completeness of resection at the first procedure (p 0.28) and the type of primary tumor (p 0.20).
• The authors' conclusion: The authors concluded that, in experienced tertiary centers and for selected patients, a repeat CRS/HIPEC has morbidity and mortality similar to the first operation. They also concluded that survival depends mainly on how completely the repeat surgery removes the tumor and on the tumor's favorable biology. They stated that they do not claim the results apply to every patient.
• Limitations the authors state:
  • The study was a retrospective review from a single institution.
  • Patients were selected based on clinical experience, mainly performance status and favorable tumor behavior, so patient selection bias is part of the reported outcomes.
  • The authors stated that the results do not apply to every patient with peritoneal surface disease.

Topics

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

Related studies

• 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)
• 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)
• Multicystic peritoneal mesothelioma: outcomes and patho-biological features in a multi-institutional series treated by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — D. Baratti, M. Vaira, et al. (2010)
• 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)
• 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)
• Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent peritoneal metastases — T.C. Chua, L.E. Quinn, et al. (2013)

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