Repeat Cytoreductive Surgery and HIPEC for Peritoneal Surface Malignancy and Peritoneal Carcinomatosis

Our plain-English summary of Repeat Cytoreductive Surgery and HIPEC for Peritoneal Surface Malignancy and Peritoneal Carcinomatosis, by J.F. Wong, G.H. Tan, W. Wang, et al (World Journal of Surgery, 2015).

The study

• Authors: J.F. Wong, G.H. Tan, W. Wang, K.C. Soo, M.C. Teo
• Journal: World Journal of Surgery
• Published: 2015;39(6):1578-83
• Cited by: 23 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Peritoneal-based malignancy (PBM), especially peritoneal carcinomatosis from gastrointestinal malignancies traditionally carries a poor prognosis. Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) have been shown to attain long median survival of 34-92 months and 5 year survival of 29-59% in patients with favorable histopathological subtypes. Recurrence after CRS and HIPEC poses a management dilemma. This paper evaluates our institution's experience with repeat CRS and HIPEC, its associated morbidity and outcomes.

Methods: One-hundred and thirty underwent CRS and HIPEC for PBM from April 2001 to June 2013. 49 had peritoneal recurrences, of which 24 had peritoneal only recurrence. 7 out of the 24 underwent a second CRS and HIPEC.

Results: Five females and two males with median age of 51 (37-63), underwent a second CRS and HIPEC. The primary malignancies were: 1 peritoneal mesothelioma, 3 appendiceal, 2 ovarian, and 1 colorectal cancers. Median peritoneal cancer indices for the initial and second CRS were 19 and 12, respectively. Completeness of cytoreduction score of 0 was achieved for all patients. Median hospitalization after second CRS and HIPEC was 12 days (7-60). 1 out of 7 (14%) experienced grade 3 or 4 post-operative complications. There was no 30-day or inpatient mortality. Median follow-up was 13 months (1-97). Median disease-free interval between the first CRS and HIPEC to peritoneal recurrence was 20 months (14-87). Median disease-free survival of 6 months (1-97) was achieved after the second CRS and HIPEC. Six patients remained alive without disease and one passed away with disease. Two had recurrences at 12 and 71 months after second CRS and HIPEC, 1 died and the other, still alive, went on to have a third CRS.

Conclusion: Repeat CRS and HIPEC can achieve prolonged survival in selected patients with peritoneal-based malignancies, and can be performed with acceptable morbidity and mortality.

In plain English

This was a retrospective review of patients at the National Cancer Centre Singapore, April 2001 to June 2013, who had a second cytoreductive surgery (removal of visible tumor in the abdomen) with heated chemotherapy in the abdomen (HIPEC) after cancer returned in the abdominal lining. Of 130 patients treated once, 24 had recurrence confined to the peritoneum, 11 were recommended for repeat surgery, and 7 had it. One of the seven had peritoneal mesothelioma. The others had appendiceal, ovarian or colorectal cancer. The article does not discuss asbestos. All seven had all visible tumor removed. One had a major complication needing further surgery, and none died within 30 days or in hospital. Median overall survival from the first operation was at least 26 months. For 17 patients with peritoneal-only recurrence who did not have repeat surgery, it was 20 months, given as 16 months elsewhere in the article. A figure gives p = 0.034 for this comparison. The authors acknowledged selection bias and a small patient group. They concluded that repeat surgery may be feasible and confer a survival benefit in selected patients.

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 (review of a prospectively maintained database at one institution)
• Who was studied: 130 patients who had CRS and HIPEC at the National Cancer Centre Singapore, April 2001 to June 2013. 24 had recurrence confined to the peritoneum, 11 were recommended for a second CRS and HIPEC, and 7 had it. The 7 were five females and two males, median age 51 (37 to 63). Primary cancers: appendiceal (3), ovarian (2), colorectal (1), peritoneal mesothelioma (1).
• Exposure: Not an asbestos exposure study. Asbestos is not mentioned. The treatment studied was a second cytoreductive surgery followed by 60 minutes of HIPEC at 42 degrees Celsius. The drug was mitomycin C for colorectal and appendiceal primaries and cisplatin for ovarian or primary peritoneal disease.
• Main results:
  • Of 11 patients recommended for a second CRS and HIPEC, 7 had it. The other 4 were found unresectable because of extensive small bowel involvement.
  • Median peritoneal cancer index was 19 at the first operation and 12 at the second. Complete cytoreduction (CC-0) was achieved in all 7 patients at the second operation.
  • Median hospital stay after the second CRS and HIPEC was 12 days (range 7 to 60).
  • 2 of the 7 patients had post-operative complications: renal impairment (1) and anastomotic leakage (1). Major complications needing invasive intervention occurred in 14% (1 patient). There was no 30-day or inpatient mortality.
  • In the 7 patients, the median disease-free interval from the first CRS and HIPEC to peritoneal recurrence was 20 months (14 to 87).
  • Median disease-free survival after the second CRS and HIPEC was 6 months (1 to 97) in the 7 patients. Median follow-up was 13 months (1 to 97).
  • For the 7 patients who had a second CRS and HIPEC, median overall survival from the initial operation was at least 26 months (11 to 131). For the 17 patients with peritoneal-only recurrence who did not, it was 20 months (2 to 70) in the results and 16 months in the discussion. The survival figure gives p = 0.034.
  • One patient with appendiceal carcinoma had a third CRS without HIPEC about 6 years after the second.
  • One patient died of his disease 20 months after the second operation.
• The authors' conclusion: The authors concluded that repeat CRS and HIPEC can achieve prolonged survival in selected patients with peritoneal-based malignancies, with acceptable morbidity and mortality. They also concluded it may be feasible and confer a survival benefit in patients whose recurrence is confined to the peritoneum after a complete first CRS and HIPEC.
• Limitations the authors state:
  • The authors recognised selection bias in comparing patients who had repeat surgery with those who did not.
  • The authors noted the small number of patients in the series.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Colon cancer, Ovarian cancer.

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Prognosis, Chemotherapy, Median Survival, Peritoneal Mesothelioma, Colorectal Cancer, Disease-Free Survival.

Related studies

• Risk of definitive stoma after surgery for peritoneal malignancy in 958 patients: comparative study between complete cytoreductive surgery and maximal tumor debulking — S. Riss, K. Chandrakumaran, et al. (2015)
• Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion in Adolescent and Young Adults with Peritoneal Metastases — M. Dhir, L. Ramalingam, et al. (2017)
• The results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1200 patients with peritoneal malignancy — B. Moran, T. Cecil, et al. (2015)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)
• Current practice in cytoreductive surgery and HIPEC for metastatic peritoneal disease: Spanish multicentric survey — R. Morales-Soriano, N. Esteve-Pérez, et al. (2018)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in Asian patients: 100 consecutive patients in a single institution — M.C. Teo, G.H. Tan, et al. (2013)

Browse more research in World Journal of Surgery, or return to medical research.