Repeated cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with recurrent peritoneal carcinomatosis

Our plain-English summary of Repeated cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with recurrent peritoneal carcinomatosis, by N. Vassos, T. Förtsch, A. Aladashvili, et al (World Journal of Surgical Oncology, 2016).

The study

• Authors: N. Vassos, T. Förtsch, A. Aladashvili, W. Hohenberger, R.S. Croner
• Journal: World Journal of Surgical Oncology
• Published: 2016;14(1):42
• Cited by: 20 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the treatment of choice for resectable peritoneal carcinomatosis (PC) and improved the survival of these patients. The situation changes if PC recurs and repeated CRS with HIPEC is considered. The patient selection and outcome of the repeated approach has not been well described. We analyzed our cohort and share the experiences.

Methods: Ninety-three CRS/HIPEC procedures, performed in 85 patients during the period 2001-2013, were examined in a retrospective analysis. Type of primary, ECOG status, peritoneal cancer index (PCI), completeness of cytoreduction (CC), duration of hospitalization, postoperative morbidity, mortality, and disease-free/overall survival were reviewed.

Results: Six patients (7%) underwent a second CRS/HIPEC (median interval between the two procedures: 26 months, range 8-61) including two patients with mesotheliomas, one patient with ovarian adenocarcinoma, one patient with leiomyosarcoma of uterus, one patient with colon adenocarcinoma, and one patient with appendiceal adenocarcinoma. The last two patients underwent a third CRS/HIPEC, 25 and 36 months, after the second procedure. The median PCI was 14 (range, 4-26) during the first and 20 (range, 7-39) during the second CRS/HIPEC of these patients. Completeness of cytoreduction score of 0 (CC-0) was achieved in all first procedures and in 67% of second procedures (CC-0; n=4 and CC-1; n=2). A CC-0 score was possible in both of the third procedures. The mean operating time was 444 min (range, 198-642) and 427 min (range, 239-617) during the first and the second procedure. Median intensive care unit (ICU) was 2 days, and hospital stay after second CRS/HIPEC was 17 days (range, 7-50). The 30-day morbidity after repeated CRS/HIPEC was 33% (16% for grade III-IV complications), and there was no 30-day mortality neither after the second nor after the third CRS/HIPEC. Median disease-free interval between first CRS/HIPEC and peritoneal recurrence was 17 months (range, 8-30). Median disease-free survival of 18 months (range, 4-33) was achieved after the second CRS/HIPEC. After a median follow-up of 74 months (range, 39-151), all patients are alive with disease (n=5) or disease free (n=1) under chemotherapy.

Conclusions: In experienced centers, repeated CRS/HIPEC can be performed with safety. Patient selection and correct timing is of particular importance in achieving control of the disease. Repeated CRS/HIPEC should be considered as treatment option for selected patients with recurrent PC.

In plain English

This retrospective study from the University Hospital Erlangen, Germany, looked at patients whose cancer on the lining of the abdomen (peritoneal carcinomatosis) came back after a combined treatment: surgery to remove visible tumor followed by heated chemotherapy circulated in the abdomen (CRS/HIPEC). Between 2001 and 2013, 85 patients had 93 procedures. Six of them (7 %) had the procedure repeated, and two of those six had malignant peritoneal mesothelioma. The article does not discuss asbestos. All six first operations scored CC-0 on the scale for tumor left behind. At the second operation, four patients scored CC-0 and two scored CC-1. Complications within 30 days of a repeat procedure occurred in 33 %, including one serious complication (16 %). None of the six patients died within 30 days of a second or third procedure. Median disease-free survival after the second procedure was 18 months. After a median follow-up of 74 months, all six patients were alive, five with disease and one disease-free, all receiving chemotherapy. The authors concluded that in experienced centers, repeated CRS/HIPEC can be performed safely in selected patients. They acknowledged the small number of patients, the retrospective design and 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 single-institution case series
• Who was studied: Six patients who had repeated CRS/HIPEC (five women, one man; mean age 48, range 16 to 64). They came from 85 patients who had 93 CRS/HIPEC procedures between 2001 and 2013 at the University Hospital Erlangen, Germany. Their primary tumors were malignant peritoneal mesothelioma (2), ovarian carcinoma (1), leiomyosarcoma of uterus (1), colon carcinoma (1) and appendiceal carcinoma (1).
• Exposure: No asbestos or fiber exposure is reported. The study examined a treatment: repeated cytoreductive surgery followed by heated intraperitoneal chemotherapy with mitomycin C 20 mg/m2 or cisplatin 50 mg/m2 at 42 °C. Cisplatin was used for peritoneal mesothelioma.
• Main results:
  • Among the six repeat patients, a CC-0 score was achieved in all first procedures and in 67 % of second procedures (CC-0 in 4, CC-1 in 2). Both third procedures achieved CC-0.
  • In the six repeat patients, median peritoneal cancer index was 14 (range 4 to 26) at the first procedure. At the second procedure it was 20 (range 7 to 39) according to the abstract; the Results section gives 21 (range 11 to 39).
  • 30-day morbidity after repeated CRS/HIPEC was 33 % (2 of 6 patients), with 16 % for grade III to IV complications. Morbidity in the full cohort of 85 after one CRS/HIPEC was 21 %.
  • Among the six repeat patients, there were no deaths within 30 days after the second or third CRS/HIPEC. Among the 79 patients who did not have a repeat procedure, five died during the hospital stay (postoperative mortality 6 %).
  • Operating time was 427 min at the repeat procedure versus 444 min at the initial procedure. The difference was not statistically significant.
  • In the six repeat patients, median disease-free survival after the second CRS/HIPEC was 18 months (range 4 to 33).
  • After a median follow-up of 74 months (range 39 to 151) from the first procedure, all six repeat patients were alive: five with disease and one disease-free, all under chemotherapy.
  • One of the two peritoneal mesothelioma patients recurred after the second procedure with no direct option for further treatment. Per Table 2, at last follow-up one mesothelioma patient (male, 60) was alive with progressive disease under chemotherapy. The other (female, 16) was alive with no evidence of disease under chemotherapy.
• The authors' conclusion: The authors concluded that in experienced centers repeated CRS/HIPEC can be performed safely. They also concluded that it could be considered for highly selected patients with recurrent peritoneal carcinomatosis.
• Limitations the authors state:
  • Small number of patients and retrospective design
  • Selection bias, because the patients offered repeat procedures were highly selected
  • Confounding by different chemotherapy regimens and by systemic therapy
  • The results cannot be applied to every patient with peritoneal surface disease

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Peritoneal Cancer Index (PCI), Overall Survival, Mesothelioma, Adenocarcinoma, Disease-Free Survival, Chemotherapy.

Related studies

• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)
• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, 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)
• Cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for children, adolescents, and young adults: the first 50 cases — A. Hayes-Jordan, H. Green, et al. (2015)
• The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — S. Kusamura, P.A. Torres Mesa, et al. (2016)
• Clinical course for patients with peritoneal carcinomatosis excluded from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy — A.P. Rodt, R.O. Svarrer, et al. (2013)

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