The Safety of Iterative Cytoreductive Surgery and HIPEC for Peritoneal Carcinomatosis: A High Volume Center Prospectively Maintained Database Analysis

Our plain-English summary of The Safety of Iterative Cytoreductive Surgery and HIPEC for Peritoneal Carcinomatosis: A High Volume Center Prospectively Maintained Database Analysis, by E. Bekhor, J. Carr, M. Hofstedt, et al (Annals of Surgical Oncology, 2020).

The study

• Authors: E. Bekhor, J. Carr, M. Hofstedt, B. Sullivan, D. Solomon, N. Leigh, N. Bolton, B. Golas, U. Sarpel, D. Labow, D. Magge
• Journal: Annals of Surgical Oncology
• Published: 2020;27(5):1448-1455
• Cited by: 22 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: Offering iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for recurrence of peritoneal carcinomatosis (PC) poses a surgical dilemma. Safety of this repeated operation in the short and long term has not been largely investigated.

Methods: Patients with PC who underwent 377 CRS/HIPEC procedures between 2007 and 2018 at our institution were included from a prospectively maintained database. Outcomes for patients who had singular CRS/HIPEC were compared with those for patients who had repeated CRS/HIPEC.

Results: Overall, there were 325 singular and 52 iterative CRS/HIPEC procedures performed during this time period. Age, sex, and ASA class were comparable between cohorts (p = NS). Optimal cytoreduction, mean operative time, mean length of hospital stay, 90-day major morbidity, and 90-day mortality were also similar. At a median follow-up of 24 months, there was no significant difference in recurrence rate (%, 60 vs 63, p = 0.76), disease-free survival (mean months, 19 vs 15, p = 0.30), and overall survival (mean months, 32 vs 27, p = 0.69). The iterative CRS/HIPEC group had significantly higher rates of major late complications than the singular CRS/HIPEC group (%, 18 vs 40, p < 0.01).

Conclusion: Repeated CRS/HIPEC for PC has similar perioperative morbidity and mortality, as well as long-term oncological benefits, when compared with singular CRS/HIPEC. However, more than twice as many patients undergoing iterative CRS/HIPEC suffered from major late complications.

In plain English

This study reviewed a database of 377 operations, recorded as they happened, at Mount Sinai Hospital, New York, from 2007 to 2018. The operations, which combined tumor-removing surgery with heated chemotherapy in the abdomen (CRS/HIPEC), treated peritoneal carcinomatosis, cancer spread across the abdominal lining. The authors compared 325 patients who had the operation once with 52 repeat (iterative) operations. Malignant diffuse mesothelioma was the tumor origin for 23 single-operation patients (7%) and 1 repeat patient (2%). The article does not discuss asbestos. Within 90 days, major complications (21% vs 25%) and deaths (3% vs 0%) did not differ significantly. At a median 24-month follow-up, recurrence (60% vs 63%) and mean overall survival (32 vs 27 months) were similar. Major late complications (those arising or persisting beyond 3 months that caused severe symptoms or required hospitalization, transfusion or an operation) occurred in 18% of the single-operation group and 40% of the repeat group, a significant difference. Among the variables examined within the repeat group, none predicted these late complications. The authors concluded that repeat patients had similar cancer outcomes but higher rates of major late complications.

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 single-institution surgical database, comparing singular with iterative (repeat) CRS/HIPEC
• Who was studied: Patients with peritoneal carcinomatosis who had 377 CRS/HIPEC procedures between 2007 and 2018 at Mount Sinai Hospital, New York. There were 325 singular procedures and 52 iterative procedures (47 second, 4 third, 1 fourth). Tumor origins included colorectal, appendiceal adenocarcinoma, low-grade appendiceal mucinous neoplasm, gastric, malignant diffuse mesothelioma (23 singular, 1 iterative), ovarian, small bowel and melanoma.
• Exposure: The exposure studied was the treatment itself: repeat versus single cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, most often using mitomycin-C. Asbestos exposure is not studied or mentioned.
• Main results:
  • Major late complications occurred in 59 of 325 (18%) in the singular group and 21 of 52 (40%) in the iterative group, with p less than 0.01. These were defined as complications occurring or persisting more than 3 months after surgery that caused severe symptoms or required hospitalization, transfusion, or an operation.
  • Compared with the iterative group, the singular group had lower rates of fistulas (3% vs 15%, p less than 0.01), small bowel obstructions (5% vs 13%, p = 0.03) and ureteral obstructions (2% vs 8%, p = 0.03).
  • The singular and iterative groups did not differ significantly in 90-day major morbidity (Clavien-Dindo class 3 or 4, 21% vs 25%), 90-day re-operation (10% vs 17%) or 90-day mortality (3% vs 0%).
  • At a median follow-up of 24 months, the singular and iterative groups had similar recurrence (60% vs 63%), mean disease-free survival (19 vs 15 months) and mean overall survival (32 vs 27 months).
  • Within the iterative group, none of the demographic, preoperative or operative variables examined predicted major late complications. The examined variables included age, sex, smoking, ASA class, obesity, tumor origin, PCI, CC score and blood loss.
  • In the iterative group, major late complications did not predict prognosis on univariate analysis.
  • Major late complications overall did not differ significantly between the earlier and later halves of the study period (22% vs 20%). The exception was abdominal wall impairment, which occurred more often in 2013 to 2018.
• The authors' conclusion: The authors concluded that patients undergoing iterative CRS/HIPEC have cancer outcomes similar to those of patients with a single procedure but higher rates of major late complications. They also concluded that risks and benefits should be weighed case by case.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma, Peritoneal mesothelioma.

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Disease-Free Survival, Overall Survival.

Related studies

• Repeat Cytoreductive Surgery and HIPEC for Peritoneal Surface Malignancy and Peritoneal Carcinomatosis — J.F. Wong, G.H. Tan, et al. (2015)
• 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)
• Evolution of locoregional treatment for peritoneal carcinomatosis: single-center experience of 308 procedures of cytoreductive surgery and perioperative intraperitoneal chemotherapy — T.C. Chua, W. Liauw, et al. (2011)
• Current practice in cytoreductive surgery and HIPEC for metastatic peritoneal disease: Spanish multicentric survey — R. Morales-Soriano, N. Esteve-Pérez, et al. (2018)
• Target region resection in patients undergoing cytoreductive surgery for peritoneal metastases-is it necessary in absence of visible disease? — A. Bhatt, Y. Yonemura, et al. (2020)
• Long-term results of laparoscopic cytoreductive surgery and HIPEC for the curative treatment of low-grade pseudomyxoma peritonei and multicystic mesothelioma — F. Mercier, G. Jeremie, et al. (2020)

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