Treatment of primary and metastatic peritoneal tumors in the Covid-19 pandemic. Proposals for prioritization from the RENAPE and BIG-RENAPE groups

Our plain-English summary of Treatment of primary and metastatic peritoneal tumors in the Covid-19 pandemic. Proposals for prioritization from the RENAPE and BIG-RENAPE groups, by O. Glehen, V. Kepenekian, O. Bouché, et al (Journal of Visceral Surgery, 2020).

The study

• Authors: O. Glehen, V. Kepenekian, O. Bouché, L. Gladieff, C. Honore, RENAPE-BIG-RENAPE
• Journal: Journal of Visceral Surgery
• Published: 2020;157(3S1):S25-S31
• Type of article: Review
• Cited by: 14 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

The Covid-19 pandemic is profoundly changing the organization of healthcare access. This is particularly so for peritoneal neoplastic diseases, for which curative treatment mobilizes substantial personnel, operating room and intensive care resources. The BIG-RENAPE and RENAPE groups have made tentative proposals for prioritizing care provision. A tightening of the usual selection criteria is needed for curative care: young patients with few or no comorbidities and limited peritoneal extension. It is desirable to prioritize disease conditions for which cytoreduction surgery with or without associated hyperthermic intraoperative peritoneal chemotherapy (HIPEC) is the gold-standard treatment, and for which systemic chemotherapy cannot be a temporary or long-term alternative: pseudomyxoma peritonei, resectable malignant peritoneal mesotheliomas, peritoneal metastases of colorectal origin if they are resectable and unresponsive to systemic chemotherapy after up to 12 courses, first-line ovarian carcinomatosis if resectable or in interval surgery after at most six courses of systemic chemotherapy. Addition of HIPEC must be discussed case by case in an expert center. The prioritization of indications must consider local conditions and the phase of the epidemic to allow optimal peri-operative care.

Copyright © 2020 Elsevier Masson SAS. All rights reserved.

In plain English

This was a review with treatment proposals, not a patient study. Written by the French RENAPE and BIG-RENAPE groups during the Covid-19 epidemic, it addressed treatment priorities for cancers of the abdominal lining (peritoneum), including malignant peritoneal mesothelioma. The article did not discuss asbestos. The authors called their suggestions "ways forward rather than guidelines." They proposed stricter selection for curative surgery, favoring young patients with few other illnesses and limited disease. For resectable malignant peritoneal mesothelioma, they proposed surgery removing all visible tumor plus heated chemotherapy inside the abdomen (HIPEC) first, without prior chemotherapy. Citing earlier work, they noted median survival of one year with chemotherapy alone versus over 50 months after complete surgery with HIPEC in expert centers. If surgery could not be scheduled, complete removal was doubtful, or poor prognosis factors were present, they proposed cisplatin (or carboplatin) with pemetrexed. Proposals for other peritoneal cancers differed by disease: for ovarian metastases, HIPEC was not recommended with first-line primary surgery but discussed case by case for interval surgery. They noted no data yet allowed objective comparison of Covid-19 risk between surgery and chemotherapy.

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: Review with expert proposals (not guidelines) from the RENAPE and BIG-RENAPE groups
• Who was studied: No patients were studied. The proposals concern patients in France with primary or metastatic peritoneal tumors during the Covid-19 epidemic, including pseudomyxoma peritonei, malignant peritoneal mesothelioma, and peritoneal metastases of colorectal, gastric, ovarian and unusual origin.
• Exposure: Not applicable. The article does not discuss asbestos or any other cause of disease. It concerns treatment choices (cytoreduction surgery, HIPEC, systemic chemotherapy) during the Covid-19 epidemic.
• Main results:
  • General proposal for all peritoneal cancers: give priority to young patients, those with the fewest other illnesses, and those with limited peritoneal disease.
  • The authors proposed making no recommendation to prefer chemotherapy over surgery, or over no therapy, on the basis of Covid-19 risk.
  • Citing earlier studies that the authors described as having low levels of proof: in people with cancer, the risk of a severe form of Covid-19 was five times higher than in people without cancer, and the risk of death was multiplied by eight.
  • For resectable malignant peritoneal mesothelioma, the authors proposed cytoreduction surgery with HIPEC as the first treatment, without chemotherapy beforehand.
  • From the literature the authors reviewed on peritoneal mesothelioma: median survival was one year with systemic chemotherapy alone, against more than 50 months after complete cytoreduction with HIPEC in expert centers.
  • From Italian and French studies the authors cited: chemotherapy given before surgery had a negative effect on overall survival in patients with resectable peritoneal mesothelioma.
  • For peritoneal mesothelioma when surgery could not be scheduled locally, complete removal was doubtful, or poor prognosis factors were present, the authors proposed chemotherapy with cisplatin (or carboplatin) and pemetrexed.
  • For asymptomatic borderline forms of mesothelioma (multicystic and well-differentiated papillary), the authors proposed that surgery could wait until the epidemic waned.
  • For peritoneal metastases of ovarian origin, the authors proposed that HIPEC is not recommended with first-line primary surgery or in platinum-sensitive recurrence.
  • For peritoneal metastases of ovarian origin, the authors proposed that HIPEC be discussed case by case in expert centers for interval surgery and for platinum-resistant recurrence.
• The authors' conclusion: The authors concluded that prioritizing treatment indications must take account of local conditions and the phase of the epidemic, so that care around the time of surgery can be optimal.
• Limitations the authors state:
  • The authors stated that no data were yet available to objectively assess the relative Covid-19 risk with chemotherapy or major surgery, or the effect on prognosis of no therapy, prolonged chemotherapy, or major surgery.
  • The authors stated that the preliminary data on Covid-19 risk in cancer patients came from studies with low levels of proof.
  • For peritoneal metastases of unusual origin, the authors stated that the scientific proof from the limited retrospective cohorts is not high.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, Chemotherapy, HIPEC, Peritoneal Mesothelioma.

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