Unresectable peritoneal metastasis treated by pressurized intraperitoneal aerosol chemotherapy (PIPAC) leading to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Our plain-English summary of Unresectable peritoneal metastasis treated by pressurized intraperitoneal aerosol chemotherapy (PIPAC) leading to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, by M. Alyami, F. Mercier, M. Siebert, et al (European Journal of Surgical Oncology, 2021).

The study

• Authors: M. Alyami, F. Mercier, M. Siebert, P.E. Bonnot, N. Laplace, L. Villeneuve, G. Passot, O. Glehen, N. Bakrin, V. Kepenekian
• Journal: European Journal of Surgical Oncology
• Published: 2021;47(1):128-133
• Type of article: Review
• Cited by: 58 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: PIPAC is a recent method of intraperitoneal chemotherapy. The aim of this study was to describe the clinical characteristics of the patients who became amenable to CRS & HIPEC after PIPAC treatment.

Methods: All patients diagnosed with unresectable PM who became resectable throughout PIPAC treatment were included. Outcome criteria were adverse events following PIPAC procedure and rate of secondary CRS and HIPEC.

Results: Four hundred thirty-seven PIPAC were done in 146 consecutive patients. Among them, 26 patients (17.8%) who underwent 76 PIPAC were scheduled for CRS and HIPEC after reduction of the peritoneal burden. PM were from gastric, peritoneal mesothelioma, ovarian, colorectal and small bowel in 13, 7, 4, 1 and 1 patients, respectively. At the time of the first PIPAC, median age was 58.6 years (32-76.3). Median PCI was 16 (1-39). All patients had systemic chemotherapy in between PIPAC session. Median consecutive PIPAC procedure was 3 (1-8). Complications occurred in 3 PIPAC session (4%) and there was no major complication (CTCAE III or higher). Complete CRS and HIPEC was achieved in 21 patients of the 26 scheduled (14.4%). The remaining 5 patients were considered unresectable at the exploratory laparotomy. Among patients who underwent CRS and HIPEC, with median follow-up of 7 (1-26) months, 14 patients (66.7%) were alive without recurrence, 2 patients (9.5%) were alive with recurrence and 5 patients (23.8%) died.

Conclusions: Complete CRS and HIPEC can be achieved in strictly selected patient with unresectable PM at diagnosis after repeated PIPAC session with palliative intent.

Copyright © 2019. Published by Elsevier Ltd.

In plain English

This retrospective single-centre study, from a hospital in Lyon, France, looked at patients whose peritoneal metastasis (cancer spread within the abdominal lining) was judged unresectable. They received pressurized intraperitoneal aerosol chemotherapy (PIPAC), which is chemotherapy sprayed into the abdomen during keyhole surgery, together with systemic chemotherapy. Between December 2015 and June 2018, 146 consecutive patients had 437 PIPAC procedures. Of these patients, 26 (17.8%) were later scheduled for cytoreductive surgery with heated abdominal chemotherapy (CRS and HIPEC). Their disease came from gastric (13), malignant mesothelioma (7), ovarian (4), colorectal (1) and small bowel (1) cancers. Complications followed 3 of their PIPAC sessions (4%), and none were major. Complete cytoreduction was achieved in 21 patients, which is 14.4% of the 146. In the other 5, surgery found the disease could not be removed. After surgery, 11 of the 21 (52.3%) had major complications and one died. After a median 7 months of follow-up, 14 were alive without recurrence, 2 were alive with recurrence and 5 had died. The article does not address asbestos. The authors concluded that surgery might become possible for highly selected patients and called for prospective studies. They said their follow-up was too short for long-term conclusions.

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 single institution's peritoneal metastasis database (case series)
• Who was studied: 146 consecutive patients with unresectable peritoneal metastasis treated with PIPAC at Centre Hospitalier Lyon-Sud, France, December 2015 to June 2018; 26 of them were scheduled for CRS and HIPEC
• Exposure: Not an asbestos exposure study. The treatment studied was PIPAC with cisplatin followed by doxorubicin, or oxaliplatin, plus systemic chemotherapy between sessions, followed in selected patients by CRS and HIPEC
• Main results:
  • Of the 146 patients, 26 (17.8%), who had undergone 76 PIPAC procedures, were scheduled for exploratory laparotomy and possible CRS and HIPEC
  • Among the 26 scheduled patients, the metastases came from gastric (13), malignant mesothelioma (7), ovarian (4), colorectal (1) and small bowel (1) cancers
  • Among the 26 scheduled patients, complications occurred after 3 PIPAC sessions (4%), with no major complication (CTCAE III or higher)
  • Complete cytoreduction (CC-0 or CC-1) was achieved in 21 patients (14.4%, a percentage of all 146 patients); the remaining 5 of the 26 scheduled patients were found unresectable at laparotomy
  • After CRS and HIPEC, major complications (CTCAE III, IV) occurred in 11 patients (52.3%), and one patient (4.7%) died after surgery from bowel ischemia
  • At a median follow-up of 7 months (range 1 to 26), of the 21 patients who had CRS and HIPEC, 14 (66.7%) were alive without recurrence, 2 (9.5%) were alive with recurrence and 5 (23.8%) had died
  • Some individual patients had prolonged disease-free survival, including 26 months for a patient with malignant mesothelioma
• The authors' conclusion: The authors concluded that secondary CRS and HIPEC might become possible after repeated PIPAC combined with systemic chemotherapy for highly selected patients, and that prospective studies are needed to determine PIPAC's role before surgery
• Limitations the authors state:
  • Retrospective design, with multiple selection biases possibly affecting which patients were scheduled for surgery
  • Heterogeneous population in origin of metastasis, number of prior chemotherapy lines and tumor chemo-sensitivity
  • Quality of life was not evaluated
  • Follow-up was too short to draw conclusions on long-term results

Topics

Medical terms in this study, explained in our Lexicon: Unresectable, Metastasis, Chemotherapy, Cytoreductive Surgery, HIPEC, Peritoneal Mesothelioma, Laparotomy, Palliative Care.

Related studies

• Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for limited peritoneal metastasis. The PSOGI international collaborative registry — A. Arjona-Sanchez, O. Aziz, et al. (2021)
• Multicenter comprehensive methodological and technical analysis of 832 pressurized intraperitoneal aerosol chemotherapy (PIPAC) interventions performed in 349 patients for peritoneal carcinomatosis treatment: An international survey study — M. Nowacki, M. Alyami, et al. (2018)
• Quality of life of patients with end-stage peritoneal metastasis treated with Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) — K. Odendahl, W. Solass, et al. (2015)
• Multicentric initial experience with the use of the pressurized intraperitoneal aerosol chemotherapy (PIPAC) in the management of unresectable peritoneal carcinomatosis — M. Alyami, J. Gagniere, et al. (2017)
• 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)
• Iterative procedures combining cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for isolated peritoneal recurrence — M. Vaira, M. Robella, et al. (2014)

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