Cytoreduction and HIPEC in the treatment of "unconventional" secondary peritoneal carcinomatosis

Our plain-English summary of Cytoreduction and HIPEC in the treatment of "unconventional" secondary peritoneal carcinomatosis, by M. Cardi, P. Sammartino, V. Mingarelli, et al (World Journal of Surgical Oncology, 2015).

The study

• Authors: M. Cardi, P. Sammartino, V. Mingarelli, S. Sibio, F. Accarpio, D. Biacchi, D. Musio, B. Sollazzo, A. Di Giorgio
• Journal: World Journal of Surgical Oncology
• Published: 2015;13:305
• Cited by: 21 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Peritoneal metastasis (PM) is considered a terminal and incurable disease. In the last 30 years, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) radically changed the therapeutic approach for these patients and is regarded as the standard of care for pseudomyxoma peritonei from appendiceal cancer and peritoneal mesotheliomas. Improved survival has also been reported in treating PM from ovarian, gastric, and colorectal cancers. However, PM often seriously complicates the clinical course of patients with other primary digestive and non-digestive cancers. There is increasing literature evidence that helped to identify not only the primary tumors for which CRS and HIPEC showed a survival advantage but also the patients who may benefit form this treatment modality for the potential lethal complications. Our goal is to report our experience with cytoreduction and HIPEC in patients with PM from rare or unusual primary tumors, discussing possible "unconventional" indications, outcome, and the peculiar issues related to each tumor.

Methods: From a series of 253 consecutive patients with a diagnosis of peritoneal carcinomatosis and treated by CRS and HIPEC, we selected only those with secondary peritoneal carcinomatosis from rare or unusual primary tumors, excluding pseudomyxoma peritonei, peritoneal mesotheliomas, ovarian, gastric, and colorectal cancers. Complications and adverse effects were graded from 0 to 5 according to the WHO Common Toxicity Criteria for Adverse Events (CTCAE). Survival was expressed as mean and median.

Results: We admitted and treated by CRS and HIPEC 28 patients with secondary peritoneal carcinomatosis from rare or unusual primary tumors. Morbidity and mortality rates were in line with those reported for similar procedures. Median survival for the study group was 56 months, and 5-year overall survival reached 40.3 %, with a difference between patients with no (CC0) and minimal (CC1) residual disease (52.3 vs. 25.7), not reaching statistical significance. Ten patients are alive disease-free, and eight are alive with disease.

Conclusions: Cytoreduction and HIPEC should not be excluded "a priori" for the treatment of peritoneal metastases from unconventional primary tumors. This combined therapeutic approach, performed in an experienced center, is safe and can provide a survival benefit over conventional palliative treatments.

In plain English

The authors reported one Rome center's experience with cytoreductive surgery, which aims to remove all visible tumor, followed by heated chemotherapy circulated through the abdomen (HIPEC). It did not study asbestos, and patients with peritoneal mesothelioma were excluded. From 253 consecutive patients treated between November 2000 and December 2013, the authors selected 28 whose cancer had spread to the abdominal lining from uncommon primary tumors, including uterine, breast and small bowel cancers. Twenty-five patients (89 %) had optimal tumor removal, 17 with no residual disease. Sixteen (57.1 %) recovered without complications, and four (14.2 %) had grade 4 (life-threatening) complications. Median survival was 56 months and 5-year overall survival was 40.3 %. Five-year survival was 52.3 % for patients with no residual disease and 25.7 % for those with minimal residual disease, a difference that was not statistically significant. Ten patients were alive without disease and eight with disease. The authors called theirs a small series. They concluded that the treatment should not be excluded "a priori" and that, in selected patients at an experienced center, it is safe and can offer a survival benefit over conventional palliative treatment.

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 drawn from clinical records
• Who was studied: 28 patients with secondary peritoneal carcinomatosis from rare or unusual ('unconventional') primary tumors. They were selected from 253 consecutive patients treated at one institution in Rome between November 2000 and December 2013. Primaries: 8 type II uterine papillary serous carcinoma, 5 breast, 4 small bowel, 3 sarcoma, 3 pancreas, 3 GIST, 1 bladder, 1 lung. Peritoneal mesothelioma, pseudomyxoma, ovarian, gastric and colorectal cases were excluded.
• Exposure: No asbestos or fiber exposure was studied. The intervention was cytoreductive surgery plus HIPEC at 42 to 43 °C for 60 minutes, using cisplatin or oxaliplatin depending on the primary tumor.
• Main results:
  • 25 of 28 patients (89 %) had optimal cytoreduction (17 CC0, 8 CC1); three had CC2 residual disease
  • 16 patients (57.1 %) had an uneventful recovery
  • Grade 3 complications occurred in two patients (7.1 %) and grade 4 in four patients (14.2 %)
  • The only HIPEC-related adverse event was one grade 1 kidney toxicity from cisplatin, reversed by medical treatment
  • Median survival for the 28-patient study group was 56 months
  • 5-year overall survival for the study group was 40.3 %
  • 5-year overall survival was 52.3 for CC0 (no residual disease) patients versus 25.7 for CC1 (minimal residual disease) patients. The difference was not statistically significant.
  • At last follow-up, 10 patients were alive disease-free and 8 were alive with disease
  • Of the 5 breast cancer patients, 4 achieved long-term survival, one surviving 10 years
• The authors' conclusion: The authors concluded that CRS and HIPEC should not be excluded 'a priori' for peritoneal metastases from rare or unusual primary tumors. They stated that in selected patients, at an experienced center, the approach is safe and has shown better palliation and a survival benefit over conventional palliative treatments.
• Limitations the authors state:
  • The authors describe their series as small
  • The authors note that the rarity of these conditions makes randomized clinical trials unlikely

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Metastasis, Peritoneal Mesothelioma, Colorectal Cancer, Median Overall Survival, Overall Survival, Statistical Significance.

Related studies

• 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)
• Repeated cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with recurrent peritoneal carcinomatosis — N. Vassos, T. Förtsch, et al. (2016)
• Peritoneal carcinomatosis: intraoperative parameters in open (coliseum) versus closed abdomen HIPEC — E. Halkia, A. Tsochrinis, et al. (2015)
• 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)
• Recurrence of Optimally Treated Malignant Peritoneal Mesothelioma with Cytoreduction and Heated Intraperitoneal Chemotherapy — D.R. Heller, C. Chiuzan, et al. (2017)

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