Efficacy and Insights from an Extensive Series of Cytoreductive Surgery for Peritoneal Neoplasms: A High-Volume Single-Center Experience

Our plain-English summary of Efficacy and Insights from an Extensive Series of Cytoreductive Surgery for Peritoneal Neoplasms: A High-Volume Single-Center Experience, by M. Aulicino, F. Santullo, G. D'Annibale, et al (Cancers, 2024).

The study

• Authors: M. Aulicino, F. Santullo, G. D'Annibale, C. Abatini, M. Attalla El Halabieh, C. Orsini, L. Barberis, L. D'Agostino, I. Tersigni, F. Pacelli, C. Lodoli, A. Di Giorgio, F. Ferracci, F. Pacelli
• Journal: Cancers
• Published: 2024;16(24)
• Cited by: 8 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Advances in cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC) have improved outcomes for selected patients with peritoneal surface malignancies (PSMs). Methods: This retrospective study analyzed 743 PSM patients treated at Fondazione Policlinico Universitario Agostino Gemelli from January 2016 to February 2024. The primary aim was to assess median overall survival (mOS), median disease-free survival (mDFS), and median progression-free survival (mPFS) stratified by tumor origin. Secondary outcomes examined the role of diagnostic laparoscopy in the management of PSMs and intra- and postoperative complications' rates. Results: A total of 1113 procedures were performed: 389 CRS, 370 PIPAC, and 354 diagnostic laparoscopies. Colorectal cancer was the predominant indication for CRS (52.4%), with a mOS of 52 months and mDFS of 22 months. Patients affected by gastric cancer undergoing CRS had a mOS of 18 months and a mDFS of 13 months, while PIPAC yielded a mOS of 9 months and a mPFS of 4 months. Among patients with pseudomyxoma peritonei undergoing CRS, the 5-year DFS rate was 64.1%, and OS rate was 89%. Patients affected by mesothelioma and treated with CRS exhibited a median OS of 43 months and a DFS of 26 months. Pancreatic and hepatobiliary cancers were treated with PIPAC, with a respective mOS of 12 and 8 months. Postoperative complications occurred in 12.6% of CRS, 3.2% of PIPAC, and 1.7% of diagnostic laparoscopies. High peritoneal cancer index (PCI), gastric resection, and blood loss over 500 mL were identified as risk factors for major complications in a multivariate analysis. Conclusions: Developing a highly experienced multidisciplinary team is crucial for delivering tailored treatment strategies which aim to achieve optimal oncological outcomes while preserving patients' quality of life.

In plain English

This retrospective study reviewed 743 patients with cancers on the lining of the abdomen (peritoneal surface malignancies). All were treated at one surgical unit in Rome, Italy, between January 2016 and February 2024. They had 1113 procedures: 389 cytoreductive surgeries (removal of visible tumor, usually followed by heated chemotherapy inside the abdomen, called HIPEC), 370 PIPAC procedures (aerosol chemotherapy given through keyhole surgery) and 354 diagnostic laparoscopies. The article does not discuss asbestos.

Twenty-seven cytoreductive surgeries were done in patients with mesothelioma; the study admitted malignant or multi-cystic mesothelioma of the peritoneum. In that group, median disease-free survival was 26 months, median overall survival was 43 months, and 5-year overall survival was 42.4%. For colorectal cancer treated with surgery, median overall survival was 52 months. For gastric cancer it was 18 months after surgery and 9 months after PIPAC. Major complications followed 12.6% of cytoreductive surgeries, 3.2% of PIPAC procedures and 1.7% of diagnostic laparoscopies.

The authors noted the limits of a non-randomized, observational study and said their mesothelioma experience was not extensive. They concluded that evaluation by specialized multidisciplinary teams in high-volume centers is crucial.

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-center case series (observational, non-randomized) of surgical and intraperitoneal chemotherapy treatments
• Who was studied: 743 adults with peritoneal surface malignancies treated at the Peritoneum and Retroperitoneum Surgical Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy, from January 2016 to February 2024. Primary peritoneal tumors (malignant or multi-cystic mesothelioma) or peritoneal spread from colorectal, gastric, appendiceal, pancreatic, hepatobiliary or other cancers.
• Exposure: No asbestos or other environmental exposure was studied. The study assessed treatments: cytoreductive surgery with or without HIPEC, PIPAC and diagnostic laparoscopy. For mesothelioma, HIPEC used mitomycin C and cisplatin.
• Main results:
  • Across 743 patients, 1113 procedures were performed: 389 cytoreductions, 370 PIPACs and 354 diagnostic laparoscopies.
  • 27 cytoreductive surgeries were performed in patients with mesothelioma.
  • In the mesothelioma group, complete cytoreduction (CC-0) was achieved in 25 patients (92.6%).
  • In the mesothelioma group, major complications occurred in 3 patients (11.1%).
  • Mesothelioma patients treated with cytoreductive surgery (median follow-up 45 months) had median DFS of 26 months (1-, 3- and 5-year DFS 81.3%, 36.4%, 24.2%) and median OS of 43 months (1-, 3- and 5-year OS 94.1%, 62.7%, 42.4%).
  • Colorectal cancer patients treated with cytoreductive surgery (204 cases) had median DFS of 22 months and median OS of 52 months.
  • Gastric cancer patients treated with PIPAC (69 patients) had a median OS of 9 months.
  • Pseudomyxoma peritonei patients treated with cytoreductive surgery (104) had 1-, 3- and 5-year OS rates of 100%, 93.2% and 89%.
  • Major postoperative complications (Clavien–Dindo grade 3 or higher) occurred in 12.6% of cytoreductive surgeries, 3.2% of PIPACs and 1.7% of diagnostic laparoscopies.
  • 30-day mortality was 1.3% after cytoreductive surgery and 1.1% after PIPAC.
  • Among patients scheduled for cytoreductive surgery, unnecessary (sham) laparotomies occurred in 3.5% of those who had laparoscopy beforehand and in 13.6% of those who did not (p less than 0.001).
  • In multivariate analysis of cytoreductive surgery, three factors were independently associated with major complications: higher PCI (OR 1.059, 95% CI 1.014 to 1.107), gastric resection (OR 5.251, 95% CI 1.889 to 14.593) and blood loss over 500 mL (OR 4.286, 95% CI 1.780 to 10.317).
• The authors' conclusion: The authors concluded that multidisciplinary evaluation by highly specialized clinicians and surgeons in high-volume centers is crucial for tailored treatment that optimizes cancer outcomes while maintaining quality of life.
• Limitations the authors state:
  • The study was non-randomized and primarily observational.
  • Because mesothelioma is rare, the center's experience with it was not extensive.
  • Patients treated for non-conventional indications could not be analyzed because the group was too mixed.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, Neoplasm, HIPEC, Chemotherapy, Median Overall Survival, Disease-Free Survival, Progression-Free Survival, Diagnostic Laparoscopy.

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• The Safety of Iterative Cytoreductive Surgery and HIPEC for Peritoneal Carcinomatosis: A High Volume Center Prospectively Maintained Database Analysis — E. Bekhor, J. Carr, et al. (2020)
• Peritoneal metastases of rare carcinomas treated with cytoreductive surgery and HIPEC - A single center case series — A. Brandl, C.B. Zielinski, et al. (2017)
• 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)
• Feasibility and outcomes of cytoreductive surgery and HIPEC for peritoneal surface malignancies in low- and middle-income countries: a single-center experience of 232 cases — S. Deo, M. Ray, et al. (2021)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin in pediatric patients with peritoneal mesothelioma: a single institution experience and long term follow up — P. Malekzadeh, M. Good, et al. (2021)

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