Impact of extent of parietal peritonectomy on oncological outcome after cytoreductive surgery and HIPEC

Our plain-English summary of Impact of extent of parietal peritonectomy on oncological outcome after cytoreductive surgery and HIPEC, by S.P. Somashekhar, K.R. Ashwin, R. Yethadka, et al (Pleura and Peritoneum, 2019).

The study

• Authors: S.P. Somashekhar, K.R. Ashwin, R. Yethadka, S.S. Zaveri, V.K. Ahuja, A. Rauthan, K.C. Rohit
• Journal: Pleura and Peritoneum
• Published: 2019;4(4):20190015
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: In peritoneal surface malignancy (PSM), in spite of optimal cytoreductive surgery (CRS), majority of recurrences that occur are intraperitoneal. In patients with PSM, studies employing fluorescent imaging and microscopic examination have shown normal looking peritoneum may harbor active disease. This study was done to assess the recurrence pattern, oncological outcomes, and morbidity and mortality of the extent of peritonectomy in patients who underwent total parietal peritonectomy (TPP) or involved field peritonectomy (IFP) as a part of the procedure during CRS and hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods: This was a retrospective analysis of prospectively collected data, from February 2013 to December 2017. A total of 163 patients with PSM underwent TPP or IFP with CRS plus HIPEC. Their oncological outcomes, recurrence pattern, postoperative morbidity and mortality were analyzed.

Results: Of the 163 cases, the primary organs of origin were ovary, colorectal, appendicular pseudomyxoma, stomach, mesothelioma and others (67.4%, 16.5%, 6.1%, 4.9%, 2% and 2%), respectively. TPP was performed in 70 patients and IFP in 93 patients. TPP group had higher mean PCI (16 vs. 14), longer duration of surgery (11 vs. 9 h), and more blood loss (1,243 vs. 675 mL). Overall G3-G4 morbidity was comparable in both groups (42.8% vs. 33.3%) as was mortality (5.7% vs. 4.4%). Kaplan-Meier analysis showed that with a median follow-up of 45 months, TPP group had a recurrence-free survival (RFS) of 26 months and overall survival (OS) was yet to be achieved, whereas the IFP group had a RFS and OS of 21 and 43 months, respectively.

Conclusions: Performing TPP reduces the chance of missing the microscopic disease, therefore can minimize local recurrence, and better oncological outcomes. TPP can be performed with acceptable morbidity and mortality, at the cost of increased duration of surgery and higher blood loss.

© 2019 Somashekhar et al., published by De Gruyter.

In plain English

This Indian study reviewed prospectively collected records of 163 patients whose cancer had spread over the abdominal lining (peritoneal surface malignancy). They were treated from 2013 to 2017 with surgery plus heated chemotherapy inside the abdomen (HIPEC). Most cancers began in the ovary. 2.4% were mesothelioma, and no separate results were given for them. Asbestos exposure was not studied. The authors compared 70 patients who had all of the parietal lining removed (total parietal peritonectomy, TPP) with 93 who had only visibly diseased lining removed (involved field peritonectomy, IFP). TPP operations were longer (11 vs. 9 hours) and had more blood loss (1,243 vs. 675 mL). Grade 3 to 4 complications (33.3% IFP, 42.8% TPP) and 30-day deaths (4.4% and 5.7%) were described as comparable. Microscopic cancer was found in normal-looking lining in 21 of 70 TPP patients. With a median follow-up of 45 months, median recurrence-free survival was 21 months (IFP) and 26 months (TPP). Median overall survival was 43 months (IFP) and not yet reached (TPP). No p-values were reported for these comparisons. The authors concluded TPP reduces the chance of missing microscopic disease and might improve survival. They noted the study was retrospective and small.

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 prospectively collected data from a single center, comparing two extents of peritoneal surgery
• Who was studied: 163 patients with peritoneal surface malignancy treated with cytoreductive surgery and HIPEC at Manipal Comprehensive Cancer Center, Manipal Hospital, Bengaluru, India, February 2013 to December 2017. Primary sites were ovary (67.4%), colorectal (16.5%), appendicular pseudomyxoma (6.1%), stomach (4.9%) and mesothelioma (2.4%). There were 93 patients in the IFP group and 70 in the TPP group.
• Exposure: No asbestos or fiber exposure was studied. The comparison was surgical. TPP was en-bloc stripping and resection of the anterior parietal, pelvic and both diaphragmatic peritoneum with supracolic greater omentectomy and lesser omentectomy. IFP was removal only of involved peritoneum with visible disease. Both groups also had cytoreductive surgery plus HIPEC.
• Main results:
  • The TPP group had a longer mean duration of surgery than the IFP group (11 vs. 9 h; p less than 0.05), more blood loss (1,243 vs. 675 mL; p less than 0.05) and a longer hospital stay (16 vs. 12 days; p less than 0.05).
  • The peritoneal carcinomatosis index (PCI) was higher in the TPP group than in the IFP group (16 vs. 14), but the difference was not statistically significant (p=0.45).
  • Overall grade 3 to 4 postoperative morbidity was 33.3% in the IFP group and 42.8% in the TPP group (p=0.21), which the authors called comparable.
  • 30-day mortality was 4 patients (4.4%) in the IFP group and 4 patients (5.7%) in the TPP group (p=0.15).
  • In the TPP group, 21 of 70 patients (30%) had microscopic tumor deposits in peritoneum where the surgeon saw no visible tumor.
  • The overall recurrence rate was 53.7% in the IFP group and 40% in the TPP group. Peritoneal recurrence made up 60% of recurrences in the IFP group and 35.7% in the TPP group. No p-values were given.
  • With a median follow-up of 45 months, median recurrence-free survival was 21 months in the IFP group and 26 months in the TPP group. Median overall survival was 43 months in the IFP group and not yet reached in the TPP group. No p-values were reported.
  • Three-year overall survival was 60% in the IFP group vs. 80% in the TPP group. Four-year overall survival was 42% in the IFP group vs. 80% in the TPP group.
• The authors' conclusion: The authors concluded that TPP reduces the chance of missing microscopic disease and therefore minimizes local recurrence, and that improved recurrence-free and overall survival might be achieved with TPP. They called for a prospective randomized multi-institutional study to define which patients benefit.
• Limitations the authors state:
  • The study was a retrospective analysis.
  • The study group was small.
  • Longer follow-up is needed to assess the oncological outcomes.

Topics

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

Related studies

• Cytoreductive surgery with selective versus complete parietal peritonectomy followed by hyperthermic intraperitoneal chemotherapy in patients with diffuse malignant peritoneal mesothelioma: a controlled study — D. Baratti, S. Kusamura, et al. (2012)
• Morbidity, mortality, and oncological outcomes of 401 consecutive cytoreductive procedures with hyperthermic intraperitoneal chemotherapy (HIPEC) — M. Desantis, J.L. Bernard, et al. (2015)
• Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality — K.I. Votanopoulos, N.A. Newman, et al. (2013)
• Multicystic peritoneal mesothelioma: outcomes and patho-biological features in a multi-institutional series treated by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — D. Baratti, M. Vaira, et al. (2010)
• 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)
• Evaluation of the cost-effectiveness of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (peritonectomy) at the St George Hospital peritoneal surface malignancy program — T.C. Chua, S. Martin, et al. (2010)

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