Long-term outcomes and survival analysis of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy in patients with pseudomyxoma peritonei at a newly established peritoneal malignancy centre in Japan

Our plain-English summary of Long-term outcomes and survival analysis of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy in patients with pseudomyxoma peritonei at a newly established peritoneal malignancy centre in Japan, by H. Yano, Y. Gohda, B.J. Moran, et al (Annals of Gastroenterological Surgery, 2024).

The study

• Authors: H. Yano, Y. Gohda, B.J. Moran, R. Suda, N. Kokudo
• Journal: Annals of Gastroenterological Surgery
• Published: 2024;8(4):701-710
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is established in the management of pseudomyxoma peritonei (PMP), selected cases of peritoneal mesothelioma, and resectable colorectal or ovarian peritoneal metastases in Western countries. However, the efficacy and feasibility of these techniques are not well established in the Asian population, and little has been reported on long-term survival outcomes for surgically resected PMP patients.

Materials And Methods: Retrospective analysis of a prospective database of short- and longer-term outcomes of consecutive patients who underwent CRS and HIPEC for PMP in a newly established peritoneal malignancy unit in Japan between 2010 and 2016.

Results: A total of 105 patients underwent CRS and HIPEC and 57 maximal tumor debulking (MTD) for pseudomyxoma peritonei. In the CRS group, the primary tumor was appendiceal in 94 patients (90%) followed by ovarian and colorectal. Major postoperative complications occurred in 22/105 patients (21%) with one in-hospital mortality (0.9%). The 5-year overall and disease-free survival rates for the CRS group were 74.2% and 50.1%, respectively. Multivariate analysis revealed unfavorable histology to be the significant predictor of reduced overall and disease-free survival. Completeness of cytoreduction, CA19-9, and CA125 were also associated with disease-free survival.

Conclusions: This is the first report on long-term outcomes and survival analysis of CRS and HIPEC for PMP in the Asian population. CRS and HIPEC can be conducted with reasonable safety and favorable survival in a new center. Complete tumor removal and histological type are the strongest prognostic factors for both overall and disease-free survival.

© 2024 The Authors. Annals of Gastroenterological Surgery published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Society of Gastroenterological Surgery.

In plain English

This retrospective study looked at patients with pseudomyxoma peritonei, a rare cancer spreading mucus-producing tumor through the abdomen. They were treated at a newly established peritoneal malignancy unit in Tokyo, Japan, between March 2010 and December 2016. The study did not examine asbestos exposure or mesothelioma. Of 171 patients who had abdominal surgery, 105 had what the authors called complete cytoreductive surgery (no residual tumor in 68, residual tumor up to 2.5 mm in 37), followed by heated chemotherapy (mitomycin C) in the abdomen. Another 57 had major tumor debulking; the rest had other operations. In the 105-patient group, 94 tumors began in the appendix. Serious complications affected 22 of these 105 (21%); one died suddenly on day 42 after surgery. At five years, 74.2% of this group were alive, versus 25.2% of the debulking group. In this group, 50.1% were alive and recurrence-free at five years. Patients whose tumors had more aggressive (unfavorable) histology did worse. The authors concluded the treatment can be done with reasonable safety at a new centre. They noted the study was retrospective, relatively small and from a single centre.

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 consecutive series of patients treated at a single centre
• Who was studied: Patients with pseudomyxoma peritonei referred to the National Center for Global Health and Medicine, Tokyo, Japan, 2010 to 2016. Of 285 referred, 171 had a laparotomy. Of these, 105 had complete cytoreductive surgery with HIPEC and 57 had major tumor debulking. Six had exploratory laparotomy only, two had a loop ileostomy and one had intestinal bypass surgery.
• Exposure: No asbestos exposure was studied. The treatment studied was cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy with mitomycin C (10 mg/m2, heated to 42 to 43°C, for 1 hour), compared with major tumor debulking.
• Main results:
  • Of 171 patients who underwent laparotomy, 105 (61%) had complete cytoreductive surgery and HIPEC with curative intent, and 57 had major tumor debulking.
  • The remaining patients who underwent laparotomy had other procedures: six had exploratory laparotomy only, two had a loop ileostomy and one had intestinal bypass surgery.
  • The authors counted CC-0 (no residual tumor) and CC-1 (residual tumor up to 2.5 mm) as complete cytoreduction.
  • Within the complete cytoreduction group, CC-0 (no residual tumor) was achieved in 68 patients and CC-1 (residual tumor up to 2.5 mm) in 37 patients.
  • In the complete-surgery group, the primary tumor was in the appendix in 94 of 105 cases (90%).
  • Major postoperative complications (Clavien–Dindo Grade III to V) occurred in 22 patients (21%) in the complete-surgery group.
  • One patient in the complete-surgery group died suddenly on day 42. The death was thought likely due to a known ischaemic heart condition, but post-mortem examination was refused.
  • Five-year overall survival was 74.2% in the complete-surgery group and 25.2% in the major tumor debulking group (p less than 0.001).
  • In the complete-surgery group, 44 of 105 patients (42%) were diagnosed with recurrence, at a median of 18 months (range 3 to 60) after surgery.
  • Five-year disease-free survival was 50.1% for the 105 patients who had complete surgery.
  • On multivariate analysis in the complete-surgery group, histological type was the only significant independent predictor of overall survival: unfavorable vs favorable histology, hazard ratio 4.23 (95% CI 1.92 to 9.33). Two factors were not statistically significant for overall survival: elevated CA125 (HR 1.93, 95% CI 0.91 to 4.01, p 0.086) and CC-1 vs CC-0 (HR 1.88, 95% CI 0.92 to 3.85, p 0.082).
  • On multivariate analysis of disease-free survival in the complete-surgery group, four factors were significant: unfavorable histology, HR 4.66 (95% CI 2.42 to 8.95); CA125 of 35 or above, HR 2.30 (1.27 to 4.13); CA19-9 of 37 or above, HR 2.08 (1.15 to 3.75); and CC-1 vs CC-0, HR 1.95 (1.10 to 3.47).
  • In the complete-surgery group, 5-year overall and disease-free survival were 88.4% and 73% for 60 patients with favorable histology. They were 55.3% and 21% for 45 patients with unfavorable histology (p less than 0.001).
• The authors' conclusion: The authors concluded that CRS combined with HIPEC can be done with reasonable safety at a new centre, and that optimal outcomes come from complete CRS and HIPEC. When complete surgery is not achievable, they said major tumor debulking gives reasonable mid- to long-term survival in many patients.
• Limitations the authors state:
  • The study was retrospective.
  • The number of patients was relatively small, and the study came from a single centre.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Peritoneal Mesothelioma, Disease-Free Survival, Multivariate Analysis, Histology.

Related studies

• Overall survival of pseudomyxoma peritonei and peritoneal mesothelioma patients after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy can be predicted by computed tomography quantified sarcopenia — A. Galan, P. Rousset, et al. (2018)
• Outcomes of repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal surface malignancy — K.I. Votanopoulos, C. Ihemelandu, et al. (2012)
• Long-term survival outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy: Single-institutional experience with 1225 cases — L.S. Kyang, N.A. Alzahrani, et al. (2019)
• 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)
• Long-term results of laparoscopic cytoreductive surgery and HIPEC for the curative treatment of low-grade pseudomyxoma peritonei and multicystic mesothelioma — F. Mercier, G. Jeremie, et al. (2020)
• Multicystic mesothelioma: Operative and long-term outcomes with cytoreductive surgery and hyperthermic intra peritoneal chemotherapy — E. Nizri, D. Baratti, et al. (2018)

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