Radical surgery-peritonectomy and intraoperative intraperitoneal chemotherapy for the treatment of peritoneal carcinomatosis in recurrent or primary ovarian cancer

Optimizing Timing of Intraperitoneal Chemotherapy to Enhance Intravenous Carboplatin Concentration

Despite advances in systemic chemotherapy, patients with gastric cancer (GC) and peritoneal metastases (PMs) continue to have poor prognoses. Intraperitoneal (IP) administration of Paclitaxel (PTX) combined with systemic chemotherapy shows promise in treating PMs from GC. However, methods of drug administration need to be optimized to maximize efficacy. In this study, we utilized a mouse model with PMs derived from a human GC cell line, administering PTX either IP or intravenously (IV), and Carboplatin (CBDCA) IV 0, 1, and 4 days after PTX administration. The PMs were resected 30 min later, and concentrations of PTX and CBDCA in resected tumors were measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Results indicated that PTX concentrations were higher with IP administration than with IV administration, with significant differences observed on days 0 and 1. CBDCA concentrations 4 days post-IP PTX administration were higher than with simultaneous IV PTX administration. These findings suggest that IP PTX administration enhances CBDCA concentration in peritoneal tumors. Therefore, sequential IV administration of anti-cancer drugs appears more effective than simultaneous administration with IP PTX, a strategy that may improve prognoses for patients with PMs.

Paclitaxel as HIPEC-Drug after Surgical Cytoreduction for Ovarian Peritoneal Metastases: A Randomized Phase III Clinical Trial (HIPECOVA)

Multidisciplinary strategies have transformed the management of advanced ovarian cancer. We aimed to evaluate the effectiveness of paclitaxel in hyperthermic intraperitoneal chemotherapy (HIPEC) following surgical cytoreduction for ovarian peritoneal metastases in a randomized phase III trial conducted between August 2012 and December 2019. Seventy-six patients were randomized to either the HIPEC or no HIPEC group. Although median values for the primary endpoints (recurrence-free survival (RFS) and overall survival (OS)) revealed superior outcomes for the HIPEC (RFS: 23 months, OS: 48 months) over the control group (RFS: 19 months, OS: 46 months), these differences were not statistically significant (p = 0.22 and p = 0.579). Notably, the HIPEC group demonstrated significantly higher 5-year OS and 3-year RFS rates (47.2% and 47.5%) compared to patients without HIPEC (34.5% and 21.3%). Stratification according to Peritoneal Surface Disease Severity Score (PSDSS) showed improved OS and RFS for patients with lower PSDSS (I-II) in the HIPEC-treated group (p = 0.033 and p = 0.042, respectively). The Clavien-Dindo classification of adverse event grades revealed no significant differences between HIPEC and controls (p = 0.482). While overall results were not statistically significant, our long-term follow-up emphasized the potential benefit of HIPEC-associated cytoreduction with paclitaxel, particularly in selected ovarian cancer patients with lower PSDSS indices.

Prognostic role of the peritoneal cancer index in ovarian cancer patients who undergo cytoreductive surgery: a meta-analysis

Advanced-stage ovarian cancer is usually associated with peritoneal carcinomatosis. This study evaluates the prognostic role of the Peritoneal Cancer Index (PCI) in predicting the survival of patients with ovarian cancer. A literature search was conducted in electronic databases (Google Scholar, PubMed, Ovid, and Science Direct) and study selection was based on precise eligibility criteria. Random-effects meta-analyses were performed to estimate survival with low and high PCI scores and to pool hazard ratios (HR) of survival between lower and higher PCI scores. A total of 20 studies (2588 patients) were included. Median follow-up was 39 months [95%CI: 25, 54]. Complete cytoreduction rate was 80% [95% CI: 73, 87]. The median PCI score was 11.3 [95% CI: 9.9, 12.7]. Median survival was 56.7 months [95% CI: 45.2, 68.2] with below and 28.8 months [95% CI: 23.0, 34.6] with above any PCI cutoff. Most studies used PCI cutoffs between 10 and 20. The median progression-free survival was 23.7 months [95% CI: 16.5, 30.8] with below and 11.9 months [95% CI: 5.9, 17.9] with above any PCI cutoff. 5-year survival rates were 61.3% [95% CI: 49.9, 72.8] with PCI<10 cutoffs, 21.7% [95% CI: 11.6, 31.8] with PCI>10 cutoffs, 50.1% [95% CI: 39.0, 61.2] with PCI<20 cutoffs, and 21.7% [95% CI: 16.2, 27.1] with PCI>20 cutoffs. Pooled analysis of HRs showed that a higher PCI score was associated with worse survival in both univariate (HR 2.14 [95%CI: 1.63, 2.66]) and multivariate (HR 1.10 [95% CI: 1.02, 1.18]) analyses. In a set of studies that used varying PCI cutoffs, the PCI has been found to have a significant inverse association with the survival of patients with advanced ovarian cancer who underwent cytoreductive surgery.

Prognosis Following Surgery for Recurrent Ovarian Cancer and Diagnostic Criteria Predictive of Cytoreduction Success: A Systematic Review and Meta-Analysis

For women achieving clinical remission after the completion of initial treatment for epithelial ovarian cancer, 80% with advanced-stage disease will develop recurrence. However, the standard treatment of women with recurrent platinum-sensitive diseases remains poorly defined. Secondary (SCS), tertiary (TCS) or quaternary (QCS) cytoreduction surgery for recurrence has been suggested to be associated with increased overall survival (OS). We searched five databases for studies reporting death rate, OS, cytoreduction rates, post-operative morbidity/mortality and diagnostic models predicting complete cytoreduction in a platinum-sensitive disease recurrence setting. Death rates calculated from raw data were pooled based on a random-effects model. Meta-regression/linear regression was performed to explore the role of complete or optimal cytoreduction as a moderator. Pooled death rates were 45%, 51%, 66% for SCS, TCS and QCS, respectively. Median OS for optimal cytoreduction ranged from 16-91, 24-99 and 39-135 months for SCS, TCS and QCS, respectively. Every 10% increase in complete cytoreduction rates at SCS corresponds to a 7% increase in median OS. Complete cytoreduction rates ranged from 9-100%, 35-90% and 33-100% for SCS, TCS and QCS, respectively. Major post-operative thirty-day morbidity was reported to range from 0-47%, 13-33% and 15-29% for SCS, TCS and QCS, respectively. Thirty-day post-operative mortality was 0-6%, 0-3% and 0-2% for SCS, TCS and QCS, respectively. There were two externally validated diagnostic models predicting complete cytoreduction at SCS, but none for TCS and QCS. In conclusion, our data confirm that maximal effort higher order cytoreductive surgery resulting in complete cytoreduction can improve survival.

Secondary Cytoreductive Surgery in Platinum-Sensitive Recurrent Ovarian Cancer: A Meta-Analysis

PURPOSE

The survival impact of secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer was studied.

METHODS

We identified published studies from 1983 to 2021 following our inclusion criteria from MEDLINE, EMBASE, and Cochrane library. To integrate the effect size of single-arm studies, meta-analysis was performed using death rate as a primary outcome. The effect of complete cytoreduction and optimal cytoreduction on survival was evaluated using meta-regression. The pooled death rate was presented with a 95% CI. The publication bias was evaluated with the funnel plot and Egger's test, and sensitivity analysis was performed. To overcome missing death rates, the linear regression model was performed on log-transformed median overall survival (OS) time using study size as a weight.

RESULTS

Thirty-six studies with 2,805 patients reporting death rates were used for this meta-analysis of the 80 eligible studies. There was strong heterogeneity, with the P value of the Cochrane Q test of < 0.0001 and Higgins's I² statistics of 86%; thus, we considered a random effect model. The pooled death rate was 44.2% (95% CI, 39.0 to 49.5), and both the complete and optimal cytoreductions were associated with better survival outcomes as significant moderators in the meta-regression model (P < .001 and P = .005, respectively). Although 14 studies were located outside the funnel plot, Egger's test indicated no publication bias (P = .327). A sensitivity analysis excluding 14 studies showed similar results. In the linear regression model on the basis of 57 studies, the median OS time increased by 8.97% and 7.04% when the complete and optimal cytoreduction proportion increased by 10%, respectively, after adjusting other variables.

CONCLUSION

Secondary cytoreductive surgery, resulting in maximal tumor resection, significantly prolongs OS in platinum-sensitive recurrent ovarian cancer.

Survival Outcomes after Hyperthermic Intraperitoneal Chemotherapy for a First Ovarian Cancer Relapse: A Systematic Evidence-Based Review

Simple Summary

Since 2000, scientific literature has recommended the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of ovarian cancer relapse. This treatment, combining heavy abdominal surgery and intraperitoneal heated chemotherapy is associated with a risk of post-operative death and severe morbidity. Previous systematic reviews of the scientific literature concluded that HIPEC was effective for improving patient survival following a first relapse of ovarian cancer. This current systematic review, emphasizing the level of evidence of the published series, using the Oxford levels of evidence grading system, has made it possible to analyze the weaknesses of this scientific literature. This literature is characterized by biases—such as patient inclusion, and weak methods—such as retrospective patient collection, a small number of included patients, and no statistical hypothesis. As a results, HIPEC must remain an experimental procedure in ovarian cancer relapse, patients until there are positive results from ongoing clinical trials.

Abstract

Background: Hyperthermic intraperitoneal chemotherapy (HIPEC) is routinely used in the treatment of a first ovarian cancer relapse. Methods: This systematic review, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, aimed to assess the quality of scientific proof of the survival benefits of HIPEC, using Medline and Google Scholar. Qualitative analysis using the Oxford CEBM Levels of Evidence 2011 grading is reported. Results: Of 469 articles identified, 23 were included; 15 based on series of patients treated with HIPEC without a control group, and 8 case control series of patients treated with or without HIPEC. The series without a control group showed median overall survival (OS) ranged from 23.5 to 63 months, highlighting a broad standard deviation. Considering the case control series, OS was significantly better in the HIPEC group in 5 studies, and similar in 1. The current review showed considerable heterogeneity and biases, with an Oxford Level of Evidence grading of 4 for 22 selected series and 2 for one. Conclusions: There is no strong evidence to suggest efficacy of HIPEC in improving survival of patients treated for a first relapse of ovarian cancer due to the low quality of the data.

Intraperitoneal chemotherapy for ovarian cancer with peritoneal metastases, systematic review of the literature and focused personal experience

Epithelial ovarian cancer (EOC) causes 60% of ovarian cancer cases and is the fourth most common cause of death from cancer in women. The standard of care for EOC includes a combination of surgery followed by intravenous chemotherapy. Intraperitoneal (IP) chemotherapy (CT) has been introduced into the therapeutic algorithm of EOC with positive results. To explore existing results regarding intraperitoneal chemotherapy a systematic review of the literature and an analysis of our own institutional prospective database of patients treated with cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) for EOC at different stages were conducted. The focused report concerning our personal experience with advanced EOC treated with cytoreductive surgery and HIPEC produced the following results: In 57 patients cisplatin + paclitaxel as HIPEC was the only significant factor improving overall survival (OS) at multivariate analysis (OR 6.54, 95% CI: 1.24-34.47, P=0.027). Patients treated with HIPEC cisplatin + paclitaxel showed a median OS of 46 months (SD 6.4, 95% CI: 33.4-58.6), while patients treated with other HIPEC regimens showed a median OS of 12 months (SD 3.1, 95% CI: 6.0-18.0). The 2y-OS was 72% and 3y-OS was 68% for cisplatin + paclitaxel as HIPEC, while the 2y- and 3y-OS was 0% for other HIPEC regimens. Patients treated with HIPEC cisplatin + paclitaxel showed a median disease-free survival (DFS) of 13 months (SD 1.6, 95% CI: 9.9-16.1), while patients treated with other HIPEC regimens showed a median DFS of 8 months (SD 3.1, 95% CI: 1.9-14.1). In conclusion, HIPEC cisplatin + paclitaxel in ovarian cancer showed positive results that may be considered semi-definitive according to the level of evidence and should be considered a starting point for further investigations. At present HIPEC cisplatin + paclitaxel should be proposed to patients with advanced ovarian cancer as standard treatment at almost all stages of disease. Platinum + taxane-based intraperitoneal regimens demonstrated superior results compared to other regimens.

Hyperthermic intraperitoneal chemotherapy in ovarian cancer: Qui Bono?

Ovarian cancer is a major cause of cancer related-death in women around the world. Recent statistics on the worldwide cancer burden by the International Agency for the research on Cancer revealed ovarian cancer being both the eighth most frequent malignancy in the west countries. Peritoneal metastasis from ovarian cancer is a major challenge in the clinical management. Despite the evidence of the benefit of Intraperitoneal Chemotherapy in ovarian cancer with peritoneal deposits it has not been widely adopted, mainly due to logistical difficulties and less to the logoregional morbidity as pain. The role of hyperthermic intraperitoneal chemotherapy (HIPEC) in patients during the end of cytoreductive surgery (CRS) is a more tolerable feasible method with potential advantages as drug distribution, combination with hyperthermia and application before tumor regrowth. The aim of this article is to investigate the potential benefits of HIPEC explains the rationale, data of major clinical trials meta-analyses and recent randomized trial are presented and explains the indications patient selection and the best time to applicate of this aggressive logo regional treatment.

Current status of hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer in the United States

OBJECTIVES

1.) To compare frequency of HIPEC use in ovarian cancer treatment before and after publication of the phase III study by van Driel et al. in January 2018. 2.) To compare associated rates of hospital-based outcomes, including length of stay, intensive care unit (ICU) admission, complications, and costs in ovarian cancer surgery with or without HIPEC.

METHODS

We queried Vizient's administrative claims database of 550 US hospitals for ovarian cancer surgeries from January 2016-January 2020 using ICD-10 diagnosis and procedure codes. Sodium thiosulfate administration was used to identify HIPEC cases according to the published protocol. Student t-tests and relative risk (RR) were used to compare continuous variables and contingency tables, respectively.

RESULTS

152 ovarian cancer patients had HIPEC at 39 hospitals, and 20,014 ovarian cancer patients had surgery without HIPEC at 256 hospitals. Following the trial publication, 97% of HIPEC cases occurred. During the index admission, HIPEC patients had longer median length of stay (8.4 vs. 5.7 days, p < 0.001) and higher percentage of ICU admissions (63.1% vs. 11.0%, p < 0.001) and complication rates (RR = 1.87, p = 0.002). Index admission direct costs ($21,825 vs. $12,038, p < 0.001) and direct cost index (observed/expected costs) (1.87 vs. 1.11, p < 0.001) were also greater in the HIPEC patients. No inpatient deaths or 30-day readmissions were identified after HIPEC.

CONCLUSIONS

Use of HIPEC for ovarian cancer increased in the US after publication of a phase III clinical trial in a high-impact journal, though the absolute number of cases remains modest. Incorporation of HIPEC was associated with increased cost, hospital length of stay, ICU admission, and hospital-acquired complication rates. Further studies are needed in order to evaluate long-term outcomes, including morbidity and survival.

Oncologic outcomes and morbidity following heated intraperitoneal chemotherapy at cytoreductive surgery for primary epithelial ovarian cancer: A systematic review and meta-analysis

OBJECTIVES

Heated intraperitoneal chemotherapy (HIPEC) has not been universally adopted at the time of interval cytoreductive surgery for primary epithelial ovarian cancer (EOC) despite evidence of a 12-month overall survival (OS) benefit in a recent landmark randomized trial. We performed a systematic review and meta-analysis to assess oncologic outcomes and perioperative morbidity following HIPEC among primary EOC patients.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, from inception to August 2019, for observational and randomized studies of primary EOC patients undergoing HIPEC. We assessed risk of bias using the Institute of Health Economics Quality Appraisal Checklist for single-arm cohort studies, Newcastle-Ottawa Scale for comparative cohort studies, and Cochrane Collaboration's Tool for randomized trials. We qualitatively summarized survival outcomes and calculated the pooled proportion of 30-day grade III-IV morbidity and postoperative death.

RESULTS

We identified 35 articles including 2252 primary EOC patients; one study was a randomized trial, and only six studies included a comparator group of surgery alone. The timing, temperature, and chemotherapeutic agents used for HIPEC differed across studies. Reported OS was highly variable (3-year OS range: 46-77%); three comparative cohort studies and the sole randomized trial reported statistically significant survival benefits for HIPEC over surgery alone, while two comparative cohort studies did not. The pooled proportions for grade III-IV morbidity and postoperative death at 30 days were 34% (95% CI 20-52) and 0% (95% CI 0-5) respectively.

CONCLUSION

One randomized trial suggests that HIPEC at time of interval cytoreductive surgery should be considered in patients with primary EOC. However, there is significant heterogeneity in literature with respect to an appropriate HIPEC regimen, short- and long-term outcomes. High-quality prospective randomized trials are urgently needed to clarify the role of HIPEC in the first-line treatment of primary EOC.

Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer

Hyperthermic intraperitoneal chemotherapy (HIPEC) in conjunction with cytoreductive surgery (CRS) holds promise as an adjunctive treatment strategy in malignancies affecting the peritoneal surface, effectively targeting remaining microscopic residual tumor. HIPEC increases concentrations of chemotherapy directly within the peritoneal cavity compared with the intravenous route and reduces the systemic side effects associated with prolonged adjuvant intraperitoneal exposure. Furthermore, hyperthermia increases tissue penetration and is synergistic with the therapeutic chemotherapy agents used. In ovarian cancer, evidence is building for its use in both primary and recurrent scenarios. In this review, we examine the history of HIPEC, the techniques used, and the available data guiding its use in primary and recurrent ovarian cancer.

Morbidity and mortality in women with advanced ovarian cancer who underwent primary cytoreductive surgery compared to cytoreductive surgery for recurrent disease: a meta-analysis

Background

The primary treatment for advanced ovarian cancer is aggressive cytoreductive surgery (CRS), which is associated with considerable morbidity. The aim of this meta-analysis is to compare morbidity associated with primary CRS and secondary CRS for recurrent disease.

Methods

A literature search was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for publications reporting morbidity and mortality in patients undergoing CRS in primary and recurrent ovarian malignancy. Embase, Medline, Pubmed, Pubmed Central, clinicaltrials. gov and Cochrane databases were searched. Two independent reviewers applied inclusion and exclusion criteria to select included papers. A total of 215 citations were reviewed; 6 studies comprising 641 patients were selected for the analysis.

Results

Results were reported as mean differences or pooled odds ratios (OR) with 95 % confidence intervals (95 % CI). The overall morbidity rate was 38.4 %, and this did not differ between the two groups (p=0.97). This did not change when only Clavien-Dindo grade 3 and 4 morbidities were accounted for (14 % primary CRS, 15 % recurrent, p=0.83). Compared to primary CRS, secondary CRS was associated with a similar operative time (mean 400 min, I2=79 %, p=0.45), rate of bowel resection (I2=75 %, p=0.37) and transfusion requirements (MD – 0.7 L, I2=76 %, p=0.45). The mortality rate in both groups was too low to allow for meaningful meta-analysis, with four deaths in the group undergoing primary cytoreductive surgery (1.0 %) and two deaths in the group with recurrent disease (0.9 %).

Conclusions

In conclusion, secondary CRS for recurrent ovarian cancer is a safe and feasible option in carefully pre-selected patients with comparable morbidity to primary CRS.

Residual tumour less than 0.25 centimetres and positive lymph nodes are risk factors for early relapse in recurrent ovarian peritoneal carcinomatosis treated with cytoreductive surgery, HIPEC and systemic chemotherapy

AIM

The cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has showed promising results for the survival in patients with recurrent ovarian carcinomatosis, however, some of them will recur within the first year. The aim of this study is focussed on identifying the risk factors to develop the recurrence within the first year after an optimal CRS-HIPEC in patients with recurrent ovarian carcinomatosis.

METHODS

A total of 100 patients with peritoneal carcinomatosis from recurrent ovarian cancer treated by CRS + HIPEC were selected for analysis. Multivariate logistic regression analysis was performed to evaluate the relationship between the variables and the early recurrence.

RESULTS

The mean follow-up was 42.5 months. The mean age was 56.2 years. Early recurrence was observed in the 36%. The group early recurrence presented a higher rate of optimal cytoreductions CC1 (16.2% vs. 3.5%), lymph nodes (32.5% vs. 15%) and the use of hemoderivates (40.5% vs. 33%). Others parameters as Peritoneal Cancer Index, major morbidity? 3, re-operations rate and time to adjuvant chemotherapy were similar in both groups. The five years OS was 58%, for the non-early recurrence was higher than the early recurrence group (64% vs. 41%). In the multivariate analysis, CC-1 (OR 5.73; 1.16-32.04) and positive lymph nodes (OR 2.26; 1.01-4.32) proved to be independent factors for the early recurrence.

CONCLUSION

The combination of both (CC1 and positive lymph nodes) makes that the indication of CRS and HIPEC should be individualised. However, the major morbidity, stage IV and the time to the adjuvant treatment were not associated with an early recurrence, so that, a major aggressiveness is recommended to achieve a CC0.

Hyperthermic Intraperitoneal Perfusion Chemotherapy and Cytoreductive Surgery for Controlling Malignant Ascites From Ovarian Cancer

BACKGROUND

Malignant ascites, a complication often seen in patients with ovarian cancer (OC), is difficult to treat, but hyperthermic intraperitoneal chemotherapy (HIPEC) has a good efficacy.

OBJECTIVE

The aim of this study was to assess the efficacy of cytoreductive surgery (CRS) combined with HIPEC for controlling malignant ascites from OC.

MATERIALS AND METHODS

From December 2009 until December 2014, 53 patients with OC and malignant ascites were treated with CRS and HIPEC. Patients in good health condition were treated with CRS followed by HIPEC (CRS + HIPEC), and patients in poor health condition were treated initially with B-mode ultrasound-guided HIPEC followed by delayed CRS upon improvement of their health condition (HIPEC + delayed CRS). Resolution of ascites, complete CRS, overall survival, and disease-free survival were analyzed.

RESULTS

All patients showed ascites regression. The total objective remission rate was 100%, even for patients in the poor condition group before CRS. Complete CRS was successful in 30 (88.23%) of 34 patients in the good condition group, and 17 (89.47%) of 19 patients in the poor condition group (P > 0.05). Median disease-free survival and median overall survival were 21 and 39 months in the good condition group, and 22 and 38 months in the poor condition group, respectively (P > 0.05).

CONCLUSIONS

Hyperthermic intraperitoneal chemotherapy is effective at controlling ascites in patients with OC, even for patients in poor condition before CRS, or when complete CRS is not feasible. Furthermore, the regression of ascites appears not to be dependent on complete resection.

1st Evidence-based Italian consensus conference on cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinosis from ovarian cancer

Ovarian cancer (OC) remains relatively rare, although it is among the top 4 causes of cancer death for women younger than 50. The aggressive nature of the disease and its often late diagnosis with peritoneal involvement have an impact on prognosis. The current scientific literature presents ambiguous or uncertain indications for management of peritoneal carcinosis (PC) from OC, both owing to the lack of sufficient scientific data and their heterogeneity or lack of consistency. Therefore, the Italian Society of Surgical Oncology (SICO), the Italian Society of Obstetrics and Gynaecology, the Italian Association of Hospital Obstetricians and Gynaecologists, and the Italian Association of Medical Oncology conducted a multidisciplinary consensus conference (CC) on management of advanced OC presenting with PC during the SICO annual meeting in Naples, Italy, on September 10-11, 2015. An expert committee developed questions on diagnosis and staging work-up, indications, and procedural aspects for peritonectomy, systemic chemotherapy, and hyperthermic intraperitoneal chemotherapy for PC from OC. These questions were provided to 6 invited speakers who answered with an evidence-based report. Each report was submitted to a jury panel, representative of Italian experts in the fields of surgical oncology, gynecology, and medical oncology. The jury panel revised the reports before and after the open discussion during the CC. This article is the final document containing the clinical evidence reports and statements, revised and approved by all the authors before submission.

Influence of simultaneous liver and peritoneal resection on postoperative morbi-mortality and survival in patients with colon cancer treated with surgical cytoreduction and intraperitoneal hyperthermic chemotherapy

INTRODUCTION

Cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy (HIPEC) has recently been established as the treatment of choice for selected patients with peritoneal carcinomatosis of colonic origin. Until recently, the simultaneous presence of peritoneal and hepatic dissemination has been considered a contraindication for surgery. The aim of this paper is to analyze the morbidity, mortality and survival of patients with simultaneous peritoneal and hepatic resection with HIPEC for peritoneal carcinomatosis secondary to colon cancer.

METHODS

Between January 2010 and January 2015, 61 patients were operated on, 16 had simultaneous peritoneal and hepatic dissemination (group RH+), and 45 presented only peritoneal dissemination (group RH-).

RESULTS

There were no differences between the groups in terms of demographic data, length of surgery and extension of peritoneal disease. Postoperative grade III-V complications were significantly higher in the RH+ group (56.3 vs. 26.6%; P=.032). For the whole group, mortality rate was 3.2% (two patients in group RH-, and none in group RH+). Patients with liver resection had a longer postoperative stay (14.4 vs. 23.1 days) (P=.027). Median overall survival was 33 months for RH-, and 36 for RH+ group. Median disease-free survival was 16 months for RH-, and 24 months for RH+ group.

CONCLUSIONS

Simultaneous peritoneal cytoreduction and hepatic resection resulted in a significantly higher Clavien grade III-V morbidity and a longer hospital stay, although the results are similar to other major abdominal interventions. The application of multimodal oncological and surgical treatment may obtain similar long-term survival results in both groups.

High Penetration of Paclitaxel in Abdominal Wall of Rabbits after Hyperthermic Intraperitoneal Administration of Nab-Paclitaxel Compared to Standard Paclitaxel Formulation

PURPOSE

Paclitaxel (PTX) is currently used in combination with cisplatin for Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for the treatment of peritoneal carcinomatosis. Albumin-bound PTX is a promising new drug for HIPEC because of its easy solubility in aqueous perfusion medium and possibly because of the tendency of albumin to cross physiological barriers and accumulate in tumor tissue.

METHODS

We tested the feasibility of using nab-paclitaxel in rabbits treated by HIPEC for 60 min compared with the classical formulation at an equivalent PTX dose. Samples of perfusate and blood were collected at different time points and peritoneal tissues were collected at the end of perfusion. PTX concentrations were determined by HPLC. The depth of paclitaxel penetration through the peritoneal barrier was assessed by mass spectrometry imaging.

RESULTS

PTX after nab-paclitaxel treatment penetrated up to 0.63 mm in the peritoneal wall, but after CRE-paclitaxel, it was not detectable in the peritoneum. Moreover, the peritoneal concentration after nab-paclitaxel was five times that after paclitaxel classical formulation. Despite the high levels reached in the peritoneum, systemic exposure of PTX was low.

CONCLUSIONS

Our results show that nab-paclitaxel penetrates into the abdominal wall better than CRE-paclitaxel, in terms of effective penetration and peritoneal tissue concentration.

A critical analysis of the cytoreductive surgery with hyperthermic intraperitoneal chemotherapy combo in the clinical management of advanced gastric cancer: an effective multimodality approach with scope for improvement

Peritoneal carcinomatosis (PC) is manifested in up to 40% of gastric cancer (GC) patients, after which their 5-year survival drops to less than 5%. The currently most acceptable treatment option for advanced GC (AGC) is systemic chemo and radio therapies with however generally very unsatisfying results and this led to a resurgence of interest in regional therapies like cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Small trials have indicated an association with prolonged survival when applying this technique to AGC manifesting with PC. High procedure-related morbidity and mortality associated with the CRS-HIPEC approach have however brought by a polemic on the merits of the latter: with the advent of regulatory approval of more effective as well as novel, more personalized treatment options in AGC, along with advances in tailoring investigational agents specifically for peritoneal delivery, there clearly is a need to outline the appropriate role of CRS-HIPEC in this disease. In a clear objective to improve the therapeutic efficiency of HIPEC, there have been immense developments in the technical aspects of this technology including the use of nanotechnology in more precise drug delivery systems (DDS) or choice of more efficient drugs such as gene-target technology, laparoscopy and so on. Henceforth, in this review, we will be highlighting the past and current status of the CRS + HIPEC procedure, shedding light on the pros and cons in order to boost up the efficiency of this multimodality approach.

Intraperitoneal chemotherapy hyperthermia (HIPEC) for peritoneal carcinomatosis of ovarian cancer origin by fluid and CO2 recirculation using the closed abdomen technique (PRS-1.0 Combat): A clinical pilot study

Background This paper reports a study of 21 patients with peritoneal carcinomatosis from ovarian cancer who underwent cytoreductive surgery and HIPEC by means of PRS-1.0 Combat®, a new model for closed abdomen HIPEC aimed at improving fluid distribution with assistance from a CO2 recirculation system. This new technology has been previously shown to be successful in an experimental study (pig model) performed by our group, and has been approved for use in our hospital. Methods Twenty-one patients with peritoneal carcinomatosis of ovarian cancer origin were included in the study. Cytoreductive surgery and HIPEC were performed by a closed abdomen fluid and CO2 recirculation technique using the PRS-1.0 Combat(®) model. We analysed the intraoperative safety tolerance and post-operative morbidity and mortality during the first 30 days. Results Between November 2011 and March 2014 21 patients with epithelial ovarian cancer, International Federation of Gynecology and Obstetrics stage II-IV, were included in the study. During the procedure there were no significant haemodynamic or analytical disturbances. Complication rates were 38.1% and 57.14% for grade III/IV and minor (grade I/II) complications, respectively. Post-operative mortality was 4.76% (one patient). Complete cytoreductive surgery and intraperitoneal chemotherapy improved overall survival and disease-free survival in women with advanced ovarian cancer. The association of intra-abdominal hyperthermia with chemotherapy (HIPEC) increased the therapeutic benefit. Conclusions This study has shown that closed abdomen intraperitoneal chemohyperthermia by a fluid and CO2 recirculation system (PRS-1.0 Combat(®)) can be a safe and feasible model for the treatment of peritoneal carcinomatosis of ovarian cancer origin.

Cytoreductive surgery and intraperitoneal chemotherapy: an evidence-based review-past, present and future

Peritoneal carcinomatosis (PC) has historically been considered a terminal condition with merely palliative treatment achieving a survival rate measured in months. Cytoreductive surgery (CyRS) and intraperitoneal chemotherapy (IPC) have emerged as potentially effective regional treatments with the potential for long-term survival in well-selected patients. The fundamentals of CyRS and IPC are patient selection and complete cytoreduction. Since there is now sufficient evidence for the superiority of CyRS and IPC to systemic chemotherapy alone in a highly select group of patients, surgeons and oncologists should be aware of this modality as a potential benefit for patients with PC. The aim of this report is to highlight cancer-specific evidence in the context of ongoing studies regarding the outcome of this treatment.

Repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: review of indications and outcomes

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an established treatment option in selected patients with peritoneal dissemination from a variety of epithelial primaries. Even though a small proportion will be alive and potentially cured at 10 years, the majority will eventually develop recurrent disease. Repeat CRS/HIPEC is a valid consideration in a selected subpopulation of patients with isolated peritoneal recurrence. This review summarizes the data on patient selection, feasibility, limitations and outcomes of repeat CRS/HIPEC.

The role of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Ovarian Cancer: A Review

Ovarian cancer is one of the leading causes of cancer related deaths in women worldwide. It is usually diagnosed in an advanced stage (Stages III and IV) when peritoneal cancer spread has already occurred. The standard treatment comprises of surgery to remove all macroscopic disease followed by systemic chemotherapy. Despite all efforts, it recurs in over 75 % of the cases, most of these recurrences being confined to the peritoneal cavity. Recurrent ovarian cancer has a poor long term outcome and is generally treated with multiple lines of systemic chemotherapy and targeted therapy. The propensity of ovarian cancer to remain confined to the peritoneal cavity warrants an aggressive locoregional approach. The combined treatment comprising of cytoreductive surgery (CRS) that removes all macroscopic disease and HIPEC (Hyperthermic Intraperitoneal Chemotherapy) has been effective in providing long term survival in selected patients with peritoneal metastases of gastrointestinal origin. Intraperitoneal chemotherapy used as adjuvant therapy has shown a survival benefit in ovarian cancer. This has prompted the use of CRS and HIPEC in the management of ovarian cancer as a part of first line therapy and second line therapy for recurrent disease. This article reviews the current literature and evidence for the use of HIPEC in ovarian cancer.

Both heat and new chemotherapeutic drug dioxadet in hyperthermic intraperitoneal chemoperfusion improved survival in rat ovarian cancer model

BACKGROUND AND OBJECTIVES

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) at the time of Cytoreductive Surgery (CRS) is an actively researched treatment in patients with advanced ovarian cancer. Relative contribution of heat and chemotherapeutic agents during HIPEC as well as efficacy of a new agent dioxadet for regional chemotherapy in a rat model of ovarian cancer was studied.

METHODS

Sixty rats were divided into three groups: no treatment control group (n = 19), hyperthermia without chemotherapy (HIPEP) (n = 14), HIPEC + cisplatin (n = 14), HIPEC + dioxadet (n = 13). The intra-abdominal tumor was not resected. End points were: median survival (primary), cause of death (secondary).

RESULTS

The median survival of the animals in the control group, HIPEP group, HIPEC + cisplatin, HIPEC + dioxadet were 9 (CI; 8-23), 22.5 (CI; 12-43), 25.5 (CI; 13-62), 49 (Cl; 28-70) days, respectively. The P-values control versus HIPEP, HIPEC + cisplatin versus HIPEC + dioxadet were 0.006, 0.002, and 0.001, respectively.

CONCLUSION

During HIPEC both the heat and the cytotoxic drug had antitumor effects in a rat ovarian cancer model. Dioxadet showed potential as a drug for regional chemotherapy. J. Surg. Oncol. 2016;113:438-442. © 2015 Wiley Periodicals, Inc.

Survival Impact of Secondary Cytoreductive Surgery for Recurrent Ovarian Cancer in an Asian Population

OBJECTIVE

The aim of this study was to evaluate the role of secondary cytoreductive surgery in Asian patients with recurrent ovarian cancer and to assess prognostic variables on overall post-recurrence survival time.

METHODS

We conducted a retrospective review of patients with recurrent ovarian cancer who underwent secondary cytoreduction at the Gynaecological Cancer Center at the KK Women's and Children's Hospital, Singapore, between 1999 and 2009. Eligible patients included those who had been firstly treated by primary cytoreductive surgery and followed by adjuvant chemotherapy and had a period of clinical remission of at least six months and subsequently underwent secondary cytoreductive surgery for recurrence. Univariate analysis was performed to evaluate various variables influencing the overall survival.

RESULTS

Twenty-five patients met our eligibility criteria. The median age was 52 years (range=31-78 years). The median time from completion of primary treatment to recurrence was 25.1 months (range=6.4-83.4). Secondary cytoreduction was optimal in 20 of 25 patients (80%). The median follow-up duration was 38.9 months (range=17.8-72.4) and median overall survival time was 33.1 months (95% confidence interval, 15.3-undefined.). Ten (40.0%) patients required bowel resection, but no end colostomy was performed. One (4.0%) patient had wedge resection of the liver, one (4.0%) had a distal pancreatectomy, one (4.0%) had a unilateral nephrectomy, and one (4.0%) had adrenalectomy. There were no operative deaths. The overall survival of patients who responded to secondary cytoreductive surgery and adjuvant chemotherapy was significantly longer than those patients who did not respond to the treatment. Of those patients who responded to the surgical management, patients with clear cell carcinoma fared well compared to those with the endometrioid, mucinous adenocarcinoma, and papillary serous type (p<0.001). Complete secondary cytoreductive surgery appeared to have some relationship to overall survival but was not statistically significant.

CONCLUSION

In carefully selected patients with recurrent ovarian cancer, optimal cytoreductive surgery is possible and in a subgroup of patients who respond to surgery and chemotherapy survival is significantly longer.

Selection of chemotherapy for hyperthermic intraperitoneal use in gastric cancer

PURPOSE

Several studies have shown the potential benefit of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in gastric cancer patients. At present the most effective chemotherapeutic regime in HIPEC for gastric cancer is unknown. The aim of this review was to provide a comprehensive overview of chemotherapeutic agents used for HIPEC in gastric cancer.

METHODS

A literature search was conducted using the PubMed database to identify studies on chemotherapy used for HIPEC in gastric cancer patients.

RESULTS AND CONCLUSION

The chemotherapeutic regime of choice in HIPEC for gastric cancer has yet to be determined. The wide variety in studies and study parameters, such as chemotherapeutic agents, dosage, patient characteristics, temperature of perfusate, duration of perfusion, carrier solutions, intraperitoneal pressure and open or closed perfusion techniques, warrant more experimental and clinical studies to determine the optimal treatment schedule. A combination of drugs probably results in a more effective treatment.

Intraperitoneal chemotherapy from Armstrong to HIPEC: challenges and promise

OPINION

The treatment of advanced stage ovarian, primary peritoneal and fallopian tube cancer represents a therapeutic challenge as evidenced by the 70 %-80 % recurrence rate. Our understanding of the synergy between surgical cytoreduction and effective systemic chemotherapy continues to evolve, with research supporting maximal cytoreductive effort followed by intraperitoneal chemotherapy. Specifically, analysis of phase III clinical trials has shown a median survival of 110 months in those treated with intraperitoneal chemotherapy, when surgery results in no visible residual disease. Additionally, incorporation of hyperthermic intraperitoneal chemotherapy at the time of surgical resection has gained attention as an alternate therapeutic option, in an attempt to obviate toxicities encountered with repetitive cycles of intraperitoneal chemotherapy. Currently, surgical cytoreduction in the hands of an experienced gynecologic oncologist, followed by intraperitoneal chemotherapy is thought to portend the greatest survival benefit in patients with advanced stage ovarian cancer spectrum cancers. Additional investigation regarding the oncologic outcomes and morbidity of hyperthermic intraperitoneal chemotherapy is warranted.

Hyperthermic intraperitoneal chemotherapy (HIPEC) in ovarian cancer

Ovarian cancer remains the fourth leading cause of cancer death in women in France. It is all too often diagnosed at an advanced stage with peritoneal carcinomatosis (PC), but remains confined to the peritoneal cavity throughout much of its natural history. Because of cellular selection pressure over time, most tumor recurrences eventually develop resistance to systemic platinum. Options for salvage therapy include alternative systemic chemotherapies and further cytoreductive surgery (CRS), but the prognosis remains poor. Over the past two decades, a new therapeutic approach to PC has been developed that combines CRS with hyperthermic intraperitoneal chemotherapy (HIPEC). This treatment strategy has already been shown to be effective in non-gynecologic carcinomatosis in numerous reports. There is a strong rationale for the use of HIPEC for PC of ovarian origin. On the one hand, three prospective randomized trials have demonstrated the superiority of intraperitoneal chemotherapy (without hyperthermia) in selected patients compared to systemic chemotherapy. Moreover, retrospective studies and case-control studies of HIPEC have reported encouraging survival data, especially when used to treat chemoresistant recurrence. However, HIPEC has specific morbidity and mortality; this calls for very careful selection of eligible patients by a multidisciplinary team in specialized centers. HIPEC needs to be evaluated by means of randomized trials for ovarian cancer at different developmental stages: as first line therapy, as consolidation, and for chemoresistant recurrence. Several European phase III studies are currently ongoing.

Intensive care unit admission after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Is it necessary?

Introduction. Cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a new approach for peritoneal carcinomatosis. However, high rates of complications are associated with CS and HIPEC due to treatment complexity; that is why some patients need stabilization and surveillance for complications in the intensive care unit. Objective. This study analyzed that ICU stay is necessary after HIPEC. Methods. 39 patients with peritoneal carcinomatosis were treated according to strict selection criteria with CS and HIPEC, with closed technique, and the chemotherapy administered were cisplatin 25 mg/m(2)/L and mitomycin C 3.3 mg/m(2)/L for 90-minutes at 40.5°C. Results. 26 (67%) of the 39 patients were transferred to the ICU. Major postoperative complications were seen in 14/26 patients (53%). The mean time on surgical procedures was 7.06 hours (range 5-9 hours). The mean blood loss was 939 ml (range 100-3700 ml). The mean time stay in the ICU was 2.7 days. Conclusion. CS with HIPEC for the treatment of PC results in low mortality and high morbidity. Therefore, ICU stay directly following HIPEC should not be standardized, but should preferably be based on the extent or resections performed and individual patient characteristics and risk factors. Late complications were comparable to those reported after large abdominal surgery without HIPEC.

Intraperitoneal chemotherapy against peritoneal carcinomatosis: current status and future perspective

Peritoneal carcinomatosis (PC), caused by advanced abdominal malignancies, such as those of the ovarian and gastrointestinal tracts, has an extremely poor prognosis. Intraperitoneal (IP) chemotherapy has been clinically applied for several decades, but its clinical efficacy has not been fully determined. An accumulating body of evidence suggests that cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is the optimal treatment for selected patients with ovarian and colorectal cancers with PC. Recent studies suggest that IP administration of taxane with systemic chemotherapy in a neoadjuvant setting improves patient survival in gastric cancer with PC. The pharmacokinetics of IP-administered drugs should be primarily considered in order to optimize IP chemotherapy. Therefore, the development of specific IP drugs using newly emerging molecular targeted reagents or new drug delivery systems, such as nanomedicine or controlled absorption/release methods, is essential to improve the efficacy of IP chemotherapy.

Security and efficiency of a closed-system, turbulent-flow circuit for hyperthermic intraperitoneal chemotherapy after cytoreductive ovarian surgery: perioperative outputs

OBJECTIVE

To present physiologic intraoperative data and immediate postoperative outcomes of patients diagnosed with epithelial ovarian cancer submitted to cytoreductive surgery and hyperthermic peritoneal intraoperative chemotherapy (HIPEC) with a closed-circuit, turbulent-flow system.

MATERIALS AND METHODS

A closed-circuit system with CO2 turbulent flow was used for paclitaxel HIPEC during 60 min for patients diagnosed with stage II or higher and recurrent epithelial ovarian cancer. Perioperative hemodynamic and metabolic statuses were followed, as well as physiologic recovery during the first 12 postoperative hours. A non-parametric statistical analysis was performed.

RESULTS

At the end of the hyperthermia phase, temperature was 37.7 ± 0.6 °C, heart rate 88 ± 19 bpm, cardiac index 2.8 ± 0.5 L min(-1) m(-2), stroke volume variation 14.6 ± 3.6 % and extravascular lung water 8.7 ± 1.9 mL kg(-1). No hyperdynamic status was recorded. The length of stay in the ICU was 2½ days, and 12.7 ± 7 days in hospital. Average postoperative intubation time was 11.7 ± 17.4 h. At the ICU admission time, glucose, lactic acid and hemoglobin were the only values out of range, but close to normal. SOFA median was 3 at admission and 0 the following day.

CONCLUSION

A turbulent-flow, closed-circuit use for hyperthermic peritoneal intraoperative chemotherapy resulted in no hyperdynamic response or coagulopathy, had good tolerance and promoted early physiologic recovery.

Intraperitoneal paclitaxel induces regression of peritoneal metastasis partly by destruction of peripheral microvessels

PURPOSE

Intraperitoneal (IP) administration of paclitaxel (PTX) can enable direct infiltrate of high amount of PTX into peritoneal nodules and elicit remarkable clinical responses against peritoneal metastases. In this study, we examined the mechanisms leading to tumor shrinkage after IP PTX.

METHODS

We compared the microscopic features of peritoneal metastases before and after IP PTX in surgically removed human samples, as well as in a murine xenograft model using immunohistochemistry.

RESULTS

We found that many microvessels exist in the peripheral areas of metastatic nodules in human samples before treatment. However, peripheral vessels were greatly reduced in number, and luminal obstructions were observed in lesions showing complete response after chemotherapy including IP PTX. Similar changes were observed in peripheral vessels of peritoneal tumors in MKN45-inoculated nude mice treated with IP-PTX. Moreover, pimonidazole staining revealed that highly hypoxic regions were produced by IP PTX at the tumor periphery.

CONCLUSIONS

These findings strongly suggest that the remarkable efficacy of IP PTX in the treatment of peritoneal metastases is, at least in part, dependent on the destruction of peripheral microvessels by exposure to infiltrated PTX.

Malignant peritoneal mesothelioma: prognostic factors and oncologic outcome analysis

BACKGROUND

Most patients with malignant peritoneal mesothelioma (MPM) present with late-stage, unresectable disease that responds poorly to systemic chemotherapy while, at the same time, effective targeted therapies are lacking. We assessed the efficacy of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) in MPM.

METHODS

We prospectively analyzed 65 patients with MPM undergoing CRS/HIPEC between 2001 and 2010. Kaplan-Meier survival curves and multivariate Cox-regression models identified prognostic factors affecting oncologic outcomes.

RESULTS

Adequate CRS was achieved in 56 patients (CC-0 = 35; CC-1 = 21), and median simplified peritoneal cancer index (SPCI) was 12. Pathologic assessment revealed predominantly epithelioid histology (81 %) and biphasic histology (8 %), while lymph node involvement was uncommon (8 %). Major postoperative morbidity (grade III/IV) occurred in 23 patients (35 %), and 60-day mortality rate was 6 %. With median follow-up of 37 months, median overall survival was 46.2 months, with 1-, 2-, and 5-year overall survival probability of 77, 57, and 39 %, respectively. Median progression-free survival was 13.9 months, with 1-, 2-, and 5-year disease failure probability of 47, 68, and 83 %, respectively. In a multivariate Cox-regression model, age at surgery, SPCI >15, incomplete cytoreduction (CC-2/3), aggressive histology (epithelioid, biphasic), and postoperative sepsis were joint significant predictors of poor survival (chi square = 42.8; p = 0.00001), while age at surgery, SPCI >15, incomplete cytoreduction (CC-2/3), and aggressive histology (epithelioid, biphasic) were joint significant predictors of disease progression (Chi square = 30.6; p = 0.00001).

CONCLUSIONS

Tumor histology, disease burden, and the ability to achieve adequate surgical cytoreduction are essential prognostic factors in MPM patients undergoing CRS/HIPEC.

Cytoreductive surgery and HIPEC after neoadjuvant chemotherapy for advanced epithelial ovarian cancer

AIM: To reduce postoperative complications and to make possible an optimal cytoreduction, neoadjuvant chemotherapy (NACT) followed by interval debulking surgery has been applied with encouraging results.

METHODS: Between December 2009 and February 2012, patients with stage IIIC-IV epithelial ovarian cancer (EOC) underwent diagnostic laparoscopy, to assess the feasibility of optimal debulking surgery. The modified Fagotti score was applied to assess the feasibility of resection with zero residual tumor. Patients who were not candidate for upfront debulking surgery were submitted to NACT, then reassessed according to the RECIST 1.1 criteria and submitted to cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) if they showed clinical response or stable disease. The remaining cycles of adjuvant systemic chemotherapy (ASCT) were administered postoperatively, to complete 6 cycles of systemic chemotherapy.

RESULTS: Nine patients were included. Clinical response to NACT was complete in 3 patients and partial in 5 patients; one patient had stable disease. All patients underwent CRS resulting in CC0 disease prior to HIPEC. Average operative time was 510 min. Average intensive care unit stay was 2 d. Average postoperative hospital stay was 25 d. No postoperative mortality was observed. One patient experienced pelvic abscess. One patient refused ASCT. The remaining 8 patients started ASCT. Average time to chemotherapy was 36 d. All patients are alive, with an average follow up of 11 mo. Eight patients are disease-free at follow up.

CONCLUSION: HIPEC after CRS for advanced EOC is feasible with acceptable morbidity and mortality. NACT may increase the chance for achieving complete cytoreduction. Phase 3 studies are needed to determine the effects of HIPEC on survival.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in epithelial ovarian cancer: State of the art

Advanced stage epithelial ovarian cancer (EOC) is difficult to treat with low overall cure rates. A new strategy combining maximal cytoreductive surgery (CRS) with intra-operative hyperthermic intraperitoneal chemotherapy (HIPEC) has been proposed to treat advanced stage EOC in the primary setting. Numerous small, heterogeneous studies have been conducted exploring outcomes in patients with predominantly advanced, recurrent or refractory disease treated with CRS + HIPEC. Although morbidity rates approaching 35% have been reported, oncologic outcomes are promising. Incorporation of HIPEC for the treatment of primary EOC has continued to gain interest. Several prospective phase 2 clinical trials were recently completed evaluating the impact of CRS + HIPEC in the primary setting. This article will briefly discuss the benefits of optimal surgical cytoreduction and the theoretical basis of intraperitoneal chemotherapy in patients with advanced stage EOC, and will then review existing literature describing oncologic outcomes in EOC patients treated with HIPEC in the primary setting.

Peritoneal debulking/intraperitoneal chemotherapy-non-sarcoma

The combination of cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) is widely practiced for appendiceal, colorectal, gastric, and ovarian cancers with isolated peritoneal metastasis as well as for primary peritoneal cancer. The aim of this report is to explain the rationale and available techniques for CRS and IPC, and to highlight disease-specific considerations that should be taken into account when evaluating potential candidates for CRS and IPC.

Morbidity and mortality outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with primary and recurrent advanced ovarian cancer

BACKGROUND

The aim of this study is to report the perioperative outcomes of CRS and HIPEC from a single institution and review those factors that are associated with a poor perioperative outcome in patients with peritoneal dissemination from primary or recurrent ovarian cancer.

PATIENTS AND METHOD

A retrospective cohort study setting was conducted in a third level hospital peritoneal surface malignancy program. Ninety one patients diagnosed with ovarian peritoneal carcinomatosis, primary and recurrent without extraperitoneal metastasis were included for cytoreductive surgery and HIPEC with paclitaxel. We analyzed the postoperative morbidity rates and a univariate and multivariate analysis of factors associated with overall (grade I-IV) and major (grade III-IV) postoperative morbidity were performed.

RESULTS

Peritoneal Cancer Index (PCI) upper than 12 (OR = 2.942 95%: 1.892-9.594 p = 0.044) was an independent factor associated with the occurrence of I-IV postoperative morbidity. Regarding major complications (grade III-IV), on multivariate analysis, in addition to PCI >12 (OR = 6.692, 95% CI: 1974-45, 674, p = 0.032), the need to carry out intestinal resection (OR = 4.987, 95% CI: 1350-27, 620, p = 0.046) was an independent factor related with major morbidity (grade III-IV).

CONCLUSIONS

The use of HIPEC after aggressive cytoreductive surgery in patients with ovarian cancer with peritoneal dissemination can be performed with acceptable postoperative morbidity rates. Knowledge of the factors associated with the onset of these postoperative adverse events allows better management of the same and offers the patient a safe procedure.