A comprehensive review of childbearing after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Patient Perspectives of Fertility Following Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy: An Opportunity for Improved Perioperative Counseling

INTRODUCTION

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is increasingly performed in young patients with peritoneal surface malignancies. Important quality of life (QoL) questions arise; however, there is limited research on fertility experiences in young women with carcinomatosis or following CRS/HIPEC.

METHODS

Retrospective review of a prospective database evaluating women less than 45 ys who underwent CRS/HIPEC at the University of Pittsburgh Medical Center from January 1998 to 2020. Eligible patients were contacted for a telephone-based interview. Themes regarding fertility counseling, childbearing, and patient-identified issues were investigated.

RESULTS

A total of 28 of 29 women who met inclusion criteria participated. The majority had appendiceal primary (16/28). Most received Mitomycin C intraperitoneal chemotherapy (26/28) with an average Peritoneal Cancer Index of 8 (0-39). Almost half of the women (43%) desired fertility discussion. Although this conversation happened more often in younger patients, 75% were over the age of 35 ys at time of initial HIPEC. Less than half were offered fertility counseling. When fertility conversations occurred, many felt that they were insufficient. In addition to fertility, women cited lack of support on postprocedure hormonal and associated QoL changes.

CONCLUSIONS

As we treat younger females with CRS/HIPEC, we must provide support for age-appropriate QoL issues including fertility and surgical menopause.

[Gender medicine in peritoneal diseases]

Diseases of the peritoneum are divided into benign and malignant, whereby malignant diseases are more frequent. The incidence of peritoneal metastases is difficult to determine as they are frequently not listed separately in cancer databases and registries. Peritoneal metastases can be caused by many primary tumors but are particularly frequent in gastric, ovarian and colorectal carcinomas. Systemic chemotherapy shows gender-specific differences in the tolerability, especially gastrointestinal side effects and hematological toxicity occur more often in women. Surgical treatment options in selected patients include cytoreductive surgery with or without hyperthermic intraperitoneal chemoperfusion (HIPEC). The treatment recommendations depend on the primary tumor entity and the stage of the disease. Hysterectomy and/or salpingo-oophorectomy is often necessary during cytoreductive surgery. As the incidence of cancerous diseases is increasing in younger patients, the aspect of fertility is becoming increasingly more important. The iatrogenically induced menopause is another aspect that needs to be addressed after these types of procedures. Women with gastric and colorectal cancer tend to have a slightly better survival rate, especially in localized tumors; however, in advanced tumor stages the survival rates are comparable. Even if gender-specific differences in incidence, treatment response and adverse events are conspicuous, there is so far no exact explanation for these differences. More studies are needed in order to treat both genders as adequately as possible, with low adverse events and to achieve the best possible outcome.

Ovarian Causes of Pseudomyxoma Peritonei (PMP)-A Literature Review

BACKGROUND

Pseudomyxoma peritonei (PMP) is a rare, progressive, slowly growing, inadequately understood neoplasm with a 5-year progression-free survival rate of as low as 48%. It is characterized by varying degrees of malignancy and the production of mucinous and gelatinous structures. Typically, the development of pseudomyxoma peritonei is associated with the rupture of appendiceal mucinous tumors and other gastrointestinal or ovarian mucinous tumors. The goal of our literature review was to identify various aspects that characterize the ovarian causes of pseudomyxoma peritonei.

MATERIALS AND METHODS

The authors performed an extensive literature search between 1 February 2024 and 2 March 2024 on the following databases: Pubmed, Scopus, Oxford Journals, and Reaxys, and the findings were summarized into seven main clinical and paraclinical situations.

RESULTS

According to our research, the main instances in which pseudomyxoma peritonei can be triggered by an ovarian cause are the following: (1) mucinous cystadenoma; (2) mucinous ovarian cancer; (3) colon cancer with ovarian metastasis; (4) malignant transformation of an ovarian primary mature cystic teratoma; (5) appendiceal mucocele with peritoneal dissemination mimicking an ovarian tumor with peritoneal carcinomatosis; (6) mucinous borderline tumor developing inside an ovarian teratoma; and (7) the association between a mucinous bilateral ovarian cancer and a colonic tumor.

CONCLUSIONS

In our study, we aimed to provide a comprehensive overview of the ovarian causes of pseudomyxoma peritonei, including its epidemiology, imagery characteristics, symptoms, current treatment, and promising future therapies, in the hopes of finding feasible solutions, as a lack of understanding of this mucus-secreting malignant disease increases the risk of delayed diagnosis or uncontrolled deterioration.

Prognosis for Young Females with Pseudomyxoma Peritonei of Appendiceal Origin and Unilateral or Bilateral Ovaries Preserved During Cytoreductive Surgery

Objective

To determine prognosis for young female patients with peritoneal pseudomyxoma (PMP) of appendiceal origin and unilateral or bilateral ovaries preserved during cytoreductive surgery (CRS).

Methods

Clinical data of female patients treated with CRS with or without hyperthermic intraperitoneal chemotherapy (HIPEC) at the Aerospace Center Hospital, Beijing between January, 2009 and December, 2019 were retrospectively reviewed. Patients had no changes in the bilateral ovaries on gross pathological observations or biopsy during CRS, and normal ovarian function. The demographic and clinical characteristics and prognosis of women with ovaries preserved (ovarian preservation group) or resected (ovarian resection group) during CRS were compared. Independent prognostic factors for survival were identified using univariate and multivariate analysis.

Results

40 patients were included in the final analysis. 19 patients chose ovarian preservation while 21 patients underwent ovarian resection. Completeness of cytoreduction (CCR) scores were CCR-0/1. There were significant differences in age (<40 vs. ≥40), symptoms, intraoperative HIPEC (Y vs. N), and histopathologic subtype of PMP (low-grade vs. high-grade) (p < 0.001) between patients in the ovarian preservation and ovarian resection groups. In the ovarian preservation group, median overall survival (OS) was 59 months (range, 53–65 months), and the 5-year survival rate was 37.9%. Median disease-free survival (DFS) was 13 months (range, 9–17 months), and the 5-year recurrence rate was 87.4%. In the ovarian resection group, the 5-year survival rate was 87.7%, and the 5-year recurrence rate was 18.3%. Median OS and median DFS were not reached. In patients with low-grade PMP, median DFS was significantly longer in patients with ovarian resection compared to ovarian preservation (p < 0.001). Univariate analysis showed histopathologic subtype of PMP (low-grade vs. high-grade, p < 0.001) was significantly associated with OS and DFS. On multivariate analysis, high-grade histopathologic subtype of PMP was an independent predictor of poor prognosis (OS and DFS).

Conclusion

Histopathologic subtype of PMP represents an independent predictor of prognosis in female patients with PMP of appendiceal origin and unilateral or bilateral ovaries preserved during CRS. These findings imply that ovarian preservation is a more suitable option for young females with low-grade PMP compared to high-grade PMP. Further prospective studies should be done investigating the role of resection of uninvolved ovaries in PMP.

Fertility outcomes after treatment with intraperitoneal chemotherapy

Intraperitoneal chemotherapy (IPC) administration has been added to the therapeutic protocols of cancers, confined to the abdominal cavity. Since, a survival benefit in patients treated with adjuvant IPC has been demonstrated, fertility questions are raised in these patients. A comprehensive search of the English literature of PubMed/MEDLINE, EmBase and Google Scholar databases was conducted, from their inception until April 2021, following the MOOSE guidelines. Twelve out of 473 studies were included in the final review and analysis. After treatment with IPC for peritoneal carcinomatosis, 19 women, who underwent fertility-sparing surgery, with 20 successful pregnancies were reported. The mean interval time between IPC and pregnancy was 38.4 months (range 9-168 months). In 16 cases, conception was spontaneous, three required in vitro fertilisation, whereas one pregnancy was achieved through intrauterine insemination. Mean disease-free survival was 76 months (range 24-177 months). Childbearing is a feasible approach in selected patients, after treatment with IPC. When future pregnancy is desirable, a multidisciplinary team of surgeons, gynaecologists, oncologists and reproductive specialists is required, to inform the patient thoroughly about the fertility preservation alternatives, without endangering patient's survival.

Fertility preservation in women with peritoneal surface malignancies: A case series

The advent of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has improved survival in patients with peritoneal surface malignancies. Not surprisingly, there is now a growing interest on the possible means to preserve fertility to ensure future childbearing. In this study, we report on five women with peritoneal surface malignancies who performed ovarian hyper-stimulation and oocytes cryostorage prior to undergo CRS and HIPEC. The presence of the disease complicated follicular growth monitoring but the oocytes retrievals could be always performed and were uneventful. At last follow-up, all women were alive and disease-free. None has yet returned to thaw her oocytes. Overall, these cases suggest that oocytes cryopreservation before CRS and HIPEC should be considered.