Cytoreductive surgery combined with hyperthermic intraperitoneal intraoperative chemotherapy in the treatment of advanced epithelial ovarian cancer

Cytoreductive surgery and perioperative intraperitoneal chemotherapy in recurrent ovarian cancer: 18 years of experience

AIM

To identify the clinical and pathological factors associated with relapse in women who had undergone secondary cytoreductive surgery due to locally advanced recurrent ovarian cancer.

METHODS

Women with locally advanced recurrent ovarian cancer who had undergone cytoreduction between 2000 and 2018 were included in this study. Demographic, clinical and biochemical intraoperative findings were recorded for each woman. All factors were assessed in order to identify which correlated with the outcomes of interest (i.e. disease relapse, mortality and morbidity).

RESULTS

In total, 181 women who had undergone secondary cytoreduction were analysed. The hospital mortality rate was 1.7 % (n = 3) and the morbidity rate was 32.1 % (n = 58). Recurrence was recorded in 101 (55.8 %) women. Infiltration of large bowel lymph nodes was a negative prognostic indicator of morbidity (p = 0.029). A prior surgical score of 1 (PSS-1) [odds ratio (OR) 0.465] and complete cytoreduction (OR 0.518) were found to be significant independent predictors for disease relapse. Median overall survival was greater for patients with PSS-1 (151.3 vs 59.4 vs 44.1 months; p = 0.049) and patients with complete cytoreduction (137.6 vs 36.2 vs 10.0 vs 27.4 months; p < 0.001).

CONCLUSION

Complete cytoreduction and PSS-1 are associated with reduced disease relapse and increased overall survival. Infiltration of large bowel lymph nodes is associated with increased morbidity.

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.

Prognostic Value of En-Block Radical Bowel Resection in Advanced Ovarian Cancer Surgery With HIPEC

PURPOSE

To identify prognostic factors of survival and recurrence in advanced ovarian cancer patients undergoing radical surgery and HIPEC.

METHODS

In a single Department of Surgical Oncology, Peritoneal Surface Malignancy Program, and over a 16-year period, from a total of 274 epithelial ovarian cancer patients, retrospectively, we identified 152 patients undergoing complete (CC-0) or near-complete (CC-1) cytoreduction, including at least one colonic resection, and HIPEC.

RESULTS

Mean age of patients was 58.8 years and CC-0 was possible in 72.4%. Rates of in-hospital mortality and major morbidity were 2.6% and 15.7%. Only 122 (80.3%) patients completed Adjuvant Systemic Chemotherapy (ASCH). Rates of metastatic Total Lymph Nodes (TLN), Para-Aortic and Pelvic Lymph Nodes (PAPLN) and Large Bowel Lymph Nodes (LBLN) were 58.7%, 58.5%, and 51.3%, respectively. Median, 5- and 10-year survival rates were 39 months, 43%, and 36.2%, respectively. The recurrence rate was 35.5%. On univariate analysis, CC-1, high Peritoneal Cancer Index (PCI), in-hospital morbidity, and no adjuvant chemotherapy were adverse factors for survival and recurrence. On multivariate analysis, negative survival indicators were the advanced age of patients, extensive peritoneal dissemination, low total number of TLN and no systemic PAPLN. Metastatic LBLN and segmental resection of the small bowel (SIR) were associated with a high risk for recurrence.

CONCLUSION

CC-O is feasible in most advanced ovarian cancer patients and HIPEC may confer a survival benefit. Radical bowel resection, with its entire mesocolon, may be necessary, as its lymph nodes often harbor metastases influencing disease recurrence and survival. The role of metastatic bowel lymph nodes has to be taken into account when assessing the impact of systemic lymphadenectomy in this group of patients.

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.

NCCN Guidelines Insights: Ovarian Cancer, Version 1.2019

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States, with less than half of patients living >5 years from diagnosis. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. The best outcomes are observed in patients whose primary treatment includes complete resection of all visible disease plus combination platinum-based chemotherapy. Research efforts are focused on primary neoadjuvant treatments that may improve resectability, as well as systemic therapies providing improved long-term survival. These NCCN Guidelines Insights focus on recent updates to neoadjuvant chemotherapy recommendations, including the addition of hyperthermic intraperitoneal chemotherapy, and the role of PARP inhibitors and bevacizumab as maintenance therapy options in select patients who have completed primary chemotherapy.

An overview and update of hyperthermic intraperitoneal chemotherapy in ovarian cancer

INTRODUCTION

Despite, the strong rationale and evidence of the benefit of postoperative intraperitoneal chemotherapy in advanced ovarian cancer, it has not been widely adopted, mainly due to its high morbidity and logistical difficulties. Intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) is a more tolerable and technically feasible method of intraperitoneal chemotherapy, whereas other potential advantages include homogenous drug distribution, application before tumor regrowth and combination with hyperthermia, which is directly cytotoxic and enhances the efficacy of many drugs.

AREAS COVERED

In this review, the authors explain the rationale and indications for cytoreductive surgery (CRS) and HIPEC in advanced ovarian cancer. Data of major clinical studies, meta-analyses, and recent randomized trials are discussed.

EXPERT OPINION

After many encouraging clinical studies and meta-analyses, a recent randomized study demonstrated survival benefit for HIPEC during interval CRS in primary ovarian cancer, without increased morbidity, whereas another implied its benefit in recurrent ovarian cancer. Results of recently completed and numerous ongoing randomized studies will further determine the benefit of HIPEC in ovarian cancer at different time points. Patient selection and appraisal of the best protocols are crucial. The field of gynecological oncology will most likely evolve to include HIPEC eventually as a routine treatment for ovarian cancer.

Ascites do not affect the rate of complete cytoreductive surgery and prognosis in patients with primary ovarian cancer with ascites treated with hyperthermic intraperitoneal chemotherapy

Cytoreductive surgery (CRS) is the current standard therapy procedure for patients with advanced ovarian cancer (OC), but numerous patients with OC are complicated with ascites. The aim of the present study was to assess whether massive ascites affect the rate of complete CRS and prognosis for patients with primary OC treated with hyperthermic intraperitoneal chemotherapy (HIPEC). Between December 2006 and December 2015, 1,293 patients with primary OC from the Intracelom Hyperthermic Perfusion Therapy Center of the Cancer Hospital of Guangzhou Medical University prospective database were treated with CRS combined with HIPEC. A total of 1,225 patients were without malignant ascites or small amounts of ascites and 68 had massive malignant ascites. The rate of complete CRS, overall survival (OS), disease-free survival (DFS) and resolution of ascites for patients with massive ascites were analyzed between patients without/small ascites, and with massive ascites. Complete CRS was successful in 86.8% (1,063/1,225) of patients without/small ascites, and 85.3% (58/68) of patients with massive ascites. No statistical differences were identified in complete CRS success between patients with ascites and patients without/small ascites (P=0.080). For patients with massive ascites, all symptoms exhibited regression; the total objective remission rate was 100% (68/68), even for patients with incomplete CRS (10/68) (P=0.100). The mean OS was 58 months and the mean DFS was 26 months in patients without/small ascite, vs. 57 months and 28 months in patients with massive ascites. No significant differences were noted in median DFS and median OS between patients with ascites, and patients without/small ascites (All P>0.05). In conclusion, the results of the present study suggest that ascites does not affect the rate of complete CRS and the prognosis of patients with massive ascites following HIPEC. CRS is suitable for the majority of patients with primary OC and massive ascites.

Cytoreductive Surgery in Combination with HIPEC in the Treatment of Peritoneal Sarcomatosis

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an effective treatment for peritoneal carcinomatosis, but it has been debated for peritoneal sarcomatosis. The purpose of the study is the presentation of perioperative and long-term results of CRS and hyperthermic intraoperative intraperitoneal chemotherapy in patients with peritoneal sarcomatosis. Retrospective study in a prospectively maintained database of 20 patients that underwent 29 CRS + HIPEC for peritoneal sarcomatosis. Clinical and histopathologic variables were correlated to survival. Complete cytoreduction was possible in 86.2% of the cases. The hospital mortality and morbidity rate were 0 and 20.7%, respectively. The median follow-up was 26 months, and recurrence was recorded in 20 cases (69%). The median and 5-year survival was 55 ± 13 (34-58) months and 43%, respectively. Prior surgical score (PSS) was the single variable related to survival (p = 0.018). The histologic subtype of the tumor was related to recurrence (p < 0.001). CRS and HIPEC in peritoneal sarcomatosis may offer a survival benefit in selected patients with low hospital mortality. The variety of histologic types of sarcomatosis has not made possible the identification of subgroups of patients that may be offered significant benefit by CRS and HIPEC. Further studies are required.

Consolidation hyperthermic intraperitoneal chemotherapy for the treatment of advanced stage ovarian carcinoma: a 3 year experience

PURPOSE

Hyperthermic intraperitoneal chemotherapy (HIPEC) potentially confers significant survival benefits in the management of ovarian cancer although the long-term data remain scant. We sought to compare the survival rates of advanced stage ovarian cancer patients who were treated with primary induction therapy alone or in conjunction with consolidation HIPEC.

METHODS

69 ovarian cancer patients who underwent surgery and completed their primary induction chemotherapy were treated with consolidation carboplatin (AUC 10) based HIPEC and compared to a historical cohort that received surgery and primary chemotherapy alone (n = 69). The demographic and clinical characteristics on which we were primarily focused, included patient age, body mass index, surgery and pathology data, chemotherapy regimen, toxicity, and progression free/overall survival.

RESULTS

The two patient groups' demographic and clinical characteristics were similar (P > 0.05). Progression-free survival was significantly more pronounced in the HIPEC (25.1 months) patients compared to the control group (20 months) (P = 0.024) and there was a decreased risk of disease progression accorded to the patients treated with HIPEC (HR 2.1028; 95% CI 1.2941-3.4167; P = 0.0027). However, we did not discern any HIPEC related overall survival advantages (P = 0.29).

CONCLUSIONS

The results from our ovarian cancer study suggest that adjunctive HIPEC proffers a significant progression-free survival advantage and a decreased risk for disease progression. There was, however, no overall survival advantage discerned by the HIPEC group. We also recognize that HIPEC remains controversial, and thus randomized studies evaluating HIPEC compared to standard chemotherapy in the management of ovarian cancer are warranted.

Cytoreductive Surgery plus Hyperthermic Intraperitoneal Chemotherapy to Treat Advanced/Recurrent Epithelial Ovarian Cancer: Results from a Retrospective Study on Prospectively Established Database

BACKGROUND

Despite the best standard treatment, optimal cytoreductive surgery (CRS) and platinum/taxane-based chemotherapy, prognosis of advanced epithelial ovarian carcinoma (EOC) remains poor. Recently, CRS plus hyperthermic intraperitoneal chemotherapy (HIPEC) has been developed to treat peritoneal carcinomatosis (PC). This study was to evaluate the efficacy and safety of CRS+HIPEC to treat PC from advanced/recurrent EOC.

METHODS

Forty-six PC patients from advanced EOC (group A) or recurrent EOC (group B) were treated by 50 CRS+HIPEC procedures. The primary endpoints were progression-free survival (PFS) and overall survival (OS); the secondary endpoints were safety profiles.

RESULTS

The median OS was 74.0 months [95% confidence interval (CI) 8.5-139.5] for group A versus 57.5 months (95% CI 29.8-85.2) for group B (P = .68). The median PFS was not reached for group A versus 8.5 months (95% CI 0-17.5) for group B (P = .034). Better median OS correlated with peritoneal cancer index (PCI) < 20 (76.6 months for PCI ≤ 20 group vs 38.5 months for PCI > 20 group, P = .01), complete cyroreduction (residual disease ≤ 2.5 mm) [79.5 months for completeness of cytoreduction (CC) score 0-1 vs 24.3 months for CC 2-3, P = .00], and sensitivity to platinum (65.3 months for platinum-sensitive group vs 20.0 for platinum-resistant group, P = .05). Serious adverse events occurred in five patients (10.0%). Multivariate analysis identified CC score as the only independent factor for better survival.

CONCLUSION

For advanced/recurrent EOC, CRS+HIPEC could improve OS with acceptable safety.

Chemotherapy for intraperitoneal use: a review of hyperthermic intraperitoneal chemotherapy and early post-operative intraperitoneal chemotherapy

Peritoneal spread of tumors is a major problem in cancer management. Patients develop a marked deterioration in quality of life and shortened survival. This is in part due to bowel obstructions, marked ascites, and overall increase debilitation. Standard medical management has shown to be inadequate for the treatment of these problems. Surgery can palliate symptoms, however, it is unable to be complete at the microscopic level by a significant spillage of tumor cells throughout the abdomen. Chemotherapy can have some improvement in symptoms however it is short lived due to poor penetration into the peritoneal cavity. The role of intraperitoneal chemotherapy is to maximize tumor penetration and optimize cell death while minimizing systemic toxicity. Hyperthermic intraperitoneal chemotherapy (HIPEC) and early post-operative intraperitoneal chemotherapy (EPIC) are two treatment methods that serve this role and have been shown to improve survival. This review will discuss different chemotherapies used for both of these treatment options.

Prognostic significance of Sugarbaker's peritoneal cancer index for the operability of ovarian carcinoma

INTRODUCTION

This study aimed to investigate Sugarbaker's peritoneal cancer index (PCI) as a prognostic indicator for the resectability of ovarian carcinoma (OC), as depicted in the study using the completeness of cytoreduction score (CCS).Currently, the intraoperative assessment of operability in OC surgery is primarily a subjective measurement that is dependent on the surgeon.

METHODS

The retrospective data from 98 patients with OC International Federation of Gynecology and Obstetrics (FIGO) III to IV who had received surgery between January 2010 and December 2011 were analyzed. The PCI and the CCS were determined retrospectively using surgical reports, histological findings, and intraoperative photographic documentation. Receiver operating characteristic curves and ordinal regression were applied to evaluate the predictability of CCS using the PCI.

RESULTS

Of 98 patients, 80 (81.6%) were staged FIGO III and 18 (18.4%) FIGO IV. A statistically significant correlation was demonstrated between the PCI and CCS (P < 0.01). A receiver operating characteristic curve with an area under the curve of 0.839 demonstrated the high precision in discrimination with which the PCI could predict the CCS. Using ordinal regression, it was possible to estimate the probabilities of achieving CCS 0, CCS 1, CCS 2, or CCS 3 for a given PCI (pseudo R(2) according to Cox and Snell 0.428, Nagelkerke 0.476, and McFadden 0.244).

CONCLUSIONS

The PCI more precisely defined the heterogeneous group of patients with OC FIGO III. The PCI provided objectivity and reproducibility, and it seems to be a possible prognostic indicator for OC resectability.

Hemodynamic Monitoring During Heated Intraoperative Intraperitoneal Chemotherapy Using the FloTrac/Vigileo System

Cytoreductive surgery with HIPEC has provided a chance for long-term survival in selected patients. However, perioperative management remains a challenge for the anesthesiology team. The aim of this study was to evaluate the changes in hemodynamic parameters during hyperthermic intraperitoneal chemotherapy (HIPEC) using the FloTrac/Vigileo system. Forty-one consecutive patients undergoing cytoreductive surgery and HIPEC were enrolled. Heart rate (HR), esophageal temperature, and cardiac output (CO) steadily increased until the end of HIPEC. In the first half of HIPEC, systolic blood pressure (SBP) and central venous pressure (CVP) increased whereas systemic vascular resistance (SVR) decreased; SVR stabilized in the second half. Diastolic blood pressure (DBP), mean arterial pressure (MAP), and stroke volume (SV) showed no significant variation. Male gender was related to increased CVP, CO, and SV, and decreased SVR; age >55 years was related to increased SBP, and peritoneal cancer index (PCI) was correlated with HR, DBP, and SV. PCI >14 was associated with increased HR and decreased DBP and MAP. American Society of Anesthesiologists score >1 was related to decreased CO and SV. Patients undergoing HIPEC develop a hyperdynamic circulatory state because of the increased temperature, characterized by a steady decrease in SVR and continuous increase in HR and CO. FloTrac/Vigileo system may provide an easy-to-handle, noninvasive monitoring tool.

A critical appraisal of hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced and recurrent ovarian cancer

OBJECTIVE

Our objective was to review the published experiences of the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced and recurrent ovarian cancer with a focus on survival outcomes.

METHODS

A search of the PubMed database (2008-2014) for articles specifically addressing the topic "HIPEC and ovarian cancer" was performed. We found a total of 22 publications that included 1450 patients. A final group of eleven studies (248 patients with advanced ovarian cancer) and eight publications (499 patients with recurrent sensitive ovarian cancer) that included information about survival were reviewed.

RESULTS

Among patients with primary ovarian cancer who were treated with primary debulking and HIPEC, the weighted median overall survival was 37.3 months (range 27-78), the median disease-free survival was 14.4 months (range 12-30), and the 5-yr-survival rate was 40% (range 28-72). In the recurrent cohort, the overall survival after HIPEC was 36.5 months (range 23-62), and the median disease-free survival was 20.2 months (range 11-29). The rates of severe morbidity were 25 and 19% in the primary and recurrent groups, respectively.

CONCLUSION

Although randomized trials are ongoing, the recently published retrospective data regarding the use of HIPEC for primary advanced and for recurrent ovarian cancer do not indicate any apparent advantage of this treatment in terms of the survival outcomes in these patients. Therefore, HIPEC cannot be considered a standard treatment and should not be offered outside of clinical trials.

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.

Cytoreduction and HIPEC after neoadjuvant chemotherapy in stage IIIC-IV ovarian cancer. Critical analysis in elderly patients

OBJECTIVES

The aim of our study was to evaluate postoperative morbidity and mortality, disease-free and overall survival in patients older than 75 years undergoing interval debulking after neoadjuvant chemotherapy and intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC).

STUDY DESIGN

Were included a series of consecutive patients diagnosed with stages IIIC/IV ovarian carcinoma, intervened after neoadjuvant systemic chemotherapy (paclitaxel and carboplatin) between January 2008 and June 2013. After completion of cytoreduction HIPEC was administered using paclitaxel (60mg/m(2)) or cisplatin (75mg/m(2)). We analyzed and compared the results of postoperative morbidity and mortality, disease-free survival and overall survival in patients ≥75 years compared to patients with lower ages intervened in the same time period.

RESULTS

From a total of 66 patients tested, 9 patients were ≥75 years (14%). Grade I-IV morbidity was significantly higher in patients ≥75 years (78% vs 35%, p<0.05) as well as grade III-IV disease (56% vs 16%, p<0.05). There were no procedure-related mortality. In patients ≥75 years the median disease-free survival was 6 months (95% CI: 3.5-8.5 months) vs 24 months (95% CI: 10.5-37.5 months) in younger patients. The median overall survival in patients ≥75 years was 13 months (95% CI: 4.7-21.3), not having reached at time of analysis of the database in younger patients.

CONCLUSIONS

Patients ≥75 years received no benefit in prognosis after interval cytoreduction with HIPEC and paid a high price in terms of postoperative morbidity. This age group should be excluded from this therapeutic procedure.

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 chemotherapy in ovarian cancer: a review of tolerance and efficacy

PURPOSE

TO REVIEW THE TWO MAIN APPROACHES OF INTRAPERITONEAL (IP) CHEMOTHERAPY DELIVERY IN OVARIAN CANCER: postoperative adjuvant IP chemotherapy after cytoreductive surgery (CRS) and intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A literature search was conducted to identify studies that employed postoperative adjuvant IP chemotherapy after CRS or combined CRS and intraoperative HIPEC in patients with ovarian cancer. Data of interest included chemotherapy protocol, morbidity and mortality, and survival data.

RESULTS

Three large randomized controlled trials comprising 707 patients with advanced ovarian cancer who received postoperative adjuvant IP chemotherapy were reviewed. Morbidity rate ranged from 56% to 94% in IP chemotherapy, and mortality rate ranged from 1% to 2%. Median disease-free survival ranged from 24 to 28 months, and overall survival ranged from 49 to 66 months. Planned chemotherapy completion rates ranged from 42% to 71%. Twenty-four nonrandomized studies that reported HIPEC comprised 1167 patients with both advanced and recurrent ovarian cancer. In patients with advanced ovarian cancer, mortality ranged from 0% to 5%, minor morbidity ranged from 16% to 90%, and major morbidity ranged from 0% to 40%. Median disease-free survival ranged from 13 to 56 months, and overall survival ranged from 14 to 64 months. Survival at 5 years ranged from 35% to 70%. In patients with recurrent ovarian cancer, the mortality rate ranged from 0% to 10%, minor morbidity ranged from 7% to 90%, and major morbidity ranged from 0% to 49%. Median disease-free survival ranged from 13 to 24 months and overall survival from 23 to 49 months. Survival at 5 years ranged from 12% to 54%.

CONCLUSION

There is level-one evidence suggesting the benefit of postoperative adjuvant intraperitoneal chemotherapy for patients with advanced ovarian cancer after cytoreductive surgery, albeit catheter-related complications resulted after treatment discontinuation. Studies report the use of HIPEC predominantly in the setting of recurrent disease and have demonstrated encouraging results, which merits further investigation in future clinical trials.