Neoadjuvant chemotherapy followed by fast-track cytoreductive surgery plus short-course hyperthermic intraperitoneal chemotherapy (HIPEC) in advanced ovarian cancer: preliminary results of a promising all-in-one approach

Complications of HIPEC for ovarian cancer surgery: evaluation over two time periods

OBJECTIVE

Cytoreductive surgery in conjunction with hyperthermic intraperitoneal chemotherapy (HIPEC) is being explored in the upfront, interval, and recurrent setting in patients with ovarian cancer. The objective of this systematic review was to assess the rate of complications associated with HIPEC in epithelial ovarian cancer surgery over two time periods.

METHODS

This study was registered in PROSPERO (CRD42022328928). A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Ovid/Medline, Ovid/Embase, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials were searched from January 2004 to April 2022. We included studies reporting on patients with advanced primary or recurrent epithelial ovarian cancer who underwent cytoreductive surgery and HIPEC. We evaluated two different time periods: 2004-2013 and 2014-2022. A random-effects meta-analysis was used to produce an overall summary. Subgroup analyses were planned according to recruited period for each specific complication type. Heterogeneity was assessed using the I2 statistic.

RESULTS

A total of 4928 patients were included from 69 studies for this systematic review; 19 published from 2004-2013, and 50 published from 2014-2022. No significant differences were found between the two time periods in terms of blood transfusions (33% vs 51%; p=0.46; I2=95%) overall gastrointestinal complications (15% vs 21%; p=0.36; I2=98%), infectious diseases (16% vs 13%; p=0.62; I2=93%), overall respiratory complications (12% vs 12%; p=0.88; I2=91%), overall urinary complications (6% vs 12%; p=0.06; I2=94%), or thromboembolic events (5% vs 3%; p=0.25; I2=63%). Also, no differences were found in intensive care unit (ICU) admissions (89% vs 28%; p=0.06; I2=99%), reoperations (8% vs 7%; p=0.50; I2=37%), or deaths (3% vs 3%; p=0.77; I2=57%).

CONCLUSIONS

Our review showed that overall complications have not changed over time for patients undergoing HIPEC in the setting of primary or recurrent ovarian cancer. There was no decrease in the rates of ICU admissions, reoperations, or deaths.

Cytoreductive Surgery (CRS) and HIPEC for Advanced Ovarian Cancer with Peritoneal Metastases: Italian PSM Oncoteam Evidence and Study Purposes

Ovarian cancer is the eighth most common neoplasm in women with a high mortality rate mainly due to a marked propensity for peritoneal spread directly at diagnosis, as well as tumor recurrence after radical surgical treatment. Treatments for peritoneal metastases have to be designed from a patient's perspective and focus on meaningful measures of benefit. Hyperthermic intraperitoneal chemotherapy (HIPEC), a strategy combining maximal cytoreductive surgery with regional chemotherapy, has been proposed to treat advanced ovarian cancer. Preliminary results to date have shown promising results, with improved survival outcomes and tumor regression. As knowledge about the disease process increases, practice guidelines will continue to evolve. In this review, we have reported a broad overview of advanced ovarian cancer management, and an update of the current evidence. The future perspectives of the Italian Society of Surgical Oncology (SICO) are discussed conclusively.

A phase 2 trial of short-course Hyperthermic IntraPeritoneal Chemotherapy (HIPEC) at interval cytoreductive surgery (iCRS) for advanced ovarian cancer

OBJECTIVE

to report the final analysis of a phase 2 trial assessing the efficacy and safety of short-course hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with advanced epithelial ovarian cancer (EOC).

METHODS

this was an open-label, multicenter, single-arm trial of HIPEC in patients with advanced EOC who underwent interval cytoreductive surgery (iCRS) after neoadjuvant chemotherapy (NACT). HIPEC was performed as a concentration-based regimen of platinum-based chemotherapy for 30 minutes. Primary endpoint was the rate of disease progression occurring at nine months following iCRS plus HIPEC (PD9). Secondary endpoints were postoperative complications, time to start adjuvant chemotherapy, length of hospital and ICU stay, quality of life (QoL) over treatment, and ultimately 2-year progression-free survival (PFS) and overall survival (OS). Analysis was by intention-to-treat with final database lock for survival outcomes on February 23, 2021.

RESULTS

fifteen patients with stage III EOC were enrolled between February 2015 and July 2019, in four centers. The intention to treat PD9 was 6.7%. With a median follow-up of 33 months (IQR, 24.3-46.5), the median PFS was 18.1 months and corresponding 2-year rates of PFS and OS was 33.3% and 93.3%, respectively. Three patients (20%) experienced graded III complications. Median length of hospital and ICU stay was 5 (IQR, 4-6.5) and 1 (IQR, 1-1) days, respectively. Time to restart systemic chemotherapy was 39 (IQR, 35-49.3) days and no significant difference over time in QoL was observed.

CONCLUSIONS

we demonstrate preliminary efficacy and safety of short-course HIPEC in patient with advanced EOC.

Narrative review of hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with advanced ovarian cancer: a critical reappraisal of the current evidence

The implementation of hyperthermic intraperitoneal chemotherapy (HIPEC) in the management of advanced stage epithelial ovarian cancer (EOC) as a standard practice remains debatable despite the emerging data supporting its beneficial effect when used to supplement cytoreductive procedures. The aim of the present review was an attempt to accumulate the currently available evidence on the use of HIPEC for patients with primary and recurrent EOC and to address directives of future research. Based on the currently available literature, the progress in cytoreductive surgical procedures and chemotherapy has brought significant improvement in the management and survival outcomes of selected patients with advanced EOC. The addition of HIPEC seems encouraging based on the outcomes of high-quality clinical trials. There are significant parameters on the use of CRS and HIPEC such as patient selection, the sequencing of procedures, the type of chemotherapy agent and time and the temperature of hyperthermic procedures which require additional investigation. Multidisciplinary team management by surgeons, gynaecologists, oncologists, pathologists and radiologists is of critical importance. Also, additional large prospective well-designed randomised studies are needed in order to update our current knowledge and provide guidelines to improve the management of patients with EOC.

Impact of insurance status on overall survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

Objectives

The impact of insurance status on oncological outcome in patients undergoing cytoreduction and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is poorly understood.

Methods

Retrospective study on 31 patients having undergone 36 CRS-HIPEC at a single institution (safety-net hospital) between 2012 and 2018. Patients were categorized as insured or underinsured. Demographics and perioperative events were compared. Primary outcome was overall survival (OS).

Results

A total of 20 patients were underinsured and 11 were insured. There were less gynecologic malignancies in the underinsured (p=0.02). On univariate analysis, factors linked to poor survival included gastrointestinal (p=0.01) and gynecologic malignancies (p=0.046), treatment with neoadjuvant chemotherapy (p=0.03), CC1 (p=0.02), abdominal wall resection (p=0.01) and Clavien–Dindo 3-4 (p=0.01). Treatment with neoadjuvant chemotherapy and abdominal wall resections, but not insurance status, were independently associated with OS (p=0.01, p=0.02 respectively). However, at the end of follow-up, six patients were alive in the insured group vs. zero in the underinsured group.

Conclusions

In this small, exploratory study, there was no statistical difference in OS between insured and underinsured patients after CRS-HIPEC. However, long-term survivors were observed only in the insured group.

Quality of life in a phase 2 trial of short-course hyperthermic intraperitoneal chemotherapy (HIPEC) at interval debulking surgery for high tumor burden ovarian cancer

INTRODUCTION

to evaluate the effect of short-course (i.e.: 30 minutes) HIPEC on health-related quality of life (HRQoL) in our feasibility study; NCT02249013.

METHODS

a prespecified secondary end-point of our open-label, multicenter, single-arm, phase 2 trial on safety and efficacy was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30, version 3.0). Patients were required to complete the HRQoL questionnaire at baseline, after HIPEC, and after the end of the treatment. Changes of HRQoL over time were assessed by median scores for each domain and analyzed by Friedman`s test at a significant two-sided level of 0.05.

RESULTS

fifteen patients with high tumor burden EOC were recruited from our public health system between February 2015 and July 2019. A baseline EORTC QLQ-C30 questionnaire and at least one follow-up questionnaire was received from all of the patients. No significant difference over time in the QLQC30 summary scores was observed (p>0.05). The transitory impairment on patients HRQoL immediately after the short-course HIPEC trended to return to baseline at the end of the multimodal treatment.

CONCLUSIONS

we found no significant impairment of short-course HIPEC on patients HRQoL into the context of our comprehensive treatment protocol.