ABSTRACT: In the 1990s, physicians started to study the combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for management of peritoneal surface malignancies. Favorable evidence from experimental data and retrospective clinical studies has supported use of combined treatment. This approach, however, is controversial because of major concerns regarding high morbidity and lack of evidence from randomized trials.
This multi-institutional retrospective study from Italy was designed to assess the efficacy of combined CRS and HIPEC treatment in recurrent epithelial ovarian cancer (EOC) and to examine the safety profile of combined treatment. Prospective data were obtained from 4 Italian centers specializing in locoregional treatment of peritoneal surface malignancies. The patient population was composed of 56 patients with recurrent EOC who were 75 years or younger of ECOG (Eastern Cooperative Oncology Group) performance status 2 or less with a histological diagnosis of recurrent EOC. Cytoreductive surgery was performed followed by HIPEC performed using the closed-abdomen technique with cisplatin and doxorubicin or cisplatin and mitomycin C. The median patient age was 55.2 years. Primary study outcome measures assessed at a median follow-up time of 23.1 months were OS, progression-free survival (PFS), morbidity, and mortality rates. To assess the extent of peritoneal carcinomatosis, the peritoneal cancer index was determined intraoperatively. Residual disease was categorized according to the completeness of cytoreduction (CC).
The median peritoneal cancer index was 15.2 (range, 4–30). Forty-seven of the patients had microscopic residual disease (CC-0), 7 had residual disease 2.5 mm or less (CC-1), and 1 had residual disease greater than 2.5 mm (CC>2). Fifteen patients (26.3%) experienced major postoperative complications. There were 3 postoperative deaths (procedure-related mortality, 5.3%). The median OS was 25.7 months (95% confidence interval [CI], 20.3–31.0 months), and the median PFS was 10.8 months (95% CI, 5.4–16.2 months). At the 5-year follow-up, OS and PFS were 23% and 7%, respectively. Multivariate analysis using the Cox proportional hazard model showed that the following variables were independent prognostic factors: ECOG performance status (P = 0.001), preoperative serum albumin (P = 0.008), and CC (P = 0.005). The authors conclude that CRS combined with HIPEC is a promising therapeutic option for recurrent EOC.
Peritoneal Surface Malignancy Program (M.D.,D.B., S.K.), Department of Surgery, National Cancer Institute, Milan, Italy; General Surgery Unit (S.V., D.R.I., S.B., A.G.), Bentivoglio Hospital, AUSL Bologna, Bentivoglio, Italy; General Surgery Unit (F.P., M.S.), Manerbio Hospital, Azienda Ospedaliera di Desenzano, Manerbio, Italy; and General Surgery Unit (A.M., C.F.), G. Martino Hospital, University of Messina, Messina, Italy