A novel preoperative risk score to optimize patient selection for performing concomitant liver resection with cytoreductive surgery/HIPEC

Abstract

Background: While parenchymal hepatic metastases were previously considered a contraindication to cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC), liver resection (LR) is increasingly performed with CRS/HIPEC. Methods: Patients from the US HIPEC Collaborative (2000-2017) with invasive appendiceal or colorectal adenocarcinoma undergoing primary, curative intent CRS/HIPEC with CC0-1 resection were included. LR was defined as a formal parenchymal resection. Primary endpoints were postoperative complications and overall survival (OS). Results: A total of 658 patients were included. About 83 (15%) underwent LR of colorectal (58%) or invasive appendiceal (42%) metastases. LR patients had more complications (81% vs. 60%; p = .001), greater number of complications (2.3 vs. 1.5; p < .001) per patient and required more reoperations (22% vs. 11%; p = .007) and readmissions (39% vs. 25%; p = .014) than non-LR patients. LR patients had decreased OS (2-year OS 62% vs. 79%, p < .001), even when accounting for peritoneal carcinomatosis index and histology type. Preoperative factors associated with decreased OS on multivariable analysis in LR patients included age < 60 years (HR,

Synchronous liver and peritoneal metastases from colorectal cancer: Is cytoreductive surgery and hyperthermic intraperitoneal chemotherapy combined with liver resection a feasible option?

“…Combined CRS–HIPEC and liver resection can be an alternative for patients with limited diseases, leading to an improvement in terms of survival compared to patients who could receive only systemic therapy ( 42 , 44 ). Despite the feasibility and safety of the combined LR and CRS–HIPEC in metastatic CRC reported from several studies ( 20 , 22 , 23 , 27 , 33 , 36 , 37 , 39 , 45 ), data on the matter show conflicting results, with updated studies and meta-analyses demonstrating evidence to the contrary ( 5 , 21 , 32 , 34 , 46 ). Razenberg et al ( 47 ) reported a significantly lower median OS in patients with concomitant PC + LM treated with palliative chemotherapy compared to the patients treated with CRS and HIPEC (12.5 vs. 23.1 months).…”

“…However, there could be a biased selection in interpreting this result as no data regarding the two groups (dissemination of the disease, history prior to treatment, and general conditions of the patients) were available. Lo Dico et al ( 39 ), in their multicenter study, showed that extended surgical management with curative resection plus HIPEC in selected patients with PM + LM is feasible with acceptable morbidity and mortality rates (31% and 4%, respectively) and a better OS. These results are probably associated with a better selection of patients and with the choice of performing the combined procedure only if a minor LR was required.…”

“…Further research is necessary to determine the prognostic effect of these two variables and the relationship with other variables such as tumor histology, performance status, and lymph node metastasis. In a recent review, Lo Dico et al reviewed all the available major experiences in the combined treatment of liver and peritoneal metastases from colorectal cancer, and their results suggested that patients with limited peritoneal disease (mean PCI of all the reviewed studies was 9.8) and those who need minor liver resections (defined as fewer than three hepatic segments) are the most likely to have better prognostic outcomes ( 39 ).…”

“…By performing CRS with hyperthermic intraperitoneal chemotherapy, median OS can be brought up to 31–40 months with complete macroscopic resection, which could be increased even more through accurate patient selection ( 20 ). Regarding HIPEC role and toxicity, a recent prospective randomized multicenter phase III French trial (PRODIGE 7) has raised concerns about the benefits of adding HIPEC to CRS on survival in patients who underwent CRS + HIPEC compared to those who underwent CRS only ( 39 ). Regarding the results of our review, only a few papers report LR + CRS without HIPEC, and mostly, this happens when a minimal peritoneal disease is discovered accidentally and thus resected ( 29 , 52 ).…”

“…In larger experiences, the association of HIPEC to CRS correlates with a survival advantage and only a little increase in morbidity. HIPEC should be avoided only in cases where the expected increase in morbidity could be high (for example, patients with multiple comorbidities, renal, hepatic, or bone marrow failure, representing common contraindications to HIPEC) ( 39 ).…”