Impact of Neoadjuvant Chemotherapy on the Outcomes of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Peritoneal Metastases: A Multi-Institutional Retrospective Review

Abstract

Cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with improved survival for patients with colorectal peritoneal metastases (CR-PM). However, the role of neoadjuvant chemotherapy (NAC) prior to CRS-HIPEC is poorly understood. A retrospective review of adult patients with CR-PM who underwent CRS+/-HIPEC from 2000-2017 was performed. Among 298 patients who underwent CRS+/-HIPEC, 196 (65.8%) received NAC while 102 (34.2%) underwent surgery first (SF). Patients who received NAC had lower peritoneal cancer index score (12.1 + 7.9 vs. 14.3 + 8.5, p = 0.034). There was no significant difference in grade III/IV complications (22.4% vs. 16.7%, p = 0.650), readmission (32.3% vs. 23.5%, p = 0.114), or 30-day mortality (1.5% vs. 2.9%, p = 0.411) between groups. NAC patients experienced longer overall survival (OS) (median 32.7 vs. 22.0 months, p = 0.044) but similar recurrence-free survival (RFS) (median 13.8 vs. 13.0 months, p = 0.456). After controlling for confounding factors, NAC was not independently associated with improved OS (OR 0.80) or RFS (OR 1.04). Among patients who underwent CRS+/-HIPEC for CR-PM, the use of NAC was associated with improved OS that did not persist on multivariable analysis. However, NAC prior to CRS+/-HIPEC was a safe and feasible strategy for CR-PM, which may aid in the appropriate selection of patients for aggressive cytoreductive surgery.

Diagnostic and therapeutic algorithm for colorectal peritoneal metastases. A consensus of the peritoneal surface malignancies onco-team of the Italian society of surgical oncology

“…The role of perioperative chemotherapy in eligible patients for CRS-HIPEC is controversial and this topic is still under study [48e51]. A randomized controlled study (CAIRO 6) addressing the role of perioperative systemic chemotherapy (SC) for patients with isolated and resectable CRCPM is ongoing in the Netherlands [52]. After CRS-HIPEC, systemic failure is a relatively common event [53], and postoperative SC can lead to better peritoneal tumor control by eradicating non-visible cells as supposed for lung and liver metastatic patients treated by potentially curative resection [54].…”

Outcomes of neoadjuvant chemotherapy before CRS‐HIPEC for patients with appendiceal cancer

“…It is important to note that the use of NAC before resection of colorectal peritoneal or hepatic metastases, particularly when metachronous, remains similarly controversial 27‐29 . While current guidelines recommend using chemotherapy regimens commonly used for colon cancer, appendiceal cancers have different genetic compositions, including greater KRAS and GNAS mutations and fewer phosphatidylinositol 3‐kinase‐AKT and TP53 mutations 30,31 .…”

Manejo De La Carcinomatosis Peritoneal De Origen Colorrectal Y Realidad en Panamá

“…Inclusive una revisión retrospectiva multi-institucional de pacientes con CPCCR sometidos a CRS con o sin HIPEC evidenció que aquellos pacientes que recibieron quimioterapia neoadyuvante experimentaron una sobrevida general más prolongada en comparación con los que se sometieron a cirugía primero; por lo que podemos deducir que, la quimioterapia neoadyuvante previo a la CRS con o sin HIPEC parece ser una técnica segura y viable para CPCCR, ayudando en la adecuada selección de pacientes para cirugía citorreductora agresiva. (39)…”