Patient selection for cytoreductive surgery and HIPEC for the treatment of peritoneal metastases from colorectal cancer

Abstract

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a viable option for selected patients with peritoneal metastases (PM) from colorectal origin, resulting in long-term survival and even cure in some cases. However, adequate patient selection for this treatment is currently one of the major challenges. The aim of this review is to provide a comprehensive overview of clinically relevant factors associated with overall survival. This may help to guide clinicians through the complex interplay of patient, tumor, and treatment characteristics to adequately select patients who benefit the most from this extensive surgical treatment. First, basic principles of colorectal PM and the CRS and HIPEC treatment will be discussed. According to available literature, especially extent of peritoneal disease, completeness of cytoreduction, and signet ring cell histology have great influence on the outcome after CRS and HIPEC. Other factors that seem to have a negative prognostic value are the presence of liver metastases and the absence of treatment with neo-adjuvant systemic therapy. Prognostic models combining the above-mentioned factors, such as the Colorectal Peritoneal Metastases Prognostic Surgical Score nomogram, may provide clinically relevant tools to use in everyday practice.

Effect of intraperitoneal chemotherapy concentration on morbidity and survival

“…Successful treatment of colorectal peritoneal metastases with CRS–HIPEC depends on several factors, including optimal patient selection and completeness of CRS. The concentration of the active agent used for intraperitoneal chemotherapy may also be important.…”

“…Selected patients with colorectal peritoneal metastases are currently offered cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). This results in improved median survival compared with systemic chemotherapy 1 -3 . Successful treatment of colorectal peritoneal metastases with CRS-HIPEC depends on several factors, including optimal patient selection and completeness of CRS 4,5 . The concentration of the active agent used for intraperitoneal chemotherapy may also be important.…”

Histopathological and molecular classification of colorectal cancer and corresponding peritoneal metastases

“…Patients are currently selected for CRS‐HIPEC based on clinical rather than biological features. The aim of this study was to investigate whether CRPC is enriched for stroma‐rich and/or CMS4 variants of colorectal cancer.…”

Therapy and Prophylaxis of Peritoneal Metastases from Colorectal Cancer

“…Asi 25 % pacientů s CRC je dia gnostikováno ve IV. stadiu onemocnění, u dalších 20-30 % dojde k manifestaci vzdálených metastáz s menším či větším časovým odstupem od kurativního operačního výkonu [3]. Čtvrté klinické stadium CRC je spojeno s vysokou mortalitou, 5leté přežití se u něj uvádí okolo 10 %, medián přežití 14,4 měsíce [4].…”

“…Optimálním terapeutickým postupem v případě synchronních PM CRC proto zůstává plánovaný jednodobý kombinovaný výkon metodu nepovažují, popř. jsou v její indikaci velmi zdrženliví [3,13].…”