Peritoneal cancer index (PCI) based patient selecting strategy for complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in gastric cancer with peritoneal metastasis: A single-center retrospective analysis of 125 patients

Abstract

Objective: The role of cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) in gastric cancer with peritoneal metastasis (GCPM) is still controversial, mainly due to the limited survival benefit and uncertain patient selection. This study aims to construct a selecting strategy in GCPM for CRS þ HIPEC. Methods: From a prospective established database, 125 patients were enrolled. All these patients were pathologically confirmed as GCPM and treated with CRS þ HIPEC with or without preoperative or postoperative chemotherapy. The clinical documents and follow-up results were collected and analyzed with the primary endpoint of overall survival (OS) and the secondary endpoint of perioperative serious adverse events (SAEs). Results: The median OS of 125 GCPM patients treated with CRS þ HIPEC was 10.7 months, with 1-, 2-, 3-, and 5-year survival rates of 43.8%, 24.7%, 18.6%, and 15.7%, respectively. The multivariate analysis identified completeness of cytoreduction (CC), SAEs, HIPEC drugs, and adjuvant chemotherapy as independent prognostic factors on OS. The median OS was 30.0 (95%CI: 16.8e43.3) months in CC-0 group, significantly better than 7.3 (95%CI: 5.8e8.8) months in CC1-3 group (P < 0.001). The median OS showed no significant difference among CC-1 (8.5, 95%CI: 6.7e10.2, months), CC-2 (5.6, 95%CI: 3.0e8.2, months) and CC-3 (6.5, 95%CI: 5.2e7.7, months) groups (P > 0.05 for all pairwise comparations). The nomogram based on peritoneal metastasis timing, preoperative tumor marker (TM), and peritoneal cancer index (PCI), with AUC of 0.985, showed a good accuracy and consistency between actual observation and prediction of the probability of complete CRS. The cutoffs of PCI were 16 for synchronous GCPM with normal TM, 12 for synchronous GCPM with abnormal TM, 10 for metachronous GCPM with normal TM, and 5 for metachronous GCPM with abnormal TM, setting the probability to achieve complete CRS as 50%.Conclusions: Only complete CRS þ HIPEC (CC-0) could improve survival for high selected GCPM patients with acceptable safety. An incomplete CRS (CC1-3) should be avoided for GCPM patients. Synchronous GCPM with PCI 16 and normal TM, synchronous GCPM with PCI 12 and abnormal TM, metachronous GCPM with PCI 10 and normal TM, or metachronous GCPM with PCI 5 and abnormal TM maybe potential indications for complete CRS þ HIPEC treatment.

Hyperthermic Intraperitoneal Chemotherapy in the Management of Gastric Cancer: A Narrative Review

“…The most common chemotherapeutic agents used were Mitomycin C and Cisplatin, which were applied in 31 and 32 regimens, respectively. The doses of the applied agents were reported either as the whole dose for the procedure in milligrams (mg) (19 papers) [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ], or in milligrams for the body surface area (mg/m 2 ) (26 papers) [ 11 , 35 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ]. One of the latter units was additionally expressed in terms of the volume of solution (mg/m 2 /L) [ 48 ].…”

“…In the studied reports, there was insufficient information about the duration of the HIPEC procedure. Generally, the procedure lasted for approximately 60 or 90 min [ 18 , 19 , 20 , 21 , 23 , 24 , 25 , 26 , 29 , 32 , 33 , 35 , 36 , 37 , 38 , 42 , 43 , 44 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 57 , 58 , 59 , 61 , 64 , 65 , 66 ]. De Roover et al reported that, in half of their cases ( n = 8), there was a need to shorten the duration of HIPEC due to central hyperthermia [ 37 ].…”

“…Most of the analyzed papers presented very modest information about the chemotherapy administered before and following the CRS + HIPEC. In 32 of the analyzed articles [ 11 , 18 , 19 , 20 , 21 , 22 , 23 , 30 , 31 , 34 , 36 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 50 , 51 , 52 , 54 , 55 , 58 , 60 , 61 , 62 , 63 , 66 ], the issue of the perioperative systemic treatment was at least mentioned (in the last analysis, the authors perceived it as an important factor), and in 19 papers it was not discussed at all [ 24 , 25 , 26 , 27 , 28 , 29 , 32 , 33 , 35 , 37 , 48 , 49 , 53 , 56 , 57 , 59 , 64 , 65 , 67 ].…”

Dual-Energy Computed Tomography-Based Radiomics to Predict Peritoneal Metastasis in Gastric Cancer

“…Nevertheless, to utmost capture information of peritoneum, we delineate the peritoneal ROIs according to the anatomical distribution of the peritoneal cancer index (PCI) (41). PCI is used to assess the extent of peritoneal dissemination and is considered as a prognostic indicator for patients with peritoneal carcinomatosis, thus providing vital information for patient management and treatment tailor for patients with gastric tumor (42,43). However, laparotomy is a must to evaluate PCI.…”

Preclinical In Vivo-Models to Investigate HIPEC; Current Methodologies and Challenges

“…Spielberg et al showed in another retrospective study in patients suffering from PM of colorectal cancer origin that the use of oxaliplatin resulted more frequently in postoperative complications compared to MMC [ 17 ]. A study in gastric cancer patients showed that complete CRS is important for survival [ 18 ], while lymph node involvement has a negative effect on progression-free survival [ 19 ]. Fagotti et al showed that recurrent ovarian cancer patients could be safely treated with minimally invasive surgery in combination with cisplatin- or oxaliplatin-based HIPEC, showing promising results [ 20 , 21 ].…”