The 30-year experience—A meta-analysis of randomised and high-quality non-randomised studies of hyperthermic intraperitoneal chemotherapy in the treatment of gastric cancer

Abstract

Importance Hyperthermic intraperitoneal chemotherapy (HIPEC) has been employed within various multimodality strategies for the prevention and treatment of gastric cancer peritoneal carcinomatosis. Objective To systematically evaluate the role of HIPEC in gastric cancer and clarify its effectiveness at different stages of peritoneal disease progression. Data Sources Medline and Embase databases between January 1, 1985, and June 1, 2016. Study Selection Randomized control trials (RTC) and high-quality nonrandomized control trials (NRCTs) selected on a validated tool (Methodological Index for Nonrandomized Studies) comparing HIPEC and standard oncological management for the treatment of advanced stage gastric cancer with and without peritoneal carcinomatosis were considered. Data Extraction and Synthesis A random-effects network meta-analysis. Main Outcomes and Measures The primary outcomes were overall survival and disease recurrence. Secondary outcomes were overall complications, type of complications, and sites of recurrence. Results A total of 11 RCTs and 21 NRCTs (2520 patients) were included. For patients without the presence of peritoneal carcinomatosis (PC), the overall survival rates between the HIPEC and control groups at 3 or 5 years resulted in favor of the HIPEC group (RR=0.82, P=0.01). No difference in the 3-year overall survival (RR=0.99, P=0.85) in but a prolonged median survival of 4 months in favor of the HIPEC group (WMD=4.04, P<0.001) was seen in patients with PC. HIPEC was associated with significantly higher risk of complications for both patients with PC (RR=2.15, P<0.01) and without (RR=2.17, P<0.01). This increased risk in the HIPEC group was related to systemic drugs toxicity. Anastomotic leakage rates were found to be similar between groups. Conclusions and Relevance Our study demonstrates a survival advantage of the use of HIPEC as a prophylactic strategy and suggests that patients whose disease burden is limited to positive cytology and limited nodal involvement may benefit the most from HIPEC. For patients with extensive carcinomatosis, the completeness of cytoreductive surgery is a critical prognostic factor for survival. Future RCTs should better define patient selection criteria.

Treatment of peritoneal metastases from gastric carcinoma

“…For patients with extensive PM, the completeness of cytoreductive surgery is a critical prognostic factor for survival [6]. This was also shown in a previous meta-analysis [30].…”

“…The 30-year experience of the HIPEC in the treatment of advanced stage GC with and without PM, has been compared with standard oncological management in a metaanalysis of randomized and high quality non-randomized studies [6]. The comparison has demonstrated the survival advantage of the use of HIPEC as a prophylactic strategy and suggested that patients whose disease burden is limited to positive cytology and limited nodal involvement may benefit the most from HIPEC.…”

Does hipec improve outcomes in gastric cancer patients treated with perioperative chemotherapy and radical surgery? A propensity‐score matched analysis

“…When perioperative chemotherapy and perioperative chemotherapy and HIPEC subgroups were compared, there was no statistical difference. This finding suggests that the real benefit for these subjects was from neoadjuvant chemotherapy, as noted in a recent metanalysis, 22 and not from HIPEC. Our study has significant limitations.…”

Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy, Part II: Implementation

“…Personnel turning over the room should pour solidifier powder into the canisters and perfusion pump reservoir container to render the contents gelatinous and prevent a spill during transport. This waste should never be flushed into the sewer system . Because fluid management systems are docked at a station to be flushed and cleaned before the fluid is released into the water sewage system, they are not an appropriate fluid collection device for HIPEC procedures.…”

“…This waste should never be flushed into the sewer system. 27,59 Because fluid management systems are docked at a station to be flushed and cleaned before the fluid is released into the water sewage system, they are not an appropriate fluid collection device for HIPEC procedures. Perioperative nurse leaders should refer to their state regulations, hospital policies, and contracted linen service and waste management companies to determine proper handling of surgical supply waste (eg, drapes, gowns, gloves) and cytotoxic contaminated linen.…”