The Role of Hyperthermic Intraperitoneal Chemotherapy in Pseudomyxoma Peritonei After Cytoreductive Surgery

Abstract

IMPORTANCEStudies on the prognostic role of hyperthermic intraperitoneal chemotherapy (HIPEC) in pseudomyxoma peritonei (PMP) are currently not available.OBJECTIVES To evaluate outcomes after cytoreductive surgery (CRS) and HIPEC compared with CRS alone in patients with PMP. DESIGN, SETTING, AND PARTICIPANTSThis cohort study analyzed data from the Peritoneal Surface Oncology Group International (PSOGI) registry, including 1924 patients with histologically confirmed PMP due to an appendiceal mucinous neoplasm. Eligible patients were treated with CRS with or without HIPEC from February 1, 1993, to December 31, 2017, and had complete information on the main prognostic factors and intraperitoneal treatments. Inverse probability treatment weights based on the propensity score for HIPEC treatment containing the main prognostic factors were applied to all models to balance comparisons between the CRS-HIPEC vs CRS-alone groups in the entire series and in the following subsets: optimal cytoreduction, suboptimal cytoreduction, high-and low-grade histologic findings, and different HIPEC drug regimens. Data were analyzed from March 1 to June 1, 2018.INTERVENTIONS HIPEC including oxaliplatin plus combined fluorouracil-leucovorin, cisplatin plus mitomycin, mitomycin, and other oxaliplatin-based regimens. MAIN OUTCOMES AND MEASURESOverall survival, severe morbidity (determined using the National Cancer Institute Common Terminology for Adverse Events, version 3.0), return to operating room, and 30-and 90-day mortality. Differences in overall survival were compared using weighted Kaplan-Meier curves, log-rank tests, and Cox proportional hazards multivariable models. A sensitivity analysis was based on the E-value from the results of the main Cox proportional hazards model. Differences in surgical outcomes were compared using weighted multivariable logistic models. RESULTSOf the 1924 patients included in the analysis (997 [51.8%] men; median age, 56 [interquartile range extremes (IQRE), 45-65] years), 376 were in the CRS-alone group and 1548 in the CRS-HIPEC group. Patients with CRS alone were older (median age, 60 [IQRE, vs 54 [IQRE, 44-63] years), had less lymph node involvement (14 [3.7%] vs 119 [7.7%]), received more preoperative systemic chemotherapy (198 [52.7%] vs 529 [34.2%]), and had higher proportions of high-grade disease (179 [47.6%] vs 492 [31.8%]) and suboptimal cytoreduction residual disease (grade 3, 175 [46.5%] vs 117 [7.6%]). HIPEC was not associated with a higher risk of worse surgical outcomes except with mitomycin, with higher odds of morbidity (1.99; 95% CI, 1.25-3.19; P = .004). HIPEC was associated with a significantly better overall survival in all subsets (adjusted hazard ratios [HRs], 0.60-0.68, with 95% CIs not crossing 1.00). The weighted 5-year overall survival was 57.8% (95% CI, 50.8%-65.7%) vs 46.2% (95% CI, 40.3%-52.8%) for CRS-HIPEC and CRS alone, respectively (weighted HR, 0.65; 95% CI, 0.50-0.83; P < .001; E-value, 2.03). Such prognostic advantage was associated with oxaliplatin plus fluorourac...

Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei of Appendiceal Origin: A Single Center Experience

“…The number of patients not receiving HIPEC was also too small and affected by selection bias to provide any insight concerning the added value of HIPEC on CRS. On this issue, a recent large retrospective study of the PSOGI registry on 1,924 patients demonstrated that CRS and HIPEC are associated with better survival than CRS alone and do not worsen the postoperative outcomes (16). Noteworthy, a more favorable prognosis was observed with cisplatin plus mitomycin HIPEC and oxaliplatin plus fluorouracil-leucovorin one, while no prognostic advantage was observed in subgroups receiving mitomycin only and or other oxaliplatin-based HIPEC.…”

Hyperthermic Intraperitoneal Chemotherapy After Cytoreductive Surgery; Experience and Short Term Outcomes

“…In our study, prophylactic HIPEC was performed to one patient. (22,25). Because of the superiority of these results compared to conventional therapy, the CRS + HIPEC approach has become the gold standard treatment for peritoneal pseudomyxoma.…”

Hyperthermic Intraperitoneal Chemotherapy: A Critical Review

“…Recently, an international cohort study was published including 1924 patients with PMP, investigating the outcome after CRS with or without HIPEC [93]. It was found that the addition of HIPEC after CRS was associated with a significantly better overall survival as compared to CRS alone with a 5-year overall survival of 58% versus 46.2% respectively.…”