Curative cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis and synchronous resectable liver metastases arising from colorectal cancer

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Abstract

Objectives

This study describes the outcomes of patients with colorectal peritoneal carcinomatosis (PC) with or without liver metastases (LMs) after curative surgery combined with hyperthermic intraperitoneal chemotherapy, in order to assess prognostic factors.

Background

Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) increases overall survival (OS) in patients with PC. The optimal treatment both for PC and for LMs within one surgical operation remains controversial.

Methods

Patients with PC who underwent CRS followed by HIPEC were evaluated from a prospective database. Overall survival and disease free survival (DFS) rates in patients with PC and with or without LMs were compared. Univariate and multivariate analyses were performed to evaluate predictive variables for survival.

Results

From 1999 to 2011, 22 patients with PC and synchronous LMs (PCLM group), were compared to 36 patients with PC alone (PC group). No significant difference was found between the two groups. The median OS were 36 months [range, 20–113] for the PCLM group and 25 months [14–82] for the PC group (p > 0.05) with 5-year OS rates of 38% and 40% respectively (p > 0.05). The median DFS were 9 months [9–20] and 11.8 months [6.5–23] respectively (p = 0.04). The grade III–IV morbidity and cytoreduction score (CCS) >0 (p < 0.05) were identified as independent factors for poor OS. Resections of LMs and CCS >0 impair significantly DFS.

Conclusions

Synchronous complete CRS of PC and LMs from a colorectal origin plus HIPEC is a feasible therapeutic option. The improvement in OS is similar to that provided for patients with PC alone.

Introduction

Peritoneal carcinomatosis (PC) arising from colorectal cancer (CRPC) affects 7–13% of patients and is the second cause of death after liver metastases (LMs).1, 2 Without cytoreductive surgery (CRS) and with systemic chemotherapy only, median overall survival (OS) does not exceed 12.7 months.3 As shown in the one prospective study that was carried out and in two large retrospective multi-institutional studies, CRS followed by hyperthermic intraperitoneal chemotherapy (HIPEC) for CRPC has a median OS rate which varies from 32 to 45 months with long-term survivors when CRS is complete.4, 5, 6 A complete CRS, a peritoneal cancer index (PCI) lower than 20, good performance status, postoperative chemotherapy and no synchronous LMs are classically identified as factors associated with a better OS.5, 7, 8, 9

Conversely, among CRC patients with metastatic disease, about 8% experience concomitant PC and LMs. The presence of LMs and PC is always a bad prognostic factor with median OS of 5 months.10 Until 2007, the occurrence of more than 3 resectable LMs with CRPC was a relative contra-indication for CRS associated with HIPEC.11, 12 Though 6 retrospective and 2 case-control studies have shown that complete CRS of PC and LMs followed with HIPEC is feasible and produces better OS results than systemic palliative chemotherapy alone, the optimal treatment both for PC and resectable LMs in within one surgical operation remains controversial.13, 14, 15, 16, 17, 18, 19, 20

The objectives of this study were to describe the outcomes and to compare OS and disease free survival (DFS) rates of patients with PC and synchronous LMs versus patients with PC alone after curative surgery followed by HIPEC.

Section snippets

Patients

In this monocentric retrospective study, the population characteristics were obtained from a prospectively collected database. From January 1999 to December 2011, all consecutive patients presenting CRPC with concomitant LMs (PCLM group) or of peritoneal carcinomatosis alone (PC group) who had undergone CRS and HIPEC were enrolled in this analysis after the approval of our institutional multidisciplinary review board. We described the outcomes of each group in order to compare morbidity,

Patients characteristics

From January 1999 to December 2011, 178 patients underwent CRS + HIPEC in our institution. Of the sixty one patients presenting with CRPC, 3 patients treated with palliative surgery only were excluded from analysis. Of the fifty eight patients enrolled in this study, 29 were men and 29 were women. The median age was 60 (range 21–77). The median time lengths between PC diagnosis and CRS + HIPEC were 137.5 days (11–622) in PC group and 125.5 (17–590) in PCLM group (p = 0.31). In overall

Discussion

This monocentric study, comparing outcomes of 2 homogeneous populations after a median follow-up of 29 months, shows better median OS in the PCLM group CCS 0–1 (median OS of 36.1 months vs 29.2), but without significant statistical difference, and with the same OS rate at 5 years (>40%). Therefore, this notion of advantage disappeared as we observed median peritoneal and median hepatic RFS. Patients in the PCLM group had more hepatic and peritoneal recurrences, and DFS are significantly

Conflict of interest statement

No funding or other financial support was received for this work. The authors declare that there is neither actual nor potential conflict of interest with reference to this article.

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