A contemporary analysis of morbidity and outcomes in cytoreduction/hyperthermic intraperitoneal chemoperfusion

Abstract

The risks and benefits of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CS/HIPEC) continue to be debated by the oncology community. A retrospective analysis of contemporary data (2003-2011) was performed to provide objective information regarding surgical morbidity, mortality, and survival for patients undergoing CS/HIPEC at a comprehensive cancer center. While procedure-associated morbidity was comparable to other major surgical oncology procedures, there was no operative or 30-day mortality and 60-day mortality was 2.7%. Increasing numbers of bowel resections were found to correlate to an increased incidence of deep surgical site infections (including abscess and enterocutaneous fistula) and need for reoperation which was in turn associated with a decreased overall survival (OS) and progression-free survival (PFS). Five-year OS rates varied by site of tumor origin and histology (disseminated peritoneal adenomucinosis [91.3%], Mesothelioma [80.8%], Appendiceal Adenocarcinoma [38.7%], and Colorectal Adenocarcinoma [38.2%]). With an acceptable morbidity and mortality rate, CS/HIPEC should be included as an effective treatment modality in the multidisciplinary care of select patients with peritoneal metastases.

Keywords: Carcinomatosis; HIPEC; colorectal cancer; cytoreduction; morbidity.

Figure 1

For a mixed population of patients, tumor origin, and tumor histologies, the procedure of cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) was associated with a median overall survival (OS) of 63.2 months with a 5-year survival rate of 55.2% in our series. The median progression-free survival (PFS) was 22 months. Cytoreduction/HIPEC as a procedure did not exhibit any prohibitive or significant procedure-related early mortality in the overall patient population.

Figure 2

Deep surgical site infection was associated with a reduced 5-year survival from 59.7% of those with no deep surgical site infection down to 16.4%. Progression-free survival was similarly reduced in patients with deep surgical site infection from 41.3% to 13.6% over 5 years. Indicative of a serious complication, patients requiring reoperation had similar reductions of 20.8% and 20.3% in 5-year overall survival and progression-free survival, respectively.

Figure 3

The site of tumor origin had a significant influence on survival. Patients with carcinomatosis from a colorectal primary had a 5-year overall survival of 38.2%, which was significantly lower than appendix origin (66.6%) or other sites (66.2%). The median time to progression exhibited a similar association to tumor location with colon (11.5 months) being less than appendix (37.4 months) or other sites (68.5 months). Tumor histology was also associated with 5-year overall survival as adenocarcinoma of either colon (38.2%) or appendiceal (38.7%) doing worse than disseminated peritoneal adenomucinosis (DPAM) (91.3%), mesothelioma (80.8%), or others (48.0%). A similar pattern was noted for the median time to progression and progression-free survival for these tumor histologies.

Figure 4

Despite being a heterogeneous population, completeness of cytoreduction in all patients (excluding DPAM) appeared to be associated with improved OS, although this did not reach statistical significance (P = 0.0659). PFS was not different in those patients undergoing a complete cytoreduction as compared with an incomplete cytoreduction. DPAM, disseminated peritoneal adenomucinosis; OS, overall survival; PFS, progression-free survival.