Hyperthermic Intraperitoneal Chemotherapy and Cytoreductive Surgery in the Management of Peritoneal Carcinomatosis

Rahul Rajeev, MBBS; Kiran K. Turaga, MD

Disclosures

Cancer Control. 2016;23(1):36-46. 

In This Article

Role of Systemic Chemotherapy

The effect of perioperative chemotherapy on outcomes after cytoreductive surgery/HIPEC has been retrospectively investigated at multiple centers. A prospective, observational study of neoadjuvant chemotherapy (folinic acid/fluorouracil/oxaliplatin or capecitabine/oxaliplatin with or without bevacizumab) in mucinous appendiceal neoplasms showed low tumor burden, fewer numbers of resections, and more completed surgeries with chemotherapy.[76] Survival rates were similar to patients without systemic chemotherapy but were better in patients who had significant histological response.[76] By contrast, Blackham et al[77] reported no survival advantage in preoperative chemotherapy but reported an 8% response rate (radiological/clinical) compared with a 29% rate in the former study.[76] Adjuvant chemotherapy was associated with better rates of progression-free survival but only in high-grade disease.[77] A retrospective review of the effect of neoadjuvant chemotherapy on high-grade appendiceal adenocarcinoma found no statistically significant differences in operative details or survival outcomes between the chemotherapy and nonchemotherapy groups, whereas another retrospective review showed improved prognosis in mucinous tumors with signet ring cell histology.[78,79]

Although it is impossible to quantify the advantage of perioperative systemic chemotherapy without a randomized controlled trial, it may be safe to assume that this therapy provides benefit in carefully selected patients without adding to postoperative complications.

A retrospective review of perioperative systemic chemotherapy in study patients with lymph-node positive colorectal cancer showed improved rates of OS and progression-free survival in a chemotherapy cohort irrespective of the timing of chemotherapy; however, a large number of these study patients did not receive chemotherapy due to major postoperative complications.[80] Therefore, these results should be interpreted with caution. The effect of adding bevacizumab to a neoadjuvant chemotherapy regimen in the setting of colorectal cancer was investigated in 2 retrospective reviews.[81,82] Although Eveno et al[81] reported that use of bevacizumab doubled the morbidity rates and need for additional surgery even after propensity score matching, Ceelen et al[82] demonstrated that bevacizumab therapy was associated with improved rates of OS and no added morbidity.

Although response to neoadjuvant chemotherapy is an indicator of favorable tumor biology, the converse is not always true. Treatment failure, as determined by imaging, surgical data, and tumor makers, should not dissuade the surgeon from proceeding with cytoreductive surgery as clinical response does not correlate with long-term prognosis in the setting of colorectal cancer; however, use of chemotherapy does.[83]

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