Debulking and intraperitoneal chemoperfusion for peritoneal metastasis from colorectal origin

Introduction : A subset of colorectal cancer (CRC) patients presents with synchronous or metachronous metastasis confined to the peritoneal surfaces. These patients may benefit from cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (HIPEC).Aim : We reviewed the morbidity and survival associated with this multimodal approach.Methods : Colorectal cancer patients with potentially resectable peritoneal metastases were evaluated. Patients with low grade appendiceal tumours including the pseudomyxoma peritonei (PMP) syndrome were excluded from the analysis. Staging consisted of CT and PET-CT ; laparoscopy was rarely performed. Neoadjuvant therapy was prescribed in patients with extensive disease. All patients underwent cytoreduction including peritonectomy procedures as indicated. When optimal resection was achieved, HIPEC was performed with the open abdomen technique and using oxaliplatin 460 mg/m2 during 30 min at 40-41°C. All consecutive patients were included in the analysis. Overall survival was estimated with the Kaplan Meier method, and multivariate modeling of overall survival was performed with Cox proportional hazards analysis. Statistical significance was assumed whenever the probability of a type I error was < 5%.Results : In a 7 year period, 123 patients, age 59 (SD :12) and 50% male were treated. In 25 patients (20%), peritoneal metastases were synchronous with the primary tumour. Neoadjuvant chemotherapy was prescribed to 53% of patients. The mean duration of the combined procedure was 8.9 (SD : 2.6) hours. Postoperative mortality was 1.6%, and major complications (requiring prolonged stay and/or reintervention) occurred in 34%. Median hospital stay was 17 days (range 8-169). After a median follow up of 16 months, median overall survival (OS) was 28 months, with a three year actuarial survival of 40.4%. In a multivariate model, the following variables were independently associated with OS : completeness of cytoreduction, tumour differentiation, and response to neoadjuvant chemotherapy.Conclusion : A multimodal approach consisting of neoadjuvant chemotherapy, cytoreductive surgery, and HIPEC results in a meaningful survival benefit in patients with peritoneal metastases from CRC. In a referral center, the procedure can be performed with low operative mortality and acceptable morbidity.Introduction : A subset of colorectal cancer (CRC) patients presents with synchronous or metachronous metastasis confined to the peritoneal surfaces. These patients may benefit from cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (HIPEC).Aim : We reviewed the morbidity and survival associated with this multimodal approach.Methods : Colorectal cancer patients with potentially resectable peritoneal metastases were evaluated. Patients with low grade appendiceal tumours including the pseudomyxoma peritonei (PMP) syndrome were excluded from the analysis. Staging consisted of CT and PET-CT ; laparoscopy was rarely performed. Neoadjuvant therapy was prescribed in patients with extensive disease. All patients underwent cytoreduction including peritonectomy procedures as indicated. When optimal resection was achieved, HIPEC was performed with the open abdomen technique and using oxaliplatin 460 mg/m2 during 30 min at 40-41°C. All consecutive patients were included in the analysis. Overall survival was estimated with the Kaplan Meier method, and multivariate modeling of overall survival was performed with Cox proportional hazards analysis. Statistical significance was assumed whenever the probability of a type I error was < 5%.Results : In a 7 year period, 123 patients, age 59 (SD :12) and 50% male were treated. In 25 patients (20%), peritoneal metastases were synchronous with the primary tumour. Neoadjuvant chemotherapy was prescribed to 53% of patients. The mean duration of the combined procedure was 8.9 (SD : 2.6) hours. Postoperative mortality was 1.6%, and major complications (requiring prolonged stay and/or reintervention) occurred in 34%. Median hospital stay was 17 days (range 8-169). After a median follow up of 16 months, median overall survival (OS) was 28 months, with a three year actuarial survival of 40.4%. In a multivariate model, the following variables were independently associated with OS : completeness of cytoreduction, tumour differentiation, and response to neoadjuvant chemotherapy.Conclusion : A multimodal approach consisting of neoadjuvant chemotherapy, cytoreductive surgery, and HIPEC results in a meaningful survival benefit in patients with peritoneal metastases from CRC. In a referral center, the procedure can be performed with low operative mortality and acceptable morbidity.C