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Cytoreductive surgery and HIPEC in peritoneal carcinomatosis from colorectal cancer: a review of the evidence-based research
Posted in Lectures on 4 June 2019

F. Borja de Lacy

Patients with peritoneal metastatic colorectal cancer have a significantly shorter overall survival rate than those with other isolated metastatis sites. Franko and colleagues reported that patients with peritoneal metastatic colorectal cancer have a median overall survival of 16 months, which is significantly shorter than those with other isolated metastasis sites. There is a subset of patients with peritoneal carcinomatosis that might achieve a prolonged survival, and those are candidates for cytoreductive surgery and HIPEC.

Verwall et al. published the first randomized controlled trial that compared cytoreductive surgery and HIPEC with systemic chemotherapy alone, showing that surgery and HIPEC significantly prolonged survival to almost two years. However, the prolonged survival was achieved in a selected group of patients, and only in cases of a macroscopically complete resection. Following that study, other observational trials have been performed, and a final review in 2016 reported a median five-year survival of 42 months in more than 1000 patients. When analyzing the main prognostic indicators, two are always included: the completeness of surgical cytoreduction and the volume of the disease, by means of the PCI. It seems that patients with a PCI lower than 12 might generally be treated with cytoreductive surgery and HIPEC, while patients with a PCI higher than 17 should not. In the gray area of patients with a PCI ranging between 12 and 17, other parameters should to be taken into account, such as tumor chemosensitivity and general performance status.

The results of the Prodige 7 trial were recently released during the 2018 American Society of Clinical Oncology Meeting. This is a randomized phase III multicenter trial that included patients with peritoneal carcinomatosis of colorectal origin with a lower than 26. The authors found that mid-term morbidity was higher in the CRS + HIPEC group, with no differences in the overall survival or in the relapse-free survival rates. It seems that only patients with a PCI between 10 and 15 would benefit from associating HIPEC to CRS. Despite some intrinsic limitations, this is the highest-quality trial published on the subject, although the scientific community is now waiting for the the published paper once it passes the critical review by the editorial board.

This video will focus on cytoreductive surgery and HIPEC in peritoneal carcinomatosis from colorectal cancer, reviewing some of the main papers on the subject.