A 30 year male underwent laproscopy and stoma formation for near obstructed rectal cancer invading seminal vesical. Scopy showed limited peritoneal diseases pelvis. He underwent short course radiotherapy rectum and 4 cycles chemotherapy as part of metastatic and larc protocol
after 4 cycles, good response, no progression peritoneal disease, mod diff adenocarcinoma. Pic less thann10 , underwent pelvic exenteration and complete cytoreduction , pelvic peritonectomy and sub diaphragmatic
should he have HIpec as well or is maximum cytoreduction sufficient?
To this date the gold-standard has been the use of “adjuvant” HIPEC after cytoreduction. But this is a fundamental question in the field of peritoneal surface oncology, and was addressed in the French fase III randomized trial “PRODIGE 7”, conducted by François Quénet. The trial compared cytoreduction alone and adjuvant HIPEC. We are anxiously waiting the results, that will be announced probably until the end of the year.
Although traditionally HIPEC is an integral part of the therapeutic strategy for complete cytoreduction for non-ovarian peritoneal carcinomatosis, however i found an interesting article published recently.
PLoS One. 2015 Mar 31;10(3):e0122816. doi: 10.1371/journal.pone.0122816. eCollection 2015.
Cytoreductive surgery of colorectal peritoneal metastases: outcomes after complete cytoreductive surgery and systemic chemotherapy only.
Désolneux G, Mazière C, Vara J, Brouste V, Fonck M, Béchade D, Bécouarn Y, Evrard S.
Abstract
BACKGROUND:
Cytoreductive peritoneal surgery (CRS) associated with hyperthermic peritoneal chemotherapy (HIPEC) has long been considered the standard treatment for colorectal peritoneal metastases (CPM). However, although efficacy of surgery has been demonstrated, evidence supporting HIPEC's role is less certain.
METHOD:
Overall survival (OS), progression-free survival (PFS) and morbidity were analysed retrospectively for fifty consecutively included patients treated for colorectal CPM with complete CRS and systemic chemotherapy only.
RESULTS:
Median peritoneal cancer index (PCI) was 8 (range 1-24). 23 patients had liver or lung metastases (LLM). 22 patients had synchronous CPM. 27 complications occurred (12 Grade 1/2, 14 Grade 3, 1 Grade 4a, 0 Grade 5). Median follow-up was 62.5 months (95 %CI 45.4-81.3), median survival 32.4 months (21.5-41.7). Three- and 5-year OS were 45.5% (0.31-0.59) and 29.64% (0.17-0.44) respectively. Presence of LLMs associated with peritoneal carcinomatosis was significantly associated with poorer prognosis, with survival at 5 years of 13.95% (95 %CI 2.9-33.6) vs. 43.87% (22.2-63.7) when no metastases were present (P= 0.018). Median PFS was 9.5 months (95 %CI 6.2-11.1).
CONCLUSION:
With an equivalent PCI range and despite one of the highest rates of LLM in the literature, our survival data of CRS + systemic chemotherapy only compare well with results reported after additional HIPEC. Tolerance was better with acceptable morbidity without any mortality. Extra-hepatic metastasis (LLM) is a strong factor of poor prognosis. Awaiting the results of the randomized PRODIGE trial, these results indicate that CRS + systemic chemotherapy only is a robust hypothesis to treat colorectal CPM.
Dear Dr ahmed
lo agrree with principle good cytoreduction and systemic chemotherapy adds to survival over and above systemic chemotherapy alone in patients with low pci
however the added benefit of Hipec is likely
patuents with pseudonyxoma do well with Hipec alone and no systemic chemotherapy
we also see that peritoneal Mets from signet ring /kraken ergs don't respond to systemic chemo alone, hence Hipec may help. T4 cancers have high rates peritoneal Mets not sorted by surgery alone
prophylactic trial may add an answer to this, so I would not give up on Hipec not as yet based on one study
psog recommends Hipec in Crc with low PCI with regular audits in high volume centres
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