Treatment of peritoneal carcinomatosis by surgical cytoreduction combined with HIPEC
Our clinical experience is focused on the treatment of peritoneal carcinomatosis and tumor recurrence. Since 1995, about 900 operations for peritoneal carcinomatosis have been performed; since January 2013 to date more than 150 patients with peritoneal carcinomatosis have been treated in our Istitute. Our operative unit is specialized in the treatment of this kind of disease by cytoreductive surgery (CRS) combined or not with hyperthermic intraperitoneal chemotherapy (HIPEC) and secondary surgical cytoreduction of advanced cancers.
In the last two years we have performed about 45 CRS + HIPEC (peritoneal mesothelioma = 8; colorectal carcinomatosis = 10; pseudomyxoma peritonei = 20; ovarian carcinomatosis = 6). Through the constant improvement of surgical and perioperative skills, we have achieved promising results in terms of long-term survival (median overall survival of 58 months for peritoneal mesothelioma, 42 months for ovarian cancer, 55 months for colorectal carcinomatosis, 144 months for PMP associated with a 10-yr overall survival of 80%) associated with low perioperative morbidity and mortality rates. We have registered an overall major morbidity rate of 15%, decreased to 6.7% considering only the last two years associated with no perioperative death. Since January 2013 in our Institution we have performed more than 100 surgical cytoreductions, which 65 for ovarian carcinomatosis. The mainstay of treatment is the attempt to achieve complete surgical cytoreduction, identified as the most significant prognostic factor: in this regard we perform a high number of primary or interval debulking surgeries with no macroscopic residual disease (CC-0) in a substantial number of patients. In cooperation with medical oncology, considerating that the follow-up is too short, the results in terms of long-term outcome are still being processed. We can assert that during the last two years we registered a major complications rate of 2-3% with no postoperative deaths. All the HIPEC procedures (45 cases) were carried out intraoperatively with an original “semi-closed” technique. During the last years we have redefined our patient selection policy and sought to restrict indications to patients with less advanced or less aggressive disease: the selection process for CRS and HIPEC is critical and prognostic factors are required to identify patients who may most benefit from these treatments. The standardization of the surgical technique borrowed from experience in the treatment of peritoneal carcinomatosis allows us to obtain good long-term results with limited costs and mean hospital stay time.
Conclusions and perspectives:
In order to perform a more careful selection of patients, we are investigating the practice of second look (technique) to identify patients that early presenting an higher risk of relapse; for that purpose we are, also, testing the use of the liquid biopsy for the detection of circulating DNA. We are also investigating the possibility of performing laparoscopic HIPEC on selected patients. Moreover, in order to evaluate achieved results, we intend to participate, subject to approval by the ethics committee, in randomized controlled trials for the treatment of peritoneal carcinomatosis of colonic and ovarian origin by cytoreductive surgery and HIPEC.