Hypothermic intraperitoneal chemo relatively safe for treating metastases

By Will Boggs MD

NEW YORK (Reuters Health) - 31/1/2019

Cytoreductive surgery with hypothermic intraperitoneal chemotherapy (CRS/HIPEC) appears to be at least as safe as other high-risk surgical oncology procedures, according to a retrospective study.

CRS/HIPEC has been the only therapy consistently to achieve significant five-year survival rates in patients with peritoneal metastases arising from the appendix, colon, rectum, mesothelioma, or ovary.

Yet fewer than 1,000 of the 60,000 patients in the U.S. diagnosed with peritoneal metastasis annually undergo this surgery, Dr. Jason M. Foster of the University of Nebraska Medical Center, in Omaha, and colleagues note in JAMA Network Open, online January 11. More than 60% of referring clinicians are reluctant to send their patients because of safety concerns, they add.

The team used the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database to compared CRS/HIPEC outcomes to outcomes of other high-risk surgical oncology procedures: right lobe hepatectomy (RLH), trisegmental hepatectomy (TSH), Whipple pancreaticoduodenectomy and esophagectomy.

Overall 30-day mortality was lower after CRS/HIPEC (1.1%) than after Whipple (2.5%), RLH (2.9%), esophagectomy (3.0%) and TSH (3.9%).

Rates of superficial-infection complications were significantly lower for CRS/HIPEC (5.4%) than for Whipple (9.7%) and esophagectomy (7.2%), but comparable to those reported for RLH and TSH.

Deep-infection rates were comparable for all procedures, except Whipple, for which rates were significantly higher than CRS/HIPEC (2.7% vs. 1.7%).

Organ-space-infection rates were significantly higher for RLH, TSH and Whipple than for CRS/HIPEC, and rates of return to the operating room were comparable to CRS/HIPEC (6.8%) for all procedures except esophagectomy (14.4%).

Median length of hospital stay was eight days for CRS/HIPEC, which was lower than for Whipple (10 days) and esophagectomy (10 days).

"CRS/HIPEC is not only safe when compared with procedures of similar risk, but is often associated with less morbidity," the researchers conclude. "These findings provide objective data to dispel the misperception of morbidity and mortality concerns surrounding CRS/HIPEC, and surgical risk should no longer remain a deterrent to patient referral or development of clinical trial for CRS/HIPEC."

Dr. Fabian M. Johnston from Johns Hopkins University School of Medicine, in Baltimore, Maryland, who was not involved in the study, recently reported that outcomes after CRS/HIPEC improve with clinical experience and careful patient selection.

He told Reuters Health by email, "Contrary to previous beliefs, CRS/HIPEC is safe. Studies have increasingly shown significant survival benefit for CRS/HIPEC for peritoneal disease. Increasingly, oncologists and surgeons are referring patients for evaluation for CRS/HIPEC. Persistent views on morbidity and mortality from CRS and HIPEC based upon older outcomes are no longer relevant."

He stressed the importance of "referral to a center with expertise in CRS/HIPEC. This study highlights that there is no substitute for experience and that not only the surgeon, but also the team is important in the care and outcomes of these patients. The volume-outcome relationship is important."

Dr. Foster did not respond to a request for comments.

SOURCE: https://bit.ly/2ASkYKx JAMA Netw Open 2019.

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