Chinese expert consensus on cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancies

Abstract

Locoregional spread of abdominopelvic malignant tumors frequently results in peritoneal carcinomatosis (PC). The prognosis of PC patients treated by conventional systemic chemotherapy is poor, with a median survival of < 6 mo. However, over the past three decades, an integrated treatment strategy of cytoreductive surgery (CRS) + hyperthermic intraperitoneal chemotherapy (HIPEC) has been developed by the pioneering oncologists, with proved efficacy and safety in selected patients. Supported by several lines of clinical evidence from phases I, II and III clinical trials, CRS + HIPEC has been regarded as the standard treatment for selected patients with PC in many established cancer centers worldwide. In China, an expert consensus on CRS + HIPEC has been reached by the leading surgical and medical oncologists, under the framework of the China Anti-Cancer Association. This expert consensus has summarized the progress in PC clinical studies and systematically evaluated the CRS + HIPEC procedures in China as well as across the world, so as to lay the foundation for formulating PC treatment guidelines specific to the national conditions of China.

Current perspectives on hyperthermic intraperitoneal chemotherapy in gastric cancer

“…49 Given the results of studies like these, CRS-HIPEC has become the recommended standard treatment for a variety of cancers with PC, including PMP, MPM, appendiceal mucinous cancer, colorectal PC, and ovarian cancer. 7 While there is a significant body of evidence supporting the use of HIPEC with surgery to improve the mortality of patients with advanced gastric cancer, some authors have noted that larger studies with more data are needed to definitively establish these techniques as the standard of care. 26,29,51,52 Regardless, the evidence is strong enough to support CRS with HIPEC as the recommended treatment for gastric cancer with peritoneal metastases.…”

“…26,29,51,52 Regardless, the evidence is strong enough to support CRS with HIPEC as the recommended treatment for gastric cancer with peritoneal metastases. 7 In fact, in 2016 China defined this therapy as the standard treatment for advanced gastric cancer. 7 In addition, new research is examining different modes of delivery (adjuvant, neoadjuvant, prophylactic HIPEC/systemic chemotherapy) and combinations of treatments (some of which have been discussed previously) to build on the promising results of CRS-HIPEC.…”

“…7 Third, hyperthermia disrupts cell membrane proteins and interferes with synthesis of DNA, RNA, and proteins. 7 Complete CRS and HIPEC is now the standard of care for pseudomyxoma peritonei (PMP) and malignant peritoneal mesothelioma (MPM), and it is rapidly becoming the standard of care for carcinomatosis from colorectal cancers. However, the data for gastric cancer are not as conclusive and more studies need to be carried out before CRS and HIPEC are accepted as a standard treatment for gastric cancer.…”

“…As a result, HIPEC increases the direct cytotoxic effect of chemotherapy on peritoneal tumors while simultaneously limiting the systemic adverse effects. 7 The rationale for hyperthermia in peritoneal infusion is 3-fold: First, hyperthermia causes microvessel embolization and induces ischemic necrosis in tumor tissue; Second, hyperthermia directly kills cancer cells in the S and M phase of the cell cycle by disturbing cell homeostasis and energy metabolism, activating lysosomes, and destroying the cytoplasm and nucleus. 7 Third, hyperthermia disrupts cell membrane proteins and interferes with synthesis of DNA, RNA, and proteins.…”

“…7 The rationale for hyperthermia in peritoneal infusion is 3-fold: First, hyperthermia causes microvessel embolization and induces ischemic necrosis in tumor tissue; Second, hyperthermia directly kills cancer cells in the S and M phase of the cell cycle by disturbing cell homeostasis and energy metabolism, activating lysosomes, and destroying the cytoplasm and nucleus. 7 Third, hyperthermia disrupts cell membrane proteins and interferes with synthesis of DNA, RNA, and proteins. 7 Complete CRS and HIPEC is now the standard of care for pseudomyxoma peritonei (PMP) and malignant peritoneal mesothelioma (MPM), and it is rapidly becoming the standard of care for carcinomatosis from colorectal cancers.…”