Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Management of Colorectal Cancer with Peritoneal Dissemination: 30 Years of Experience at a Single Institution

Abstract

BACKGROUND: Cytoreductive surgery (CRS) is at the forefront of treatment for colorectal cancer with peritoneal metastasis or “carcinomatosis” (CRC-PC). We report outcomes of the operative management of CRC-PC at a single center. STUDY DESIGN: We retrospectively reviewed our database from 1992 through 2021. The Kaplan-Meier method was used to estimate survival. Proportional hazards regression and multivariable models were used for assessments. RESULTS: This study included 345 patients with mean age 53.5 years. Multivariate analysis revealed performance and resection status were associated with overall survival (OS; p < 0.001). Within the R0/R1 group, adverse impact on OS was found with increasing Peritoneal Cancer Index (PCI) score starting at 9 (hazard ratio [HR] = 1.98, CI 1.39–2.82, p = 0.0001) with the most significant hazard noted at PCI >14 (HR = 2.35, CI 1.52–3.63, p = 0.0001). Incomplete resection (R2) had significantly worse OS compared with complete CRS 33.4 (n = 206) vs R2: 12.7 months (n = 139; p < 0.0001. When stratified by PCI for the R0/R1 group, median OS for PCI less than 10, 10 to 15, and greater than 15 was 38.2, 19.7, and 22.2 m, respectively (p = 0.0007 comparing PCI less than 10 and greater than 15). Ten-year increments—1991 through 2000, 2001 through 2010, 2011 through 2020—revealed improvement in median OS (13.4 [n = 66], 19.3 [n = 139], and 29.1 months [n = 140]). However, by resection status, median OS remained stable for R0/R1 (32.3 [n = 23], 31.1 [n = 76], and 34.1 months [n = 107]) and improved for R2 (5.2 [n = 43], 14.4 [n = 63], and 14.6 months [n = 33]). Clavien-Dindo complication rate (greater than or equal to grade III) was 29.4%. CONCLUSION: CRS improves outcomes for CRC-PC compared with historic outcomes with nonoperative management. This benefit is greatest with complete resection and lower disease burden. Results of CRS (with or without heated intraperitoneal chemotherapy) are improving, and surgery for CRC-PC should be routinely considered.

Peritoneal Metastasis: A Dilemma and Challenge in the Treatment of Metastatic Colorectal Cancer

“…CRS improves OS and colorectal cancer-specific survival (CSS) in patients with CRC-PM compared with no CRS (p < 0.001) [146]. It not only improves patient prognosis but also the efficacy of CRS alone and CRS/HIPEC are improving, so CRS should be routinely considered for patients with CRC-PM [147]. The peritoneal cavity is carefully explored during the operation, and the severity of the lesion is assessed using the PCI score.…”

“…The CC-0 and CC-1 were considered as complete CRS [153]. An incomplete CRS negatively affects survival [154]; OS in patients with complete CRS is better than incomplete CRS [147,149]. Thus, CC0-1 or R0/1 resection should be strived for in patients with CRC-PM.…”

Comparison of outcomes between surgical treatment of colorectal cancer metastatic to the liver and the peritoneum: Review of the literature

“…14 NCCN guidelines do not list CRS/HIPEC as a treatment option for colorectal cancer with PSD, 15 even though a recent phase III multicenter randomized trial demonstrated a 42-month median OS for complete cytoreduction of colorectal peritoneal carcinomatosis. 16 There are multiple studies reviewing outcomes of metastasectomy for colorectal liver disease [17][18][19][20] and for peritoneal surface metastases; [21][22][23][24] however, studies comparing the two are lacking. The goal of this article will be to review the current literature comparing outcomes between surgical management of colorectal liver metastases and colorectal PSD.…”

Invited commentary: Author's response to “CRS and HIPEC: Best model of antifragility in surgical oncology”

“…The Wake Forest experience with CRS-HIPEC is one of the most extensive and the high success rate of complete cytoreduction reflects the centers reputation as one of the leading peritoneal surface malignancy centers in the world. 2,3 Lastly, insight into the study analysis regarding the decision making behind which cases received HIPEC and which cases did not was requested. As the publication detailed the majority, over 60%, of incomplete CRS cases that underwent HIPEC the decision to perfuse was to improve control of malignant ascites.…”