Outcomes of Combined Peritoneal and Local Treatment for Patients with Peritoneal and Limited Liver Metastases of Colorectal Origin: A Systematic Review and Meta-Analysis

Abstract

Background Almost half of all colorectal cancer (CRC) patients will experience metastases at some point, and in the majority of cases, multiple organs will be involved. If the peritoneum is involved in addition to the liver, the current guideline-driven treatment options are limited. The reported overall survival ranges from 6 to 13 months for the current standard of care (systemic treatment). This study aimed to evaluate morbidity and clinical long-term outcomes from a combined local treatment of hepatic metastases with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) used to treat peritoneal metastases. Methods A systematic search was performed in PubMed, Embase.com, Web of Science, and Cochrane. Studies evaluating the clinicopathologic data of patients who had both peritoneal and hepatic metastases treated with CRS-HIPEC were included provided sufficient data on the primary outcomes (overall and disease-free survival) were presented. The quality of included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Results Patients treated for peritoneal and liver metastases (PMLM group) had a pooled mean survival of 26.4 months (95% confidence interval [CI] 22.4–30.4 months), with a 3-year survival rate of 34% (95% CI 26.7–42.0%) and a 5-year survival rate of 25% (95% CI 17.3–33.8%). Surgical complications occurred more frequently for these patients than for those with peritoneal metastasis only (40% vs 22%; p = 0.0014), but the mortality and reoperation rates did not differ significantly. Conclusion This systematic review showed that CRS and HIPEC combined with local treatment of limited liver metastasis for selected patients is feasible, although with increased morbidity and an association with a long-term survival rate of 25%, which is unlikely to be achievable with systemic treatment only.

Local Treatment of Colorectal Liver Metastases in the Presence of Extrahepatic Disease: Survival Outcomes from the Amsterdam Colorectal Liver Met Registry (AmCORE)

“…The outcomes of patients with CRLMs and peritoneal metastases evaluated in this study correlate to the results of previous studies, where 5-year OS varied from 8 to 25% [ 33 , 55 ]. HIPEC combined with CRS is considered a standard of care to treat limited peritoneal metastases.…”

“…Here, a peritoneal cancer index of < 20 is considered to be limited and therefore signifies a potential curative disease [ 26 , 27 ]. A systematic review by Polderdijk et al states that a 5-year OS rate of 25% can be achieved when combining local treatment of limited CRLM and CRS-HIPEC in selected cases with a previous response to systemic therapy [ 55 ]. Current national guidelines advise a maximum of three CRLMs present when considering a combined treatment strategy with local treatment of CRLM and CRS-HIPEC of peritoneal metastases [ 26 ].…”

Consensus Guideline for the Management of Colorectal Cancer with Peritoneal Metastases

“…Emerging evidence suggests that CRS ± IPCT may benefit patients with limited extraperitoneal disease, but it requires careful consideration [39]. A recent systematic review of 20 studies revealed a mean overall survival of 26.4 months and a 5-year overall survival rate of 25% in patients receiving combined peritoneal and local treatment for peritoneal and limited liver metastases [40]. Our consensus recommends avoidance of major hepatectomy with CRS.…”

Effect of hyperthermic intraperitoneal chemotherapy in combination with cytoreductive surgery on the prognosis of patients with colorectal cancer peritoneal metastasis: a systematic review and meta-analysis

“…Patients have been found to respond well to this treatment, with median overall survival (OS) rates increasing to between 20 and 63 months and 5-year OS rates of 23–52% [ 10 , 11 ]. Specific outcomes are associated with various factors representing the severity of the disease, including the peritoneal cancer index (PCI), the completeness of cytoreduction (CC), and tumor histopathology [ 12 ]. The success of CRS + HIPEC is dependent on the careful selection of suitable patients (e.g., PCI < 20), in whom the combined therapy has been reported to be better than the best current systemic chemotherapies [ 13 ].…”