The Initial Indian Experience with Cytoreductive Surgery and HIPEC in the Treatment of Peritoneal Metastases

Abstract

Worldwide, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been used for nearly 3 decades to treat peritoneal metastases (PM), improve quality of life, and prolong survival substantially in selected patients. In India, the use of the combined modality of treatment dates back a decade with majority of the efforts taking place within the last 5 years. The first PSOGI workshop (India) held in April 2015, at Bangalore, India offered an opportunity for Indian surgeons performing CRS and HIPEC to share their experience. To study the methodologies of CRS and HIPEC (hospital set up, equipment, training and surgical background) as well as the outcomes in terms of perioperative morbidity and mortality and short and long term survival of patients treated in India, Indian surgeons who had treated at least 10 patients with this combined modality were invited to present their experience. Data collection was retrospective. Analysis of the pooled data was carried out. Eight surgeons treated 384 patients with CRS and HIPEC over a period of 10 years. The commonest primary sites were ovary (as first line therapy n = 124), followed by appendix, including pseudomyxoma peritonei (n = 99), colorectum (n = 77), recurrent ovary (as second line therapy, n = 33), stomach (n = 15), primary peritoneal cancer (n = 10), peritoneal mesothelioma (n = 9) and rare tumors in 17 patients. The weighted mean PCI for all 384 patients was 18.25. 349/384 patients (90.88 %) had a complete cytoreduction (completeness of cytoreduction score of CC-0/1). Grade 3-5 complications developed in 108 patients (27.34 %) and 30 day mortality occurred in 28 (7.29 %) patients. This study showed that CRS and HIPEC can be performed with an acceptable morbidity and mortality in Indian patients. Most of the surgeons are on the learning curve and further improvement in these outcomes is expected over a period of time. Pooling of data related to both common and rare peritoneal cancers would be useful in knowing the disease behavior, response to treatment and outcomes in Indian patients. The 2015 PSOGI meeting provided a unique platform for data presentation with feedback from international experts in the field of peritoneal surface oncology. Future meetings are planned to expand the evaluation of Indian data and progress.

Treading the beaten path with old and new obstacles: a report from the Indian HIPEC registry

“…In comparison to our previous study in which 42.7% of the patients were lost to follow up, we had a complete followup in 98.5%, which is a significant improvement [5]. The data capturing was non-uniform before the registry was instituted, for example, most surgeons used the Clavien-Dindo classification and systemic toxicity and 90-day morbidity was not recorded [5,29]. The registry thus provided an effective solution for complete and uniform data collection.…”

“…In the last 5 years, the number of centres offering this treatment in India has increased rapidly [5]. Introducing such complex surgeries in a different healthcare system requires an integrated effort from different medical specialties, investment on infrastructure and developing disease-specific treatment strategies [6].…”

Setting up of the Indian HIPEC Registry: A Registry for Indian Patients with Peritoneal Surface Malignancies

“…In India, the combined modality treatment has been used for a few years only [5]. The patterns of healthcare vary from rural to semi-urban and urban areas [6].…”

“…Most centers do not have allocated resources or personnel for record keeping, and even if records are maintained, there are deficiencies in the information stored. Almost all the centers currently offering this treatment are in major cities [5].…”

“…Even patients from the same city may run out of resources to continue to follow up and obtain further treatment [7]. This was reflected in a combined analysis of 330 patients from eight Indian centers in which 43.1% of the patients were lost to follow up [5]. A system for tracking and follow-up of these patients is needed.…”