Statement of the AGO Kommission Ovar, AGO Study Group, NOGGO, AGO Austria and AGO Switzerland Regarding the Use of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Ovarian Cancer

Statement of the AGO Kommission Ovar, AGO Study Group, NOGGO, AGO Austria, Swiss AGO, BGOG, CEEGOG, GEICO, and SFOG regarding the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in epithelial ovarian cancer

An international joint statement about the use of hyperthermic intraperitoneal chemotherapy (HIPEC) in ovarian cancer was published in 2016, warning about the uncritical use of HIPEC outside controlled studies. This statement has now been updated after the most recent literature was reviewed by the participating study groups and societies. HIPEC became a treatment option in patients with advanced colon cancer after positive results of a randomized trial comparing surgery and HIPEC versus palliative treatment alone. Although this trial did not compare the added value of HIPEC to surgery alone, HIPEC for the treatment of peritoneal metastases was in the subsequent years generalized to many other cancer types associated with peritoneal carcinomatosis including epithelial ovarian cancer (EOC). In the meantime, new evidence from prospective randomized trials specifically for EOC-patients emerged, with however contradicting results and several quality aspects that made the interpretation of their findings critical. Moreover, three additional trials in colorectal cancer failed to confirm the previously presumed survival benefit through the implementation of HIPEC in peritoneally disseminated colorectal cancers. Based on a still unclear and inconsistent landscape, the authors conclude that HIPEC should remain within the remit of clinical trials for EOC-patients. Available evidence is not yet sufficient to justify its broad endorsement into the routine clinical practice.

Hyperthermic Intraperitoneal Chemotherapy and Cytoreductive Surgery in Ovarian Cancer: An Umbrella Review of Meta-Analyses

Background

The utility of heated intraperitoneal chemotherapy (HIPEC) in the management of epithelial ovarian cancer (EOC) has been assessed in several randomised clinical trials and meta-analyses, and it is still a subject of controversy. Therefore, we performed an umbrella review of existing meta-analyses to summarise the outcomes of HIPEC and cytoreductive surgery (CRS) association in ovarian cancer.

Methods

We examined the MEDLINE, Cochrane Library, Scopus, Prospero, Web of Science and Science Direct from inception to May 30, 2020, for meta-analyses of randomised controlled trials and observational studies. Analyses of overall survival, disease free survival and progression survival were performed separately for primary and recurrent ovarian cancers.

Results

We identified 6 meta-analyses investigating the association of HIPEC with CRS in the management of ovarian cancer. Three year overall survival was significantly improved by the association of CRS and HIPEC for primary (HR: 0.66, 95%CI:0.56-0.78) and recurrent ovarian cancers (HR:0.50, 95%CI:0.38-0.64). This benefit was also demonstrated on disease-free survival for primary (HR: 0.54, 95%CI:0.48-0.61) and recurrent ovarian cancer (HR: 0.60, 95%CI:0.46-0.78). The pooled hazard ratios confirmed the advantage of HIPEC and CRS association with respect to CRS alone on progression free survival for primary and recurrent ovarian cancer respectively with HR: 0.50, 95%CI: 0.43-0.58 and HR: 0.59, 95%CI: 0.41-0.85.

Conclusion

While waiting for the results of the current prospective studies, the present umbrella study suggests that HIPEC performed at the end of CRS may be a complementary effective asset for ovarian cancer patient management.

Narrative review of cytoreductive surgery and intraperitoneal chemotherapy for peritoneal metastases in ovarian cancer

Due to numerous factors, such as no specific symptoms and ineffective screening to identify premalignant or early-stage disease, most patients with ovarian cancer present with advanced-stage disease and overt peritoneal metastases. Currently, the most effective treatment for these patients is complete cytoreductive surgery with systemic platinum/taxane-based chemotherapy. Over the past few decades, many researchers have evaluated the use of postoperative normothermic intraperitoneal (NIPEC) and intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) delivery as additional treatment modalities. Here, we will review the current status and future directions for these treatment strategies in the management of ovarian cancer. Most of the studies in this area of research have been retrospective in nature, limited by heterogeneous patient populations and large variance in chemotherapeutic regimens used, leading to mixed results and difficulties in evaluating the clinical impact of the data. More mature data from prospective trials are lacking, and IP therapy for advanced ovarian cancer should still be considered an investigational approach and evaluated only in clinical trials; the exception is for patients with stage III disease who undergo interval debulking surgery after neoadjuvant chemotherapy, for whom HIPEC can be considered in selected patients as part of first-line therapy.

Hyperthermic intraperitoneal chemotherapy in ovarian cancer: Qui Bono?

Ovarian cancer is a major cause of cancer related-death in women around the world. Recent statistics on the worldwide cancer burden by the International Agency for the research on Cancer revealed ovarian cancer being both the eighth most frequent malignancy in the west countries. Peritoneal metastasis from ovarian cancer is a major challenge in the clinical management. Despite the evidence of the benefit of Intraperitoneal Chemotherapy in ovarian cancer with peritoneal deposits it has not been widely adopted, mainly due to logistical difficulties and less to the logoregional morbidity as pain. The role of hyperthermic intraperitoneal chemotherapy (HIPEC) in patients during the end of cytoreductive surgery (CRS) is a more tolerable feasible method with potential advantages as drug distribution, combination with hyperthermia and application before tumor regrowth. The aim of this article is to investigate the potential benefits of HIPEC explains the rationale, data of major clinical trials meta-analyses and recent randomized trial are presented and explains the indications patient selection and the best time to applicate of this aggressive logo regional treatment.

Development of new medical treatment for epithelial ovarian cancer recurrence

Epithelial ovarian cancer (EOC) is the scariest gynaecological cancer. Many advances have been done with evolving knowledge, leading to the introduction of new drugs, most in maintenance setting. The antiangiogenic Bevacizumab and the three approved PARP-inhibitors-olaparib, niraparib and rucaparib-are gradually improving PFS of patients with EOC, with initial effects on OS too. But recurrence is still a heavy sentence and lethality continues to be high. Ovarian cancer is a complex disease, with different clinical presentation, histological aspect, and molecular expression, leading to disappointing results, when using a single drug. Implementation of biobanking and analysis of patients' tumour samples, before starting a treatment, could be a promising way to better understand molecular aspects of this disease, to identify markers predictive of response and to allow a better use of experimental drugs, as immunomodulators, targeted therapies, and combinations of these, to fight tumour growth and clinical progression. We reviewed the literature on the updated treatments for recurrent ovarian cancer, summarizing all the available drugs and combinations to treat patients with this diagnosis, and focusing the attention on the new approved molecules and the contemporary Clinical Trials, investigating new target therapies and new associations.

Hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer: a "useless intraoperative fever" or the next hot voice in the surgical management of the "silent killer"?

The aim of our opinion letter is to highlight the recent findings in the field of hyperthermic intraperitoneal chemotherapy (HIPEC) use in ovarian cancer management. Two recent studies reveal that ovarian cancer patients treated with HIPEC can extend their survival independently of the timing offered-either at the initial cytoreductive effort or at the time of disease relapse. The research field is flourishing and further data are awaited from randomised control trials. Although, HIPEC is not considered yet as the standard of care in the management of ovarian cancer patients, the initial findings of its use are promising.

It's time to warm up to hyperthermic intraperitoneal chemotherapy for patients with ovarian cancer

The peritoneal spread of ovarian cancer makes it a potential target for hyperthermic intraperitoneal chemotherapy (HIPEC). Intraperitoneal delivery exposes the tumor to concentrations of cytotoxic drugs much greater than with intravenous delivery, and in vitro studies have also shown that combining hyperthermia and platinum leads to an additive cytotoxic effect. Pharmacokinetic analyses have confirmed very high concentrations of cytotoxic drugs in the peritoneal cavity, with minimal systemic exposure and toxicity. The majority of historical data evaluating HIPEC in ovarian cancer are based on retrospective research, which included heterogeneous groups of patients and drugs used for HIPEC. Recent publications on the findings of prospective studies, including the first randomized trial in which the only difference in intervention was the addition of HIPEC with cisplatin to interval debulking surgery in stage III patients, have shown a benefit in favor of HIPEC. Yet, a recent prospective study from Korea did not find a benefit. Opponents of HIPEC have cited higher rates of complications with this approach, yet most of the serious adverse events observed are likely related to the surgery itself, and are comparable to the rates reported in studies evaluating cytoreductive surgery without HIPEC. Findings from a recent randomized controlled trial showed no delays in initiation or completion of postoperative chemotherapy in patients treated with HIPEC. A growing body of evidence is indicating that it might be time to seriously consider HIPEC as a complementary treatment at the time of cytoreductive surgery for patients with advanced-stage ovarian cancer in the setting of an experienced center. Yet, more research is needed to identify the population of patients who gain the most benefit from this therapy.

Peritoneal cancer index as a predictor of survival in advanced stage serous epithelial ovarian cancer: a prospective study

Objective

A numerical score, the peritoneal cancer index (PCI), was developed to reflect the extent of tumor growth in gastric and colorectal cancers and to tailor treatment. This study aimed to examine the value of the PCI score in advanced epithelial ovarian cancer (EOC) regarding completeness of surgical cytoreduction and survival.

Methods

This was a prospective observational cohort study. Patients with primary serous EOC at International Federation of Gynecology and Obstetrics (FIGO) stages IIIB or higher were included. Patients with FIGO stage IVB as well as those assigned to receive neoadjuvant treatment were excluded from the study. The PCI was obtained and registered intraoperatively.

Results

In the study period we recruited 96 patients with serous EOC stage IIIB–IVA. A PCI score cut-off value of 13 was calculated using a receiver operator characteristic (ROC) curve, above which worse survival is expected (area under the curve [AUC]=0.641; 95% confidence interval [CI]=0.517–0.765; sensitivity and specificity 80.6%, 45.0%, respectively; p=0.050). A multivariate analysis determined that suboptimal surgical cytoreduction was the only independent predictive factor for recurrence (odds ratio [OR]=7.548; 95% CI=1.473–38.675; p=0.015). A multivariate analysis determined that only suboptimal surgical cytoreduction (hazard ratio [HR]=2.33; 95% CI=0.616–8.795; p=0.005), but not PCI score >13 (HR=1.289; 95% CI=0.329–5.046; p=0.716), was an independent predictive factor for death.

Conclusion

We conclude from this study that the PCI score is a reliable tool helping to assess the extent of disease in advanced serous EOC patients and may help predicting complete surgical cytoreduction but cannot qualify as a predictor of survival.