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Bhatt A, Sinukumar S, Damodaran D, Parikh L, Goswami G, Mehta S, Kammar P. Perioperative outcomes and platinum resistant recurrence in patients undergoing systematic, protocol-based, total parietal peritonectomy during interval cytoreductive surgery for advanced ovarian cancer: results of the TORPEDO study. J Gynecol Oncol 2024; 35:35.e95. [PMID: 38710529 DOI: 10.3802/jgo.2024.35.e95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/19/2023] [Accepted: 03/31/2024] [Indexed: 05/08/2024] Open
Abstract
OBJECTIVE The TORPEDO (CTRI/2018/12/016789) is the single-arm, prospective, interventional study evaluating the role of a total parietal peritonectomy (TPP) in patients undergoing interval cytoreductive surgery (iCRS). In this manuscript, we report the perioperative outcomes and platinum resistant recurrence (PRR) in 218 patients enrolled in the study. METHODS A TPP was performed in all patients undergoing iCRS irrespective of the residual disease extent. hyperthermic intraperitoneal chemotherapy (HIPEC) was performed as per the clinician's discretion with 75 mg/m² of cisplatin. Maintenance therapy was also used at the discretion of the treating clinicians. RESULTS From 9th December 2018 to 31st July 2022 (recruitment complete), 218 patients were enrolled at 4 medical centers in India. The median surgical peritoneal cancer index was 14 and a complete gross resection was achieved in 95.8%. HIPEC was performed in 130 (59.6%) patients. The 90-day major morbidity was 17.4% and 2.7% patients died within 90 days of surgery. Adjuvant chemotherapy was delayed beyond 6 weeks in 7.3%. At a median follow-up of 19 months (95% confidence interval [CI]=15.9-35 months), 101 (46.3%) recurrences and 19 (8.7%) deaths had occurred. The median progression-free survival was 22 months (95% CI=17-35 months) and the median overall survival (OS) not reached. Platinum resistant recurrence was observed in 6.4%. The projected 3-year OS was 81.5% and in 80 patients treated before may 2020, it was 77.5%. CONCLUSION The morbidity and mortality of TPP with or without HIPEC performed during iCRS is acceptable. The incidence was of PRR is low. Early survival results are encouraging and warrant conduction of a randomized controlled trial comparing TPP with conventional surgery.
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Affiliation(s)
- Aditi Bhatt
- Department of Surgical Oncology, Zydus Hospital, Ahmedabad, India.
| | - Snita Sinukumar
- Department of Surgical Oncology, Jehangir Hospital, Pune, India
| | - Dileep Damodaran
- Department of Surgical Oncology, MVR Cancer Center, Calicut, India
| | - Loma Parikh
- Department of Pathology, Zydus Hospital, Ahmedabad, India
| | - Gaurav Goswami
- Department of Radiology, Zydus Hospital, Ahmedabad, India
| | - Sanket Mehta
- Department of Surgical Oncology, Saifee Hospital, Mumbai, India
| | - Praveen Kammar
- Department of Surgical Oncology, Saifee Hospital, Mumbai, India
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Aronson SL, Sonke GS, van Driel WJ. Cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy in advanced ovarian cancer - Authors' reply. Lancet Oncol 2023; 24:e458. [PMID: 38040000 DOI: 10.1016/s1470-2045(23)00588-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 12/03/2023]
Affiliation(s)
- S Lot Aronson
- Netherlands Cancer Institute, Amsterdam, 1066 CX, Netherlands
| | - Gabe S Sonke
- Netherlands Cancer Institute, Amsterdam, 1066 CX, Netherlands
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Lee JY, Lee YJ, Son JH, Kim S, Choi MC, Suh DH, Song JY, Hong DG, Kim MK, Kim JH, Chang SJ. Hyperthermic Intraperitoneal Chemotherapy After Interval Cytoreductive Surgery for Patients With Advanced-Stage Ovarian Cancer Who Had Received Neoadjuvant Chemotherapy. JAMA Surg 2023; 158:1133-1140. [PMID: 37672264 PMCID: PMC10483378 DOI: 10.1001/jamasurg.2023.3944] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/19/2023] [Indexed: 09/07/2023]
Abstract
Importance Hyperthermic intraperitoneal chemotherapy (HIPEC) followed by interval cytoreductive surgery (ICS) has shown survival benefits for patients with advanced-stage ovarian cancer. However, there is still a lack of consensus regarding the integration of HIPEC into clinical practice. Objective To evaluate the safety and effectiveness of ICS with HIPEC compared with ICS alone in clinical practice for patients with advanced-stage ovarian cancer. Design, Setting, and Participants This prospective, multicenter, comparative effectiveness cohort study enrolled 205 patients with stage III or IV ovarian cancer who had received at least 3 cycles of neoadjuvant chemotherapy followed by ICS with HIPEC or ICS without HIPEC at 7 Korean Gynecologic Oncology Group institutions between September 1, 2017, and April 22, 2022. Nine patients were excluded because they did not meet the inclusion criteria. Exposures Neoadjuvant chemotherapy followed by ICS with HIPEC or ICS without HIPEC. Main Outcomes and Measures The primary end point was progression-free survival (PFS). Overall survival (OS) and the safety profile were the key secondary end points. Results This study included 196 patients (median age, 58.0 years [range, 38-82 years]), of whom 109 underwent ICS with HIPEC and 87 underwent ICS without HIPEC. The median duration of follow-up was 28.2 months (range, 3.5-58.6 months). Disease recurrence occurred in 128 patients (65.3%), and 30 patients (15.3%) died. Interval cytoreductive surgery with HIPEC was associated with a significant improvement in median PFS compared with ICS without HIPEC (22.9 months [95% CI, 3.5-58.6 months] vs 14.2 months [95% CI, 4.0-56.2 months]; P = .005) and median OS (not reached [95% CI, 3.5 months to not reached] vs 53.0 [95% CI, 4.6-56.2 months]; P = .002). The frequency of grade 3 or 4 postoperative complications was similar in both groups (ICS with HIPEC, 3 of 109 [2.8%] vs ICS without HIPEC, 3 of 87 [3.4%]; P > .99). Among patients with recurrence, the frequency of peritoneal recurrence was lower in the ICS with HIPEC group than in the ICS without HIPEC group (21 of 64 [32.8%] vs 41 of 64 [64.1%]; P = .001). Conclusions and Relevance This study suggests that ICS in conjunction with HIPEC was associated with longer PFS and OS than ICS without HIPEC for patients with advanced-stage ovarian cancer and was not associated with higher rates of postoperative complications. The lower rate of peritoneal recurrence after HIPEC may be associated with improved OS.
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Affiliation(s)
- Jung-Yun Lee
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Jae Lee
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Joo-Hyuk Son
- Comprehensive Gynecologic Cancer Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Sunghoon Kim
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Min Chul Choi
- Comprehensive Gynecologic Cancer Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae-Yun Song
- Department of Obstetrics and Gynecology, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Dae Gy Hong
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Mi Kyung Kim
- Department of Obstetrics and Gynecology, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jae-Hoon Kim
- Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, South Korea; Korean Gynecologic Oncology Group, Seoul, South Korea
- Korean Gynecologic Oncology Group, Seoul, South Korea
| | - Suk-Joon Chang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
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Aronson SL, Lopez-Yurda M, Koole SN, Schagen van Leeuwen JH, Schreuder HWR, Hermans RHM, de Hingh IHJT, van Gent MDJM, Arts HJG, van Ham MAPC, van Dam PA, Vuylsteke P, Aalbers AGJ, Verwaal VJ, Van de Vijver KK, Aaronson NK, Sonke GS, van Driel WJ. Cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy in patients with advanced ovarian cancer (OVHIPEC-1): final survival analysis of a randomised, controlled, phase 3 trial. Lancet Oncol 2023; 24:1109-1118. [PMID: 37708912 DOI: 10.1016/s1470-2045(23)00396-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/25/2023] [Accepted: 08/04/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND The OVHIPEC-1 trial previously showed that the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery resulted in improved progression-free and overall survival compared with cytoreductive surgery alone at 4·7 years of follow-up in patients with stage III epithelial ovarian cancer who were ineligible for primary cytoreduction. We report the final survival outcomes after 10 years of follow-up. METHODS In this open-label, randomised, controlled, phase 3 trial, patients with primary epithelial stage III ovarian cancer were recruited at eight HIPEC centres in the Netherlands and Belgium. Patients were eligible if they were aged 18-76 years, had not progressed during at least three cycles of neoadjuvant carboplatin plus paclitaxel, had a WHO performance status score of 0-2, normal blood counts, and adequate renal function. Patients were randomly assigned (1:1) to undergo interval cytoreductive surgery without HIPEC (surgery group) or with HIPEC (100 mg/m2 cisplatin; surgery-plus-HIPEC group). Randomisation was done centrally by minimisation with a masked web-based allocation procedure at the time of surgery when residual disease smaller than 10 mm diameter was anticipated, and was stratified by institution, previous suboptimal cytoreductive surgery, and number of abdominal regions involved. The primary endpoint was progression-free survival and a secondary endpoint was overall survival, analysed in the intention-to-treat population (ie, all randomly assigned patients). This study is registered with ClinicalTrials.gov, NCT00426257, and is closed. FINDINGS Between April 1, 2007, and April 30, 2016, 245 patients were enrolled and followed up for a median of 10·1 years (95% CI 8·4-12·9) in the surgery group (n=123) and 10·4 years (95% CI 9·5-13·3) in the surgery-plus-HIPEC group (n=122). Recurrence, progression, or death occurred in 114 (93%) patients in the surgery group (median progression-free survival 10·7 months [95% CI 9·6-12·0]) and 109 (89%) patients in the surgery-plus-HIPEC group (14·3 months [12·0-18·5]; hazard ratio [HR] 0·63 [95% CI 0·48-0·83], stratified log-rank p=0·0008). Death occurred in 108 (88%) patients in the surgery group (median overall survival 33·3 months [95% CI 29·0-39·1]) and 100 (82%) patients in the surgery-plus-HIPEC group (44·9 months [95% CI 38·6-55·1]; HR 0·70 [95% CI 0·53-0·92], stratified log-rank p=0·011). INTERPRETATION These updated survival results confirm the long-term survival benefit of HIPEC in patients with primary stage III epithelial ovarian cancer undergoing interval cytoreductive surgery. FUNDING Dutch Cancer Foundation (KWF Kankerbestrijding).
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Affiliation(s)
- S Lot Aronson
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Marta Lopez-Yurda
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Simone N Koole
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | - Ralph H M Hermans
- Department of Gynecology and Obstetrics, Catharina Hospital, Eindhoven, Netherlands
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands; Department of Epidemiology, GROW-School for Oncology Reproduction, Maastricht University, Maastricht, Netherlands
| | - Mignon D J M van Gent
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, Netherlands; Center for Gynecologic Oncology Amsterdam, Amsterdam, Netherlands
| | - Henriëtte J G Arts
- Department of Gynecologic Oncology, University Medical Center Groningen, Groningen, Netherlands
| | - Maaike A P C van Ham
- Department of Gynecologic Oncology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Peter A van Dam
- Department of Gynecologic Oncology, University Hospital Antwerp, Antwerp, Belgium
| | - Peter Vuylsteke
- Department of Medical Oncology, UCL Louvain, CHU Namur Sainte-Elisabeth, Namur, Belgium; Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Arend G J Aalbers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | - Neil K Aaronson
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Willemien J van Driel
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands; Center for Gynecologic Oncology Amsterdam, Amsterdam, Netherlands.
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Filis P, Mauri D, Markozannes G, Tolia M, Filis N, Tsilidis K. Hyperthermic intraperitoneal chemotherapy (HIPEC) for the management of primary advanced and recurrent ovarian cancer: a systematic review and meta-analysis of randomized trials. ESMO Open 2022; 7:100586. [PMID: 36116421 PMCID: PMC9588894 DOI: 10.1016/j.esmoop.2022.100586] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/12/2022] [Accepted: 08/13/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Ovarian cancer is the most lethal gynecologic malignancy. Although treatment with hyperthermic intraperitoneal chemotherapy (HIPEC) has shown promising results, its role remains elusive. The aim of this study was to assess the comprehensive randomized evidence for the use versus non-use of HIPEC in primary and recurrent ovarian cancer. Materials and methods The Medline, Embase and Cochrane databases, as well as the European Society for Medical Oncology (ESMO) and American Society of Clinical Oncology (ASCO) conference abstracts of the last 5 years, were scrutinized in January 2022 for randomized, controlled trials that studied the use of HIPEC in ovarian cancer. Overall survival (OS), disease-free survival (DFS) and progression-free survival, as well as post-operative morbidity were the outcomes of interest. This study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Results Six randomized, controlled trials that randomized 737 patients were included in our analysis; of these, four studies (519 patients) were in primary and two (218 patients) in recurrent settings. In primary ovarian cancer, the combination of HIPEC with interval cytoreductive surgery (CRS) and neoadjuvant chemotherapy significantly improved the 5-year OS [393 patients, risk ratio (RR) = 0.77; 95% confidence interval (CI) 0.67-0.90; P value = 0.001] and DFS (hazard ratio = 0.60; 95% CI 0.41-0.87; P value = 0.008) compared with standard treatment alone. In the absence of neoadjuvant chemotherapy, the use of HIPEC + CRS was not associated with any survival advantage (126 patients, 4-year OS, RR = 0.93; 95% CI 0.57-1.53; P value = 0.781), but the sample size was smaller in this subset. Use of HIPEC in recurrent ovarian cancer did not provide any survival advantage (5-year OS: 218 patients, RR = 0.85; 95% CI 0.45-1.62; P value = 0.626). The risk for grade ≥3 adverse events was similar between HIPEC and no HIPEC (RR = 1.08; 95% CI 0.98-1.18; P value = 0.109). Conclusions In primary ovarian cancer the combination of HIPEC with interval CRS and neoadjuvant chemotherapy is a safe option that significantly improved 5-year OS and DFS. Its use in other settings should continue to be considered investigational. Addition of HIPEC to a complete cytoreductive surgery could be a valid treatment option for advanced ovarian cancer. HIPEC following neoadjuvant chemotherapy significantly increases 5-year overall survival in primary advanced ovarian cancer. HIPEC following neoadjuvant chemotherapy significantly increases disease-free survival in primary advanced ovarian cancer. HIPEC is a safe treatment option in ovarian cancer.
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Affiliation(s)
- P Filis
- Department of Medical Oncology, University of Ioannina, Ioannina, Greece; Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - D Mauri
- Department of Medical Oncology, University of Ioannina, Ioannina, Greece.
| | - G Markozannes
- Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, Ioannina, Greece; Department of Epidemiology and Biostatistics, St. Mary's Campus, School of Public Health, Imperial College London, London, UK
| | - M Tolia
- Department of Radiotherapy, School of Medicine, University of Crete, Heraklion, Greece
| | - N Filis
- Medical School, University of Ioannina, Ioannina, Greece
| | - K Tsilidis
- Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, Ioannina, Greece; Department of Epidemiology and Biostatistics, St. Mary's Campus, School of Public Health, Imperial College London, London, UK
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van Stein RM, Aalbers AGJ, Sonke GS, van Driel WJ. Hyperthermic Intraperitoneal Chemotherapy for Ovarian and Colorectal Cancer: A Review. JAMA Oncol 2021; 7:1231-1238. [PMID: 33956063 DOI: 10.1001/jamaoncol.2021.0580] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance The peritoneal surface is a common site of disease in ovarian and colorectal cancer. Peritoneal metastases carry a poor prognosis, despite maximal therapeutic efforts, including surgical removal of tumor deposits and intravenous chemotherapy. Hyperthermic intraperitoneal chemotherapy (HIPEC) is a single intraoperative procedure that delivers chemotherapy directly into the abdominal cavity, leading to high intracellular drug concentration at the peritoneal surface. This review describes the current knowledge regarding the mechanism of action, safety, and efficacy of HIPEC in the treatment of peritoneal metastases from epithelial ovarian and colorectal cancers and explores current knowledge gaps. Observations Toxic effects of HIPEC are limited. Evidence from a randomized trial shows improved recurrence-free and overall survival after HIPEC in patients with ovarian cancer who are ineligible for primary cytoreductive surgery (CRS). The effect of HIPEC for patients with ovarian cancer undergoing primary CRS or CRS for recurrent disease has not yet been determined, and results of ongoing trials must be awaited. A recent study in patients with peritoneal metastases from colorectal cancer did not show a benefit of HIPEC when added to perioperative chemotherapy. Conclusions and Relevance Based on available evidence, various international guidelines include the option to add HIPEC to interval CRS for patients with stage III ovarian cancer. The role of HIPEC in colorectal cancer is less well defined. Future studies will need to tailor patient selection, timing, and optimal regimens of HIPEC to improve the effectiveness of this specialized treatment in ovarian, colorectal, and other tumor types.
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Affiliation(s)
- Ruby M van Stein
- Department of Gynecologic Oncology, The Netherlands Cancer Institute, Amsterdam
| | - Arend G J Aalbers
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam
| | - Gabe S Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam
| | - Willemien J van Driel
- Center for Gynecologic Oncology Amsterdam, The Netherlands Cancer Institute, Amsterdam
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The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis: a systematic review including evidence from Japan. Surg Today 2020; 51:1085-1098. [PMID: 33185798 DOI: 10.1007/s00595-020-02180-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/29/2020] [Indexed: 02/07/2023]
Abstract
The prognosis of peritoneal carcinomatosis is poor. However, the emergence of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) as a treatment option has prolonged survival and it can even potentially cure patients with peritoneal carcinomatosis. Randomized controlled studies and other observational studies indicated that this combined therapy potentially improved the prognosis of patients with colon, gastric, and ovarian cancers with acceptable morbidity and mortality rates. Even in rarer diseases, such as pseudomyxoma peritonei and malignant peritoneal mesothelioma, CRS + HIPEC markedly improved the prognoses over those with conventional treatment. Based on the accumulated evidence, clinical guidelines recommend CRS + HIPEC for selected patients with peritoneal carcinomatosis. However, several issues still need to be overcome. A standard method for HIPEC has not yet been established. Furthermore, the criteria employed for patient selection need to be clarified to achieve real benefits. The peritoneal cancer index, chemo-sensitivity and several biological markers are considered to be key factors.
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