Combined cytoreductive surgery and hyperthermic intraperitoneal chemotherapy as a treatment for recurrent epithelial ovarian cancer-National Cancer Institute experience

Complications of HIPEC for ovarian cancer surgery: evaluation over two time periods

OBJECTIVE

Cytoreductive surgery in conjunction with hyperthermic intraperitoneal chemotherapy (HIPEC) is being explored in the upfront, interval, and recurrent setting in patients with ovarian cancer. The objective of this systematic review was to assess the rate of complications associated with HIPEC in epithelial ovarian cancer surgery over two time periods.

METHODS

This study was registered in PROSPERO (CRD42022328928). A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Ovid/Medline, Ovid/Embase, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials were searched from January 2004 to April 2022. We included studies reporting on patients with advanced primary or recurrent epithelial ovarian cancer who underwent cytoreductive surgery and HIPEC. We evaluated two different time periods: 2004-2013 and 2014-2022. A random-effects meta-analysis was used to produce an overall summary. Subgroup analyses were planned according to recruited period for each specific complication type. Heterogeneity was assessed using the I2 statistic.

RESULTS

A total of 4928 patients were included from 69 studies for this systematic review; 19 published from 2004-2013, and 50 published from 2014-2022. No significant differences were found between the two time periods in terms of blood transfusions (33% vs 51%; p=0.46; I2=95%) overall gastrointestinal complications (15% vs 21%; p=0.36; I2=98%), infectious diseases (16% vs 13%; p=0.62; I2=93%), overall respiratory complications (12% vs 12%; p=0.88; I2=91%), overall urinary complications (6% vs 12%; p=0.06; I2=94%), or thromboembolic events (5% vs 3%; p=0.25; I2=63%). Also, no differences were found in intensive care unit (ICU) admissions (89% vs 28%; p=0.06; I2=99%), reoperations (8% vs 7%; p=0.50; I2=37%), or deaths (3% vs 3%; p=0.77; I2=57%).

CONCLUSIONS

Our review showed that overall complications have not changed over time for patients undergoing HIPEC in the setting of primary or recurrent ovarian cancer. There was no decrease in the rates of ICU admissions, reoperations, or deaths.

Risk factors for postoperative delayed gastric emptying in ovarian cancer treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has shown promising results in improving the survival of ovarian cancer patients. Although the safety profiles of CRS-HIPEC exist, more attention should be paid to gastrointestinal complications, as the procedure involves a considerable proportion of bowel resection and anastomosis.

AIM

To identify the risk factors for delayed gastric emptying in ovarian cancer treated with CRS-HIPEC.

METHODS

A cross-sectional study was conducted. According to the inclusion and exclusion criteria, we retrospectively analyzed 77 patients admitted between March 2014 and April 2018 with advanced and recurrent ovarian cancer treated with CRS-HIPEC in Beijing Shijitan Hospital of Capital Medical University. Risk factors for delayed gastric emptying were analyzed using univariate analysis. All of the statistically significant variables in the univariate analysis were entered into the multivariable logistic regression model to determine factors independently associated with delayed gastric emptying.

RESULTS

Among the 77 included patients, 36.4% (28/77) had delayed gastric emptying after CRS-HIPEC. The median age and body mass index of all patients were 59 years and 22.83 kg/m², respectively. Preoperative chemotherapy was administered in 55 patients (71%). Sixty-two patients (81%) had a history of at least one previous pelvic surgery. The median operation time and intraoperative hemorrhage volume were 630 min and 600 mL, respectively. Omentectomy was performed in 32 cases of primary ovarian cancer and 24 cases of recurrence. The median peritoneal cancer index was 16. The risk factors for delayed gastric emptying from the univariate analysis were body mass index < 23 kg/m² (X² = 5.059, P = 0.025), history of pelvic surgery (X² = 4.498, P = 0.034), history of chemotherapy (X² = 4.334, P = 0.037), operation time ≥ 7 h (X² = 4.827, P = 0.047), and intraoperative hemorrhage ≥ 800 mL (X² = 7.112, P = 0.008). Multivariable analysis revealed that age ≥ 70 years (HR = 7.127; 95%CI 1.122-45.264; P = 0.037) and intraoperative hemorrhage ≥ 800 mL (HR = 3.416; 95%CI 1.067-10.939; P = 0.039) were independently associated with postoperative delayed gastric emptying after CRS-HIPEC.

CONCLUSION

Postoperative gastrointestinal management, including prolonged nasogastric intubation, should be promoted for patients over 70 years or those with intraoperative bleeding exceeding 800 mL.

Intraperitoneal chemotherapy for ovarian cancer with peritoneal metastases, systematic review of the literature and focused personal experience

Epithelial ovarian cancer (EOC) causes 60% of ovarian cancer cases and is the fourth most common cause of death from cancer in women. The standard of care for EOC includes a combination of surgery followed by intravenous chemotherapy. Intraperitoneal (IP) chemotherapy (CT) has been introduced into the therapeutic algorithm of EOC with positive results. To explore existing results regarding intraperitoneal chemotherapy a systematic review of the literature and an analysis of our own institutional prospective database of patients treated with cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) for EOC at different stages were conducted. The focused report concerning our personal experience with advanced EOC treated with cytoreductive surgery and HIPEC produced the following results: In 57 patients cisplatin + paclitaxel as HIPEC was the only significant factor improving overall survival (OS) at multivariate analysis (OR 6.54, 95% CI: 1.24-34.47, P=0.027). Patients treated with HIPEC cisplatin + paclitaxel showed a median OS of 46 months (SD 6.4, 95% CI: 33.4-58.6), while patients treated with other HIPEC regimens showed a median OS of 12 months (SD 3.1, 95% CI: 6.0-18.0). The 2y-OS was 72% and 3y-OS was 68% for cisplatin + paclitaxel as HIPEC, while the 2y- and 3y-OS was 0% for other HIPEC regimens. Patients treated with HIPEC cisplatin + paclitaxel showed a median disease-free survival (DFS) of 13 months (SD 1.6, 95% CI: 9.9-16.1), while patients treated with other HIPEC regimens showed a median DFS of 8 months (SD 3.1, 95% CI: 1.9-14.1). In conclusion, HIPEC cisplatin + paclitaxel in ovarian cancer showed positive results that may be considered semi-definitive according to the level of evidence and should be considered a starting point for further investigations. At present HIPEC cisplatin + paclitaxel should be proposed to patients with advanced ovarian cancer as standard treatment at almost all stages of disease. Platinum + taxane-based intraperitoneal regimens demonstrated superior results compared to other regimens.

Anlotinib combined with etoposide for platinum-resistant recurrent ovarian cancer: A case report

INTRODUCTION

Platinum-resistant ovarian cancer is characterized by its poor prognosis and limited treatment options. Angiogenesis plays a fundamental role in the development of drug-resistance in ovarian cancer. Anlotinib, a novel oral multi-targeted tyrosine kinase inhibitor which targets a board spectrum of angiogenesis-associated growth factor receptors, has shown promising anti-tumor efficacy in clinical trials. Herein, we report a case of ovarian cancer treated with anlotinib plus etoposide after secondary cytoreductive surgery.

PATIENT CONCERNS

A 45-year-old female with primary platinum-resistant ovarian cancer who progressed rapidly after the first cytoreductive surgery, the second cytoreductive surgery, and several lines of treatment. The patient refused to receive intravenous chemotherapy any more.

DIAGNOSIS

Primary platinum-resistant ovarian cancer.

INTERVENTIONS

The oral combination treatment of anlotinib (12 mg, qd) and etoposide (100 mg, qd) were delivered.

OUTCOMES

Finally, the patient was responsive to the orally treatment of anlotinib combined with etoposide. The patient has been alive with no evidence of disease progression for 18 weeks.

CONCLUSION

Our case suggests that oral treatment of anlotinib combined with etoposide which is acceptable and convenient, may be an additional option for the management of platinum-resistant ovarian cancer.