E. A. Strong1, M. V. Hembrook1, S. Tsai1, K. K. Christians1, H. D. Mogal1, T. C. Gamblin1, C. N. Callisia1 1Medical College of Wisconsin,Surgical Oncology,Milwaukee, WI, USA
Introduction: Palliation is a controversial indication for cytoreductive surgery (CRS) and hyperthermic intraperitoenal chemotherapy (HIPEC) in patients with peritoneal carcinomatosis (PC). However, with more effective systemic therapies, patients with metastatic disease are living longer and the role of palliative surgery is increasingly challenged. The purpose of this study is to evaluate the indications for surgery, morbidity, and symptom improvement from CRS/HIPEC in patients with advanced PC.
Methods: We performed a retrospective review of a prospectively maintained clinical registry of patients undergoing CRS/HIPEC at the Medical College of Wisconsin from February 2008 to February 2018. Patient undergoing surgeries with palliative intent were included in this study. Indications for surgery, clinical and pathological factors, operative details, and postoperative course were analyzed. Main endpoints included symptom improvement, discharge to home, progression-free (PFS), and overall survival (OS).
Results: 277 patients were referred for CRS/HIPEC at our institution over this 10-year period. 18 patients underwent 19 procedures with palliative intent. 10 patients (56%) were female, 8 (44%) were male with a median age at surgery of 57 years (IQR:7). All patients had an ASA class of 3 (68%) or 4 (32%). Metastatic colorectal cancer was the most common malignancy treated [n=7 (39%)], followed by appendiceal cancer [n=6 (33%)], peritoneal mesothelioma [n=3 (17%)], gastric cancer [n=1 (6%)], and sarcoma [n=1 (6%)]. At time of surgery, 4 (21%) patients had an ECOG performance status of 0, 11 (58%) ECOG of 1, 3 (16%) ECOG of 2, and 1 (5%) ECOG of 3. Median preoperative serum albumin and prealbumin levels were 3.3 g/dL (IQR:0.6) and 13 mg/dL (IQR:7.5). Indications for palliative surgery were ascites 8 (42%), obstruction 5 (26%), abdominal pain 4 (21%), GI bleed 1 (5%), and other 1 (5%). 5 (26%) patients required preoperative admission for nutritional optimization. 9 (47%) patients underwent CRS and HIPEC, 1 (5%) underwent HIPEC only, 9 (47%) underwent CRS only. 30-day mortality was n=2 (10.5%). 11 (58%) patients had postoperative complications; 6 (32%) minor (Clavien I/II) and 5 (26%) major (Clavien ≥III) complications. Median hospital LOS was 11 days (IQR=12). 30-day readmission rate was 10.5%. 2 patients (11%) were discharged to hospice and subsequently died from their disease. 1 (5%) patient was discharged to a skilled nursing facility, the remaining 16 (84%) were discharged home. 17 (89%) had at least partial of symptom improvement at 30 postoperative days. Median PFS was 2.9 months (IQR:5.6), and median OS was 8.2 months (IQR:12).
Conclusion: Palliative CRS and/or HIPEC achieves adequate symptom palliation in patients with advanced peritoneal carcinomatosis. However, these interventions are associated with high morbidity and mortality.