Abstract
Peritoneal carcinomatosis is a sign of advanced disease of ovarian cancer. The prognosis of ovarian cancer is significantly improved after cytoreductive surgery with complete tumor debulking followed by platin based chemotherapy. If cytoreductive surgery results in a tumor free situation with remaining tumor less than 0.25 cm, HIPEC may further improve prognosis. Materials and methods: The results of the Krefeld study are presented and the literature is reviewed according to overall survival and progression free survival with or without HIPEC. In the Krefeld study, patients with ovarian cancer and peritoneal carcinomatosis underwent cytoreductive surgery. In patients with optimal tumor debulking, HIPEC was performed. The peri- and postoperative course was observed. Adverse events were recorded after the Clavien-Dindo classification. Results: 43 patients were treated with cytoreductive surgery and HIPEC. In all patients an optimal cytoreductive situation with remaining tumor less than 0.25 cm was achieved. HIPEC was performed with a cisplatin solution (50 mg/m2) at 41°C. The median age of the patients was 56 years (range: 32–74 years), the median peritoneal cancer index (PCI) was 13 (range: 4–21), the median operation time was 356 minutes (range: 192–507 minutes). The median time to postoperative systemic treatment with chemotherapy was 29 days (range 21–70). There was no postoperative surgically associated death. No adverse events were recorded in 16 (37.2%) of 43 patients, no grade III or IV adverse events were reported for 33 (76.7%) patients, and no grade IV adverse events were reported for 41 (95.3%) patients. Grade III adverse events occured in 19 (44.2%) of the 43 patients; a total of 29 grade III adverse events were reported in these 19 patients. Grade IV adverse events occured in 3 (7.0%) of the 43 patients; a total of 3 grade IV adverse events were reported. Two of them resulted in return to the operating room. This was a fistula of the distal small bowel caused by drainage and a revision of wound infection. Conclusion: In ovarian cancer multiple surgical procedures may be necessary in order to have macroscopically eradicated tumor tissue. Combined with HIPEC, this seems to have positive effects on the survival of patients with peritoneal carcinomatosis. Since we have no marked additional adverse events caused by HIPEC in our case series, HIPEC seems to be an additional treatment option of peritoneal carcinomatosis in ovarian cancer. This statement is strengthened by the literature review in that metaanalysis show significant improved OAS and PFS.
Highlights
Most patients with advanced ovarian cancer will suffer from recurrence, because the five year overall survival for stage FIGO III and IV epithelial ovarian cancer is still very low with 20–30%
It was shown that the combination of postoperative intraperitoneal and intravenous chemotherapy improves survival in women with optimally resected stage III ovarian cancer compared with iv chemotherapy alone
While macroscopic disease is removed by cytoreductive surgery, microscopic disease from the peritoneal surface should be eradicated by HIPEC
Summary
Most patients with advanced ovarian cancer will suffer from recurrence, because the five year overall survival for stage FIGO III and IV epithelial ovarian cancer is still very low with 20–30%. Gynecologic oncologists are looking for better treatment strategies [1]. In most patients with advanced ovarian cancer the spread to the peritoneum is the primary site of failure. It seems reasonable to assess additional local treatment strategies apart from maximal tumor debulking. According to prior studies the intraperitoneal application of cisplatin is assiciated with a 20-fold higher concentration in the intraperitoneal space compared to that measured in plasma after intravenous administration. It was shown that the combination of postoperative intraperitoneal and intravenous (ip/iv) chemotherapy improves survival in women with optimally resected stage III ovarian cancer compared with iv chemotherapy alone. There are many aspects like treatment-related toxicities, adhesion barriers after surgery, dysfunction of implanted i.p. catheters (Tenckhoff catheters), the absence of a standard treatment regimen, patientspreference and the inconvenience of an inpatientregimen that prevent the integration of ip/Iv chemotherapy into clinical routine [2]
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