Abstract

Simple SummaryAbsence of survival benefits when adding hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin to cytoreductive surgery in peritoneal metastasis from colorectal cancer has recently been shown in the randomized controlled PRODIGE 7 trial. We therefore aimed to investigate the effects of this treatment modality in a preclinical micrometastasis model. Cancer cells were incubated with either patient samples obtained during HIPEC procedures or with defined oxaliplatin-containing solutions prepared according to clinically established HIPEC protocols. Our results demonstrate a limited effectiveness of short-term HIPEC in simulations with oxaliplatin to eliminate micrometastases, although we used platinum-sensitive cell lines for our model. Since these results are in line with findings from current research, our studies might offer further convincing evidence and potential explanations for HIPEC futility observed in clinical application.Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) was considered a promising treatment for patients with peritoneal metastasis from colorectal cancer. However, the recently published randomized controlled PRODIGE 7 trial failed to demonstrate survival benefits through the addition of short-term oxaliplatin-based HIPEC. Constituting a complex multifactorial treatment, we investigated HIPEC in a preclinical model concerning the elimination of minimal tumor residues, thereby aiming to better understand the size of effects and respective clinical trial results. Patient samples of peritoneal perfusates obtained during HIPEC treatments and oxaliplatin-containing solutions at clinically relevant dosages, conforming with established HIPEC protocols, were assessed regarding their ability to eliminate modelled ~100 µm thickness cancer cell layers. Impedance-based real-time cell analysis and classical end-point assays were used. Flow cytometry was employed to determine the effect of different HIPEC drug solvents on tumor cell properties. Effectiveness of peritoneal perfusate patient samples and defined oxaliplatin-containing solutions proved limited but reproducible. HIPEC simulations for 30 min reduced the normalized cell index below 50% with peritoneal perfusates from merely 3 out of 9 patients within 72 h, indicating full-thickness cytotoxic effects. Instead, prolonging HIPEC to 1 h enhanced these effects and comprised 7 patients’ samples, while continuous drug exposure invariably resulted in complete cell death. Further, frequently used drug diluents caused approximately 25% cell size reduction within 30 min. Prolonging oxaliplatin exposure improved effectiveness of HIPEC to eliminate micrometastases in our preclinical model. Accordingly, insufficient penetration depth, short exposure time, and the physicochemical impact of drug solvents may constitute critical factors.

Highlights

  • The combined use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer (CRC) peritoneal metastasis has been supported by a leadoff randomized controlled trial (RCT) in 2003 showing prolonged overall survival for this treatment compared to palliative chemotherapy alone [1]

  • The theoretical rationale of HIPEC is the elimination of residual tumor cells remaining after CRS through the locoregional administration of chemotherapy, which is justified by the assumption that a compartmental effect caused by the so-called peritoneal– plasma barrier prevents the penetration of intravenous drugs into the abdominal space [3]

  • In 2018 an RCT demonstrated an increase in overall survival through adding 90-min cisplatin-based HIPEC to surgery in selected patients suffering from peritoneal metastasis that originated from platinum-sensitive ovarian cancers [6]

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Summary

Introduction

The combined use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer (CRC) peritoneal metastasis has been supported by a leadoff randomized controlled trial (RCT) in 2003 showing prolonged overall survival for this treatment compared to palliative chemotherapy alone [1]. For decades this combined treatment approach has been in use to treat peritoneal metastases of different cancers [2]. In 2018 an RCT demonstrated an increase in overall survival through adding 90-min cisplatin-based HIPEC to surgery in selected patients suffering from peritoneal metastasis that originated from platinum-sensitive ovarian cancers [6]. The necessity of uniform and comparable treatment protocols has been rarely addressed, this

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