Quadrant-Specific Distribution of Peritoneal Metastases as a Prognostic Factor in Colorectal Cancer Treated with CRS and HIPEC

Peritoneal cancer index (PCI) based patient selecting strategy for complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in gastric cancer with peritoneal metastasis: A single-center retrospective analysis of 125 patients

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

International guidelines exclude from surgery patients with peritoneal carcinosis of colorectal origin and a peritoneal cancer index (PCI) ≥ 16. This study aims to analyze the outcomes of patients with colorectal peritoneal carcinosis and PCI greater or equal to 16 treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) (CRS + HIPEC). We retrospectively performed a multicenter observational study involving three Italian institutions, namely the IRCCS Policlinico San Matteo in Pavia, the M. Bufalini Hospital in Cesena, and theASST Papa Giovanni XXIII Hospital in Bergamo. The study included all patients undergoing CRS + HIPEC for peritoneal carcinosisfrom colorectal origin from November 2011 to June 2022. The study included 71 patients: 56 with PCI < 16 and 15 with PCI ≥ 16. Patients with higher PCI had longer operative times and a statistically significant higher rate of not complete cytoreduction, with a Completeness of Cytoreduction score (CC) 1 (microscopical disease) of 30.8% (p = 0.004). The 2-year OS was 81% for PCI < 16 and 37% for PCI ≥ 16 (p < 0.001). The 2-years DFS was 29% for PCI < 16 and 0% for PCI ≥ 16 (p < 0.001). The 2-year peritoneal DFS for patients with PCI < 16 was 48%, and for patients with PCI ≥ 16 was 57% (p = 0.783). CRS and HIPEC provide reasonable local disease control for patients with carcinosis of colorectal origin and PCI ≥ 16. Such results form the basis for new studies to reassess the exclusion of these patients, as set out in the current guidelines, from CRS and HIPEC. This therapy, combined with new therapeutical strategies, i.e., pressurized intraperitoneal aerosol chemotherapy (PIPAC), could offer reasonable local control of the disease, preventing local complications. As a result, it increases the patient's chances of receiving chemotherapy to improve the systemic control of the disease.

The aim of this study was to examine the early surgical and long-term survival outcomes of cytoreductive surgery (CRS) alone and CRS plus perioperative intraperitoneal chemotherapy (IPC) in patients with peritoneal metastases (PM). CRS alone or CRS plus IPC was performed on 122 patients for various intraabdominal PMs. Patients were divided into two groups as PCI ≤19 and PCI >19 to compare early surgical outcomes. Among PM patients 70 (57.4%) were of non-ovarian and 52 (42.6%) were of ovarian origin. Of the patients 74 (60.7%) were in the peritoneal cancer index (PCI) ≤19 group and 48 (39.3%) were in the PCI >19 group. The complication ratio of PCI >19 group was higher than that of the PCI ≤19 group and median overall survival (OS) of PCI >19 group was lower than that of the PCI ≤19 group. Complete or nearly complete (CCR-0/CCR-1) resections rates were similar in both groups (95.9% in the PCI ≤19 group and 93.8% in the PCI >19 group). However, CCR-0 resection rate was found to be lower in the PCI >19 group compared to the PCI ≤19 group (60.8% vs. 39.6%) (p <0.001). CCR-0/CCR-1 resections can be achieved with CRS in most patients with PCI >19 score. It would be appropriate to consider CRS or CRS plus perioperative IPC for palliative purposes in selected patients with PCI >19 score.

Simple SummaryPeritoneal metastases from colorectal cancer represent a distinct and aggressive disease pattern with historically poor outcomes. Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) offers selected patients the potential for long-term survival, yet prognostic factors that guide treatment selection remain under investigation. This study evaluated 75 consecutive patients treated at a tertiary oncology centre to identify variables influencing three-year survival after surgery and HIPEC. We found that the Peritoneal Cancer Index, reflecting the extent of peritoneal disease, was the only independent predictor of outcome. Completeness of cytoreduction, operative extent, and choice of intraperitoneal drug showed no additional prognostic effect. These findings support the dominant role of tumour burden in patient selection and underscore the need to integrate molecular and biological markers into future prognostic models.Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) can cure selected patients with colorectal peritoneal metastases (CPM). Real-world prognostic data, especially for the Peritoneal Cancer Index (PCI) and completeness of cytoreduction (CCR), are limited. Methods: We retrospectively analysed 75 consecutive patients treated with CRS + HIPEC at a tertiary centre (2014–2022), giving ≥36 months potential follow-up. Overall survival (OS) was assessed by Kaplan–Meier and Cox models. PCI was grouped 0–10, 11–20, >20; CCR was dichotomised (CCR-0 vs. CCR 1/2). Multivariable analysis included PCI, CCR, and resection extent; HIPEC drug was examined univariately. Results: The median follow-up was 41 months. Crude 3-year OS was 50.7% (38/75). Survival decreased with higher PCI: 69% for 0–10 (n = 42), 38% for 11–20 (n = 21), and 0% for > 20 (n = 4). Versus PCI 0–10, the adjusted hazard ratios (HR) were 3.02 (95% CI 1.52–6.03) for PCI 11–20 and 7.29 (1.72–30.81) for > 20. CCR-0 improved OS univariately (HR 0.43) but was non-significant after adjustment (HR 0.89). Resection limited to the peritoneum (HR 0.99) and choice of intraperitoneal drug showed no independent effect. Conclusions: In this real-world cohort, PCI was the only independent predictor of 3-year survival after CRS + HIPEC for CPM; neither CCR status, surgical extent, nor HIPEC agent altered prognosis once PCI was considered. PCI should therefore remain the principal selection criterion while molecular and biological markers are integrated into future risk models.

BackgroundThere is no currently available treatment for peritoneal metastasis of gastric cancer. This phase II study aimed to evaluate the efficacy and safety of neoadjuvant systemic chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC) combined with cytoreductive surgery (CRS) for the treatment of these patients.MethodsNeoadjuvant chemotherapy comprised two cycles of HIPEC and four cycles of S-1 plus paclitaxel. HIPEC was administered intraperitoneally with paclitaxel (75 mg/m2). For systemic chemotherapy, paclitaxel was administered intravenously(150 mg/m2) on day 1, and S-1 was administered orally(80 mg/m2/day)on days 1–14 of a 3-week cycle. Another two cycles of HIPEC and four cycles of S-1 plus paclitaxel were administered after second diagnostic staging laparoscopy or CRS. The primary endpoints were treatment efficiency and safety; the secondary endpoint was 3-year overall survival (OS).ResultsA total of 40 patients were enrolled and 38 patients have been analyzed. Of these, 18 (47.4%) patients received neoadjuvant systemic chemotherapy, HIPEC and CRS (conversion therapy group), while 20 patients received only chemotherapy and HIPEC (palliative chemotherapy group). Median OS was markedly improved in the conversion therapy group (21.1 months, 95% confidence interval [CI] 16.7–25.6 months) in comparison with the palliative chemotherapy group(10.8 months, 95%CI 7.3–14.2 months, p = 0.002). After neoadjuvant systemic chemotherapy and HIPEC, a second laparoscopic exploration was performed, and the prognosis of patients with low peritoneal cancer index (PCI) (PCI < 6) was significantly better than that of patients with high PCI (PCI ≥ 6)(20.1 vs.11.3 months, p = 0.006).ConclusionNeoadjuvant systemic chemotherapy and HIPEC combined with CRS is safe and feasible, and could potentially improve the prognosis of gastric cancer patients with limited peritoneal metastasis. However, further clinical trials are still warranted.Trial registrationThis study has been registered with ClinicalTrials.gov as NCT02549911. Trial registration date: 15/09/2015.

In Taiwan, colorectal cancer with peritoneal carcinomatosis is considered a terminal condition. We examined the clinical outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) treatment for colorectal cancer with peritoneal carcinomatosis in Taiwan.We enrolled patients with colorectal cancer and peritoneal metastasis from Taipei Medical University, Wanfang Hospital between January 1999 and December 2014. Of the enrolled patients, 3 had mucinous-type tumors. In total, we enrolled 31 patients who underwent a total of 33 procedures. Of the 31 patients, 2 received the HIPEC procedure twice. Cytoreductive surgery was performed followed by HIPEC. The hazard ratios of death following cytoreductive surgery and HIPEC were calculated using the Cox proportional hazards model.The 2- and 5-year overall survival rates of these patients following cytoreductive surgery and HIPEC were 57% and 38%, respectively. The completeness of cytoreduction (CC) scores were CC-0, CC-1, CC-2, and CC-3 in 18 (54.5%), 3 (9%), 7 (21.2%), and 5 (15.2%) patients, respectively. The mean peritoneal cancer index (PCI) was 16.20, and the mean postoperative PCI (PPCI) was 4.6. The major risk factors for death in these patients were a total PCI score > 20, total PPCI score > 0, and CC score ≥ 2 (P = 0.022, 0.031, and 0.0001, respectively; log-rank test). Multivariate analysis revealed that the total PPCI score was the strongest predictor of death following cytoreductive surgery and HIPEC in these patients.In Taiwan, performing cytoreductive surgery and administering HIPEC for treating colorectal cancer with peritoneal metastasis are feasible and resulted in long-term survival. In addition, the total PPCI score was related to poor prognosis following cytoreductive surgery and HIPEC in patients with colorectal cancer and peritoneal metastasis.

28 Background: Hyperthermic intraperitoneal chemotherapy (HIPEC) in addition to Cytoreductive surgery (CRS) has survival benefit observed in management of Peritoneal Carcinomatosis (PC) from Colo-rectal cancer (CRC)origin. We report the outcomes and prognostic factors of patients with CRC, who presented with PC and underwent CRS and HIPEC at King Faisal Specialist Hospital &amp; Research Center, Riyadh, Saudi Arabia. Methods: Patients presented with PC from CRC origin and underwent CRS and HIPEC; from February 2009 to September 2015 were recruited. Results: 52 patients identified. A total of 55 CRS procedures were performed, where 3 patients underwent repeated CRS and HIPEC for tumor recurrence. All except 3 used mitomycin-C for HIPEC, the remaining received either melphalan (2 patients) or cisplatin plus mitomycin-C regimen (1 patient). Melphalan used for patients who underwent repeated HIPEC as 2nd line chemotherapeutic agent. Intraoperative Radiation therapy performed in 5 patients with tumor invading the surrounding structures, where performing a safe or complete resection was either technically difficult or carried high risk. Complication assessment by Clavien-Dindo score, 62 % grade (I-II), while 31% had grade (3–4). Two patients (3.6%) died postoperatively; both from sepsis. Respiratory complications were the most commonly encountered morbidities. The 5-year overall survival(OS) was 50% with disease free survival (DFS) 29.5%. Univariate analysis showed poor OS and DFS encountered in; Signet-ring tumors (p &lt; 0.0001) for both, peritoneal cancer index (PCI) ≥ 6 (p &lt; 0.0009) for both, completeness of cytoreduction(CC) score &gt;1 (p &lt; 0.0001) for both, and high 3-month postoperative carcinoembryonic antigen value (p &lt;0.0001) for both. In multivariate analysis; DFS was significant for (PCI) ≥ 6 (p &lt; 0.0131) and (CC) score &gt;1 (p &lt; 0.0031) while PCI &gt; 6 was the only significant factor (p &lt; 0.0030) for OS. Conclusions: Addition of HIPEC to CRS was safe, and improved survival in patient with peritoneal Carcinomatosis of colo-rectal origin. PCI and CC score are prognostic factors of survival, signet-ring subtype may not benefit of this procedure.

BackgroundThe multi-institutional registry in this study evaluated the outcome after cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with peritoneal metastases (PM) from small bowel adenocarcinoma (SBA).MethodsA multi-institutional data registry including 152 patients with PM from SBA was established. The primary end point was overall survival (OS) after CRS plus HIPEC.ResultsBetween 1989 and 2016, 152 patients from 21 institutions received a treatment of CRS plus HIPEC. The median follow-up period was 20 months (range 1–100 months). Of the 152 patients, 70 (46.1%) were women with a median age of 54 years. The median peritoneal cancer index (PCI) was 10 (mean 12; range 1–33). Completeness of cytoreduction (CCR) 0 or 1 was achieved for 134 patients (88.2%). After CRS and HIPEC, the median OS was 32 months (range 1–100 months), with survival rates of 83.2% at 1 year, 46.4% at 3 years, and 30.8% at 5 years. The median disease-free survival after CCR 0/1 was 14 months (range 1–100 months). The treatment-related mortality rate was 2%, and 29 patients (19.1%) experienced grades 3 or 4 operative complications. The period between detection of PM and CRS plus HIPEC was 6 months or less (P = 0.008), and multivariate analysis identified absence of lymph node metastasis (P = 0.037), well-differentiated tumor (P = 0.028), and PCI of 15 or lower (P = 0.003) as independently associated with improved OS.ConclusionThe combined treatment strategy of CRS plus HIPEC achieved prolonged survival for selected patients who had PM from SBA with acceptable morbidity and mortality.

BackgroundMore information is needed for selection of patients with peritoneal metastases from endometrial cancer (EC) to undergo cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsThis study analyzed clinical, pathologic, and treatment data for patients with peritoneal metastases from EC who underwent CRS plus HIPEC at two tertiary centers. The outcome measures were morbidity, overall survival (OS), and progression-free survival (PFS) during a median 5 year follow-up period. Uni- and multivariate analyses were performed to identify significant factors related to outcome.ResultsA total of 33 patients met the inclusion criteria and completed the follow-up period. At laparotomy, the median peritoneal cancer index (PCI) was 15 (range 3–35). The CRS procedure required a mean 8.3 surgical procedures per patient, and for 22 patients (66.6%), a complete cytoreduction was achieved. The mean hospital stay was 18 days, and major morbidity developed in 21% of the patients. The operative mortality was 3%. When surgery ended, HIPEC was administered with cisplatin 75 mg/m2 for 60 min at 43 °C. During a median follow-up period of 73 months, Kaplan–Meier analysis indicated a 5 year OS of 30% (median 33.1 months) and a PFS of 15.5% (median 18 months). Multivariate analysis identified the completeness of cytoreduction (CC) score as the only significant factor independently influencing OS. Logistic regression for the clinicopathologic variables associated with complete cytoreduction (CC0) for patients with metachronous peritoneal spread from EC who underwent secondary CRS plus HIPEC identified the PCI as the only outcome predictor.ConclusionsFor selected patients with peritoneal metastases from EC, when CRS leaves no residual disease, CRS plus HIPEC achieves outcomes approaching those for other indications such as colon and ovarian carcinoma.

Modified selection criteria for complete cytoreductive surgery plus HIPEC based on peritoneal cancer index and small bowel involvement for peritoneal carcinomatosis of colorectal origin

To evaluate the optimal candidates for hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRS) in ovarian cancer. Descriptive study. Place and Duration of the Study: Health Sciences University, Dr. Abdurrahman YurtasianAnkara Oncology Training and Research Hospital, Ankara, Turkey, between 2013 and 2021. Ovarian cancer patients who underwent HIPEC and CRS for peritoneal involvement were included in this study. Thermosolutions were prepared as a closed system by using HT 2000 hyperthermic perfusion device. Then, cisplatin was applied at 100 mg/m2 at 42-42.5 °C for 60 minutes after CRS. A total of 47 patients were enrolled. The median age was 54 years (27-80) at the time of diagnosis. Forty (85.1%) patients had high grade serous carcinoma and 22 (46.7%) patients had clinical stage 3C disease. The median peritoneal cancer index (PCI) was 13 (3-24) in the whole population. HIPEC was applied as first-line treatment in 25 (51%) patients. Eleven (23.4%) patients had HIPEC in the post-neoadjuvant interval whereas 10 (21.3%) patients had it in platinum sensitive relapse. Median progression free survival (PFS) was 31(95% CI:11-50), 33 (95% CI:1-67), and 18 (95% CI:8-27) months in the primary, post-neoadjuvant interval, and platinum-sensitive relapse HIPEC groups, respectively. The patients with lower PCI (PCI<13) had significantly better OS than others with higher PCI (PCI>13, 145 months versus 42 months, p=0.034). HIPEC with CRS should be considered in selected serous carcinoma patients with peritoneal involvement, especially for the patients with primary ovarian cancer with lower PCI (PCI<13). Ovarian cancer, HIPEC, Peritoneal cancer index.

Background. Prolonged survival of patients affected by peritoneal metastasis (PM) of colorectal origin treated with complete cytoreduction followed by intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) has been reported. However, two-thirds of the patients after complete cytoreduction and perioperative chemotherapy (POC) develop recurrence. This study is to analyze the prognostic factors of PM from colorectal cancer following the treatment with cytoreductive surgery (CRS) + POC. Patients and Methods. During the last 8 years, 142 patients with PM of colorectal origin have been treated with CRS and perioperative chemotherapy. The surgical resections consisted of a combination of peritonectomy procedures. Results. Complete cytoreduction (CCR-0) was achieved at a higher rate in patients with peritoneal cancer index (PCI) score less than 10 (94.7%, 71/75) than those of PCI score above 11 (40.2%, 37/67). Regarding the PCI of small bowel (SB-PCI), 89 of 94 (91.5%) patients with ≤2 and 22 of 48 (45.8%) patients with SB-PCI ≥ 3 received CCR-0 resection (P < 0.001). Postoperative Grade 3 and Grade 4 complications occurred in 11 (7.7%) and 14 (9.9%). The overall operative mortality rate was 0.7% (1/142). Cox hazard model showed that CCR-0, SB-PCI ≤ 2, differentiated carcinoma, and PCI ≤ 10 were the independent favorite prognostic factors. Conclusions. Complete cytoreduction, PCI, SB-PCI threshold, and histologic type were the independent prognostic factors.

Colorectal peritoneal metastases are associated with poor prognosis. Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy may improve survival in selected patients. To evaluate survival outcomes and identify prognostic factors affecting overall survival and disease-free survival in patients with colorectal peritoneal metastases undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Retrospective cohort study. This study was conducted at a single tertiary referral center between January 2013 and March 2024. Ninety-two patients with colorectal peritoneal metastases treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were included. The cohort comprised 52 men and 40 women with a mean age of 46 years. Synchronous metastases were present in 75% of cases. All patients underwent cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy. Overall survival, disease-free survival, and prognostic factors influencing outcomes were the main outcome measures. Complete cytoreduction was achieved in 92.3% of patients. The median overall survival was 24 months, and the median disease-free survival was 11 months. The 3- and 5-year overall survival rates were 43.6% and 32.2%, respectively. An increased Peritoneal Cancer Index was independently associated with decreased overall survival, with poorer outcomes observed for a Peritoneal Cancer Index greater than 16 (HR 1.06, p = 0.016). The presence of perineural invasion (HR 2.06, p = 0.030) and intraoperative blood loss >1500 mL (HR 1.96, p = 0.018) were also associated with reduced survival. These factors may help stratify patients for optimal surgical outcomes. Retrospective design, single-center experience, and limited molecular data may affect generalizability. Longer follow-up is needed to evaluate late recurrences and long-term survival. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy improves survival in selected patients with colorectal peritoneal metastases. High Peritoneal Cancer Index, perineural invasion, and excessive blood loss predict poorer outcomes and should guide patient selection. See Video Abstract . ANTECEDENTES:Las metástasis peritoneales colorrectales se asocian con un mal pronóstico. La cirugía citorreductora combinada con quimioterapia intraperitoneal hipertérmica puede mejorar la supervivencia en determinados pacientes.OBJETIVOS:Evaluar los resultados de supervivencia e identificar los factores pronósticos que afectan a la supervivencia global y a la supervivencia libre de enfermedad en pacientes con metástasis peritoneales colorrectales sometidos a cirugía citorreductora y quimioterapia intraperitoneal hipertérmica.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO:Este estudio se llevó a cabo en un único centro terciario de referencia entre enero de 2013 y marzo de 2024.PACIENTES:Se incluyeron 92 pacientes con metástasis peritoneales colorrectales tratados con cirugía citorreductora y quimioterapia intraperitoneal hipertérmica. La cohorte estaba compuesta por 52 hombres y 40 mujeres, con una edad media de 46 años. En el 75 % de los casos se observaron metástasis sincrónicas.INTERVENCIONES:Todos los pacientes se sometieron a cirugía citorreductora seguida de quimioterapia intraperitoneal hipertérmica.PRINCIPALES MEDIDAS DE RESULTADOS:Supervivencia global, supervivencia libre de enfermedad y factores pronósticos que influyen en los resultados.RESULTADOS:Se logró una citorreducción completa en el 92,3 % de los pacientes. La mediana de la supervivencia global fue de 24 meses y la mediana de la supervivencia libre de enfermedad fue de 11 meses. Las tasas de supervivencia global a 3 y 5 años fueron del 43,6 % y del 32,2 %, respectivamente. Un aumento del índice de cáncer peritoneal se asoció de forma independiente con una disminución de la supervivencia global, observándose peores resultados para un índice de cáncer peritoneal superior a 16 (razón de riesgo 1,06, p = 0,016). La presencia de invasión perineural (razón de riesgo 2,06, p = 0,030) y una pérdida de sangre intraoperatoria superior a 1500 mililitros (razón de riesgo 1,96, p = 0,018) también se asociaron con una reducción de la supervivencia. Estos factores pueden ayudar a estratificar a los pacientes para obtener resultados quirúrgicos óptimos.LIMITACIONES:El diseño retrospectivo, la experiencia de un solo centro y los datos moleculares limitados pueden afectar a la generalización. Se necesita un seguimiento más prolongado para evaluar las recidivas tardías y la supervivencia a largo plazo.CONCLUSIONES:La cirugía citorreductora con quimioterapia intraperitoneal hipertérmica mejora la supervivencia en determinados pacientes con metástasis peritoneales colorrectales. Un índice de cáncer peritoneal alto, la invasión perineural y la pérdida excesiva de sangre predicen peores resultados y deben guiar la selección de pacientes. ( AI-generated translation ).

Patients with peritoneal metastases of gastric cancer have a poor prognosis and median survival of 7months. This study compared treatment options and outcomes based on the Peritoneal Cancer Index (PCI). This retrospective analysis included patients with gastric cancer treated between August 2008 and December 2017 with synchronous peritoneal metastases only diagnosed by laparoscopy. The three treatments were as follows: (1) cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in combination with pre- and postoperative systemic chemotherapy (n = 58), (2) laparotomy/laparoscopy without CRS, but HIPEC in combination with pre- and postoperative systemic chemotherapy (n = 11), and (3) systemic chemotherapy only (n = 19). A total of 88 patients aged 54.6 ± 10.9years with mean PCI of 14.3 ± 11.3 were included. The PCI was significantly lower in group 1 (8.3 ± 5.7) than in group 2 (23.9 ± 11.1, p < 0.001) and group 3 (27.3 ± 9.3, p < 0.001). Mean time from diagnosis to laparoscopy was 5.2 ± 2.9months. The median overall survival was 9.8 ± 0.7 for group 1, 6.3 ± 3.0 for group 2 and 4.9 ± 1.9months for group 3 (p < 0.001). Predictors for deteriorated overall patient survival included > 4 cycles of preoperative chemotherapy (HR 4.49, p < 0.001), lymph-node metastasis (HR 3.53, p = 0.005), PCI ≥ 12 (HR 2.11, p = 0.036), and incompleteness of cytoreduction (HR 4.30, p = 0.001) in patients treated with CRS and HIPEC. CRS and HIPEC showed convincing results in selected patients with PCI < 12 and complete cytoreduction. Prolonged duration (> 4 cycles) of preoperative intravenous chemotherapy reduced patient survival in patients suitable for CRS and HIPEC.