Predictors of Recurrence of Peritoneal Carcinomatosis among Patients with Colorectal Cancer Following Cytoreductive Surgery alone versus Cytoreductive Surgery Plus HIPEC

Gareer, Waheed Yousry; Mohamed, Gamal Amira; Zedan, Mohamed H.; Baradei, Tarek Sherif Al; Abdalgeleel, Shaimaa Abdalaleem; Khairallah, Sherif Mohamed

doi:10.1055/s-0041-1740472

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Journal of Coloproctology (Rio de Janeiro)

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Sumário

Original Article • J. Coloproctol. (Rio J.) 42 (2) • June 2022 • https://doi.org/10.1055/s-0041-1740472 copy

Predictors of Recurrence of Peritoneal Carcinomatosis among Patients with Colorectal Cancer Following Cytoreductive Surgery alone versus Cytoreductive Surgery Plus HIPEC

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background

Peritoneal carcinomatosis (PC) is a lethal regional progression in patients with colorectal cancer (CRC). Treatment with complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) achieves better local control than systemic palliative chemotherapy.

Objectives

To assess the efficacy on the prognosis of CRS and HIPEC compared with CRS only and to identify possible clinicopathological factors associated with the recurrence of PC.

Methods

The present retrospective study included all colorectal carcinoma cases with PC subjected to CRS with or without HIPC from January 2009 to June 2018 at the National Cancer Institute (NCI), Cairo University, Cairo, Egypt. The outcome is evaluated in terms of recurrence-free survival (RFS) and its predictors.

Results

Out of the 61 patients, 45 patients (73.8%) underwent CRS plus HIPEC, and 16 (26.2%) underwent CRS alone. The 1-year RFS was 55.7%, with a median of 12 months. The risk factors for recurrence identified in the univariate analysis were T4 primary tumor, high-grade, positive lymphovascular invasion (LVI), positive extracapsular nodal spread, and patients treated with CRS only, without HIPEC. In the multivariate analysis, the independent risk factors for recurrence were high grade and patients treated with CRS only.

Conclusion

T4 primary tumor, high grade, positive LVI, and positive extracapsular nodal spread seemed to be important predictors of recurrence following the treatment of PC. Our study also demonstrated that the addition of HIPEC to CRS improved the RFS.

Keywords:
colorectal cancer; peritoneal carcinomatosis; cytoreductive surgery; HIPEC

		Number	Percentage
Age (years old)	< 45	25	41.0
Age (years old)	≥ 45	36	59.0
Gender	Male	28	45.9
Gender	Female	33	54.1
Primary tumor characteristics
T stage	T2 +T3	43	70.5
T stage	T4a +T4b	18	29.5
*N stage (n = 59)^ Some data missing.*	N0	13	22.0
	N1	22	37.3
	N2	24	40.7
M stage	−ve	33	54.1
M stage	+ve	28	45.9
Histopathological type	Signet ring	6	9.8
	Mucinous	23	37.7
	Adenocarcinoma	32	52.5
Grade	Low (G1,2)	47	77.0
Grade	High (G3,4)	14	23.0
*LNs harvested during resection (n = 59)^ Some data missing.*	≤ 12	23	39.0
	> 12	36	61.0
*Lymphovascular invasion (n = 51)^ Some data missing.*	Yes	32	62.7
*Lymphovascular invasion (n = 51)^ Some data missing.*	No	19	37.3
Extracapsular node invasion (n = 44)^ for N1 and N2 only.	Yes	33	75.0
	No	11	25.0
Peritoneal disease characteristics
Presentation	Symptomatic	4	6.6
Presentation	Asymptomatic	57	93.4
Onset	Synchronous	27	44.2
Onset	Metachronous	34	55.7
*PCI score (n = 60)^ Some data missing.*	≤ 10	37	61.7
*PCI score (n = 60)^ Some data missing.*	> 10	23	38.3
CC score	CC0	54	88.5
CC score	CC1	7	11.5
Surgical procedure	CRS only	16	26.2
Surgical procedure	CRS + HIPEC	45	73.8

		n	Failures (n)	RFS (%)	Median survival (months)	p-value
Whole Group		59	26	55.7	12
Surgery for primary peritoneal disease	CRS	15	12	23.8	9	0.002
Surgery for primary peritoneal disease	CRS + HIPEC	44	14	66.2	35	0.002
Age (years old)	< 45	23	14	48.8	11	0.415
	≥ 45	36	12	58.2	35	0.415
Gender	Female	32	16	36.6	11	0.105
	Male	27	10	69.0	56	0.105
Primary tumor characteristics
T stage	T2 & T3	31	14	62.4	35	0.035
	T4 a & b	28	12	37.2	11	0.035
N stage	N0	13	2	76.9	NR	0.087
	N1	22	9	51.0	35
	N2	24	14	44.0	12
M stage	Negative	31	7	75.5	35	0.009
	Positive	28	19	33.0	9	0.009
Final stage	Stages 1 & 2	10	1	80.0	NR	0.024
	Stage 3	21	6	73.4	35
	Stage 4	28	19	33.0	9
Histopathological type	Adenocarcinoma	31	9	73.6	35	0.061
	Signet ring	6	4	40.0	9
	Mucinous	22	13	38.5	20
Grade	Low grade	46	17	64.5	16	0.007
	High grade	13	9	13.2	9.0	0.007
LNs harvested during resection (n = 59)^* *Some data missing.	≤ 12	23	11	24.8	10	0.06
	> 12	36	14	67.4	35	0.06
LVI (n = 51)^* *Some data missing.	Yes	32	20	34.2	10	0.001
	No	19	4	89.7	35	0.001
Extracapsular node invasion (n = 44)^* *Some data missing.	Yes	32	21	39.0	10	0.005
Extracapsular node invasion (n = 44)^* *Some data missing.	No	11	3	83.3	35	0.005
Peritoneal disease characteristics
Onset	synchronous	26	16	38.9	11	0.073
	metachronous	33	9	68.3	35	0.073
PCI score	≤ 10	37	17	48.3	12	0.546
	> 10	22	9	61.2	35	0.546
CC score	CC0	53	23	55.4	13	0.270
	CC1	6	3	66.7	NR	0.270

	p-value	HR	95% CI for HR
	p-value	HR	Lower	Upper
Management of primary peritoneal disease (CRS versus CRS + HIPEC)	0.011	2.924	1.282	6.667
Grade of primary colonic disease (high grade versus low grade)	0.037	2.488	1.057	5.857

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[1] Address for correspondence Shaimaa Abdalaleem Abdelgeleel, MD, Department of Epidemiology and Biostatistics, National Cancer Institute, Cairo University, Cairo, Egypt (e-mail: bossykhaled1@hotmail.com).

Recurrence after CRS ± HIPEC	Yes	26	42.6%
Recurrence after CRS ± HIPEC	No	35	57.4%
Time to recurrence (months) (n = 26)	Early < 12 m	20	76.9%
Time to recurrence (months) (n = 26)	Late ≥ 12 m	6	23.1%
Site of recurrence (n = 26)	HIPEC + CRS	CRS	Total
Peritoneum only	6	8	14
Peritoneum plus distant metastasis	4	1	5
Peritoneum plus local recurrence	2	1	3
Local recurrence	0	1	1
Distant metastasis only	2	1	3