Victor J Verwaal; Mette Moller Sorensen
In the last 20 years the treatment of peritoneal surface malignancies grained a special at- tention of the medical and surgical world. Previously peritoneal surface malignancies where seen as metastasized disease which could not be surgical removed due to technical diffi - culties and wouldn't be treated with systemic chemotherapy because of the leak of measu- rable disease. In 2003 the fi rst randomized trial was published on the treatment colorectal peritoneal metastasis in a more active way.(1,2) This trial showed a survival benefi t of cyto-reductive surgery with hyperthermic intra peritoneal chemotherapy followed by systemic chemotherapy when compared to systemic chemotherapy alone. This study was followed by a large number of studies which showed an even further improvement of the survival than published in the randomized trial. Most recently another randomized trial comparing systemic chemotherapy followed by cyto reduction and hyperthermic intraperitoneal chemotherapy to systemic chemotherapy followed by cytoreduction without hyperthermic intra peritoneal chemotherapy doubted the additional eff ect of hyperthermic intra peritoneal chemotherapy in patients with peritoneal metastasis of colorectal origin.(3) Whatever way one looks at these results it is clear from both trials that a complete cytoreduction is the cornerstone of the treatment of peritoneal metastasis.
Ovarian carcinoma is probably the most classic tumour with spreading to the peritoneum. Traditional this disease is treated with debulking and systemic chemotherapy. Several studies showed that the completeness of the cytoreduction determines the outcome.(4) This year a randomized trial was published showing a benefi t of adding hyperthermic intra peri- toneal to the cytoreduction when combined with systemic chemotherapy.(5)
In both above described situations it is clear that cytoreduction, thus the complete resection of all visible disease is key to success. Hyper thermic intra peritoneal chemotherapy give an extra benefit in ovarian cancer patients with peritoneal metastasis and give a benefit in colorectal cancer effected with peritoneal metastasis in the med range disease load. Probably the difference between the two diseases is that ovarian cancer is much more chemo sensitive to the current known chemotherapy agents and we are leaking really effective chemotherapy for colorectal cancer.
Systemic chemotherapy might help to improve the survival combined with cytoreduction, but we are leaking a trial comparing cytoreduction with and without systemic chemotherapy. If we compare this situation to liver metastases surgery one should doubt whether chemotherapy give a benefit to resection of metastatic disease because most studies of adjuvant chemotherapy after liver metastasis do not have a overwhelming result.(6)
To conclude, surgical resection of peritoneal metastasis is the key, all treatment around it is whether it is intra peritoneal chemotherapy or systemic chemotherapy has not established it final position. However it is mostly likely that the combination of everything is give the best results for the patients.
1.Verwaal VJ, Bruin S, Boot H, van Slooten G, van TinterenH. 8-year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer. Ann Surg Oncol. 2008; 15(9):2426-32.
2. Verwaal VJ, van Ruth S, de Bree E, van Sloothen GW, vanTinteren H, Boot H, et al. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versussystemic chemotherapy and palliative surgery in patientswith peritoneal carcinomatosis of colorectal cancer. J ClinOncol. 2003;21(20):3737-43.
3. Quenet F, Elias D, Roca L, Goere D, Ghouti L, Pocard M, etal. UNICANCER phase III trial of hyperthermic intra-peritoneal chemotherapy (HIPEC) for colorectal peritoneal carcinomatosis (PC): PRODIGE 7. 2018 ASCO Annual Meeting.
[Internet]. [cited 2018 JUl 15]. Available from: http://abstracts asco.org/214/AbstView_214_222851.html
4. Chi DS, Eisenhauer EL, Zivanovic O, Sonoda Y, Abu-RustumNR, Levine DA, Guile MW, Bristow RE, Aghajanian C, Barakat RR. Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgicalparadigm. Gynecol Oncol. 2009; 114(1):26-31.
5. van Driel WJ, Koole SN, Sikorska K, Schagen van Leeuwen JH,Schreuder HWR, Hermans RHM, et al. Hyperthermic intraperitoneal chemotherapy in ovarian cancer. N Engl J Med.2018; 378(3):230-40.
6. Nordlinger B, Sorbye H, Glimelius B, Poston GJ, Schlag PM,Rougier P, et al. Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergrouptrial 40983): a randomised controlled trial. Lancet. 2008;371(9617):1007-16.
Comment to: Batista TP, Levon Badiglian-Filho L, Baiocchi G. How much "surgical eff ort" should be added to HIPEC. Braz J Oncol. 2018, 14(48):1-2. DOI: 10.26790/BJO20181448A218.
July 1 2018.
Accepted em January 15 2018.
Funding Source: None
Conflict of Interest Statement: None