ICACT: Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemoperfusion Beneficial in Recurrent Ovarian Carcinoma
By Chris Berrie
PARIS, FRANCE -- February 2, 2005 -- Cytoreductive surgery plus hyperthermal peritoneal perfusion can be performed in women with recurrent ovarian cancer, with morbidity and mortality rates that are in line with those of other major oncological operations, according to a presentation here February 1st at the 16th International Conference on Anti-Cancer Treatment.
Dr. Herwart Müller, MD, PhD, Head, Department of Surgical Oncology, Hospital Hammelburg GmBH, Hammelburg, Germany, outlined that with ovarian cancer the response rates to monotherapy in platinum-refractory patients remains around 25% and 30% for platinum-sensitive patients. However, surgical treatment in recurrent ovarian cancer appears more promising, even without the inclusion of intraperitoneal chemotherapy, he said.
Thus Dr. Müller and colleagues evaluated cytoreductive surgery with multivisceral resection and peritonectomy, followed by hyperthermic peritoneal perfusion and postoperative intraperitoneal chemotherapy, and adjuvant chemotherapy. "With incomplete cytoreduction, we do not use intraoperative chemotherapy, hyperthermic perfusion or postoperative intraperitoneal chemotherapy, but we add systemic chemotherapy in a palliative setting," added Dr. Müller.
The operative strategy included all of the anastomoses being made after intraoperative intraperitoneal chemotherapy, a liberal use of anus praeter, and the prevention of fluid accumulation by insertion of thoracic tubes in the right and left pleural cavities.
For their first chemotherapeutic strategy, the Coliseum technique was used, with open peritoneal perfusion at 41.5 °C, a perfusion time of 45 minutes (now increased to 60 minutes), a flow rate of 1,500 mL/minute, and the addition of 20 mg/m2 of mitomycin.
The postoperative intraperitoneal chemotherapy consisted of artificial ascites with 6% HAES (days 1 to 3 postoperative) and 500 mg/m2 of 5-fluorouracil given over about 24 hours. The amount of fluid used depended on the abdominal pressure, as this should remain below 15 cm H2O.
The adjuvant chemotherapy used would then include topotecan 0.5 mg/m2 on days 1 to 5 and gemcitabine 600 mg/m2 on days 1 and 8, thus following 3 cycles of the North-East Society of Gynaecological Oncology scheme (Sehouli et al., Ann Oncol. 2002 Nov;13(11):1749-55). Finally, in the case of incomplete cytoreduction, the palliative chemotherapy used would depend on previous chemotherapies..
Thirty procedures have been completed on 28 patients (median age, 56 years) who had been treated previously with a mean of 2.6 (range, 1-5) chemotherapies. Complete cytoreduction was achieved in 73% of these procedures, all of which included hyperthermic perfusion.
One of the most interesting aspects can be seen in their complication rate, Dr. Müller said, a morbidity of 13%, no 30-day mortality, and a 3% rate of in-hospital mortality. Of note, Dr. Müller stressed that they had also had a learning curve over the past 3 years: with their first 19 cases in 2002, morbidity and mortality were around 40% and 11%, respectively; 2 years later, these were reduced to 20% and 0%, respectively, with 67 cases.
With a median follow-up of 10.9 months, the 1-year overall survival of 75% is predicted to be 67% at 2 years. If only the complete cytoreductions are included, the projected 2-year survival would reach 80%. Conversely, the incomplete cytoreductions alone give a median survival of 6 months. While this dramatic effect of incomplete cytoreduction agrees with some earlier data, more recent data has not seen this effect, Dr. Müller said.
He cautioned, however, that while he believes that there is a clear trend to prolonged survival after complete cytoreduction, the role of hyperthermal peritoneal perfusion remains unclear, even in cases of complete cytoreduction.
[Study title: Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemoperfusion in the Treatment of Recurrent Ovarian Carcinoma. Abstract A163] |