Preoperative Performance Status Predicts Outcome Following Heated Intraperitoneal Chemotherapy

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Preoperative Performance Status Predicts Outcome
Following Heated Intraperitoneal Chemotherapy

• Jay M. MacGregor, MD

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Peritoneal Carcinomatosis

• Tumor growing on the peritoneal surface
• Commonly arises from pseudomyxoma peritoneii,
  colonic and appendiceal adenocarcinoma
• Traditionally managed with palliative systemic IV
  chemotherapy
• Rapidly fatal despite systemic IV chemotherapy
• Cytoreductive surgery alone typically results in
  rapid recurrence of tumor

Sadeghi, et al. Cancer 2000 88(2)358-363.
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Peritoneal Carcinomatosis IndexDegree of Tumor
Burden

• Scored at the time of exploration ranges from 0-39

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Heated Intraperitoneal Chemotherapy
HIPEC HIC
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HIC
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HIPEC Perfusion Method

• Circuit temp to 42º C
• Chemotherapy agent
• Abdomen agitated for 90 minutes
• Chemotherapy is rinsed out

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HIPEC Overall Survival

• 5 year survival is seen with HIPEC
• 60-99 for pseudomyxoma peritoneii
• 40-60 for appendiceal adenocarcinoma
• 20-30 for nonappendiceal colorectal carcinoma

Smenk et al. Eu J Surg Oncol. 2006 Deraco et al.
Tumori. 2002 Levine, et al. J Am Coll Surg.
2007 Shen, et al. Ann Surg Oncol. 2004
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Hypothesis

• Patients at high risk of postoperative morbidity
  can be identified preoperatively
• Dedicated regional centers can perform HIPEC with
  acceptable morbidity and mortality rates

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Methods

• Retrospective review of all patients who
  presented for an initial Cytoreduction Surgery
  with HIPEC between January 2003 and July 2007 at
  two centers
• HIPEC done via closed technique

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Methods

• All clinicopathologic data along with
  perioperative complications were recorded
• Univariate and multivariate analyses were
  performed to determine predictors of
  peri-procedural complications
• Defined as 90 days from surgery
• Kaplan-Meier survival curves were generated

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Complication Grading
Martin, et al. Am J Surg. 2004
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Patient Characteristics

• 28 patients
• Male 61
• Age (mean) 55
• PCI score (median) 9

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Histology

• Colonic adenocarcinoma 29
• Pseudomyxoma peritoneii 25
• Appendiceal carcinoma 11
• Mucinous carcinoma 11
• Primary peritoneal ca 7
• Other 18

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Completeness of Cytoreduction
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Complications (90 day)

• 46 of patients experienced a complication
• 29 of patients experienced a major complication
• Intra abdominal abscess, fistula, temporary
  dialysis, pleural effusion

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Specific Complications
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Eastern Cooperative Oncology Group
0 fully awake, no restriction 1 able to
carry out light work 2 able to perform self
cares 3 limited self cares 4 bedridden,
disabled 5 dead
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Predictors of Complications
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Predictors of Major Complications
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Performance Status Extent Surgery
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Performance Status Outcomes
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Overall Survival
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Comparison to Published Series
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Summary of HIPEC Experience

• Predictors of Major Morbidity
• Performance status
• Extent of carcinomatosis
• Completeness of cytoreduction
• Number of anastomoses
• Number of organs resected

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Conclusion

• HIPEC can be done at moderate volume centers with
  acceptable morbidity and mortality rates
• Postoperative complications are predicted by
• Poor ECOG performance status
• Heavy tumor burden
• Careful patient selection is prudent

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Thank You

• Robert Sticca, MD
• Nathan Reuter, MD