Outcomes and prognostic factors of cytoreductive surgery and perioperative intraperitoneal chemotherapy in high-volume peritoneal carcinomatosis

Figures & data

Figure 1. Flowchart showing total number of patients included in the study after exclusion of those with incomplete cytoreduction and without HIPEC.

Table 1. Study population characteristics and perioperative numbers.

Patient characteristics	Low PCI (<30) (n = 320)	High PCI (≥30) (n = 175)	p Value
Gender
Female	182 (56.9%)	78 (44.6%)	0.009
Male	138 (43.1%)	97 (55.4%)
Mean age (SD)	51.63 (12.62)	56.07 (12.72)	<0.001
Diagnoses
LAMN	143 (44.7%)	60 (34.3%)	0.034
HAMN	130 (40.6%)	92 (52.5%)
Mesothelioma	47 (14.7%)	23 (13.1%)
Mean PCI score (SD)	16.15 (8.17)	35.07 (3.20)	<0.001
cc-score
0	241 (75.3%)	49 (28%)	<0.001
1	79 (24.7%)	126 (72%)
EPIC
Yes	163 (50.9%)	85 (48.6%)	0.615
No	157 (49.1%)	90 (51.4%)
Preoperative CEA
Normal	212 (70.2%)	46 (27.2%)	<0.001
Elevated	90 (29.8%)	123 (72.8%)
Preoperative CA125
Normal	209 (70.4%)	40 (24.1%)	<0.001
Elevated	88 (29.6%)	126 (75.9%)
Preoperative CA19.9
Normal	233 (79.8%)	80 (47.9%)	<0.001
Elevated	59 (20.2)	87 (52.1%)
Three elevated tumor markers (CEA, CA19.9, CA125)
Yes	25 (8.4%)	71 (42.5%)	<0.001
No	271 (91.6%)	96 (57.5%)

SD: standard deviation; LAMN: low-grade appendiceal mucinous neoplasm; HAMN: high-grade appendiceal mucinous neoplasm; CC: completeness of cytoreduction; PCI: peritoneal carcinomatosis index; EPIC: early postoperative intraperitoneal chemotherapy.

Table 2. Comparisons of clinicopathological factors in low and high PCI groups.

Clinicopathological factors	Low PCI (<30) (n = 320)	High PCI (≥30) (n = 175)	p Value
Blood transfusion
≤8 units	289 (90.3%)	90 (51.4%)	<0.001
>8 units	31 (9.7%)	85 (48.6%)
FFP transfusion
≤10 units	279 (87.2%)	87 (49.7%)	<0.001
>10 units	41 (12.8%)	88 (50.3%)
Morbidity
Grade 1–2	203 (63.4%)	56 (32%)	<0.001
Grade 3–4	117 (36.6%)	119 (68%)
Mean length of stay (SD)	24.0 (18.576)	37.16 (23.992)	<0.001
Mean length of ICU stay (SD)	3.67 (7.239)	7.13 (12.119)	<0.001
Mean length of HDU stay (SD)	3.75 (3.661)	4.94 (5.132)	0.003
Mean operating hours	8.25 (2.43)	11.09 (2.31)	<0.001
Readmission rate
Yes	101 (31.8%)	59 (34%)	0.638
No	219 (68.2%)	116 (66%)
Blood transfusion
≤8 units	289 (90.3%)	90 (51.4%)	<0.001
>8 units	31 (9.7%)	85 (48.6%)
FFP transfusion
≤10 units	279 (87.2%)	87 (49.7%)	<0.001
>10 units	41 (12.8%)	88 (50.3%)
Morbidity
Grade 1–2	203 (63.4%)	56 (32%)	<0.001
Grade 3–4	117 (36.6%)	119 (68%)
Mean length of stay (SD)	24.0 (18.576)	37.16 (23.992)	<0.001
Mean length of ICU stay (SD)	3.67 (7.239)	7.13 (12.119)	<0.001
Mean length of HDU stay (SD)	3.75 (3.661)	4.94 (5.132)	0.003
Mean operating hours	8.25 (2.43)	11.09 (2.31)	<0.001
Readmission rate
Yes	101 (31.8%)	59 (34%)	0.638
No	219 (68.2%)	116 (66%)

SD: standard deviation; ICU: intensive care unit; HDU: high dependency unit.

Figure 2. Kaplan-Meier Graphs for overall and disease-free survivals of (A,B) LAMN and (C,D) HAMN comparing PCI < 30 and PCI ≥ 30.

Table 3. Overall and disease-free survivals in low and high PCI groups stratified by diagnoses.

Diagnoses	Overall survival									Disease-free survival
	Low PCI (<30)				High PCI (≥30)					Low PCI (<30)				High PCI (≥30)
	Median survival months (95% CI)	Survivals (%)			Median survival months (95% CI)	Survivals (%)			p-Value	Median survival months (95% CI)	Survivals (%)			Median survival months (95% CI)	Survivals (%)			p-Value
		3-year	5-year	10-year		3-year	5-year	10-year			3-year	5-year	10-year		3-year	5-year	10-year
LAMN	NR	99.2	96.2	81.8	83 (56–110)	80.1	63.5	–	<0.001	143 (74–212)	77.8	70.3	56.7	41 (29–53)	54.7	37.1	–	<0.001
HAMN	63 (32–94)	69.1	52.9	36.8	69 (38–100)	68.5	53.4	–	0.942	32 (20–44)	45.1	39.8	–	19 (16–22)	17.4	6.5	–	<0.001
Mesothel-ioma	72 (37–108)	62.6	59.7	35.6	42 (24–60)	55.1	23.6	–	0.058	29 (8–50)	42.4	29.8	–	14 (10 − 18)	17.7	11.8	–	0.088

NR: not reached; CI: confidence interval; LAMN: low-grade appendiceal mucinous neoplasm; HAMN: high-grade appendiceal mucinous neoplasm; CC: completeness of cytoreduction; PCI: peritoneal carcinomatosis index.

Figure 3. Kaplan-Meier Graphs for (A) overall and (B) disease-free survivals of mesothelioma comparing PCI < 30 and PCI ≥ 30.

Table 4. Prognostic factors influencing OS and DFS in high PCI group.

Variables	Overall survival				Disease-free survival
	Univariate analysis		Multivariate analysis		Univariate analysis		Multivariate analysis
	HR (95% CI)	p-Value	HR (95% CI)	p-Value	HR (95% CI)	p-Value	HR (95% CI)	p-Value
Gender
Female	Ref	0.017	Ref	0.204	Ref	0.014	Ref	0.094
Male	1.88 (1.12–3.14)		1.43 (0.82–2.49)		1.89 (1.14–3.14)		1.59 (0.93–2.73)
Age	1.01 (0.99–1.04)	0.203	–	–	1.00 (0.98–1.03)	0.679	–	–
Diagnoses
LAMN	Ref		Ref		Ref	–	Ref	–
HAMN	1.27 (0.73–2.22)	0.404	1.26 (0.69–2.31)	0.448	1.32 (0.75–2.32)	0.333	1.44 (0.74–2.81)	0.284
Mesothelioma	2.44 (1.24–4.78)	0.01	1.02 (0.36–2.89)	0.972	2.62 (1.34–5.14)	0.005	1.73 (0.72–4.14)	0.224
PCI	1.02 (0.94–1.10)	0.675	–	–	1.01 (0.94–1.09)	0.847	–	–
CC-score
0	Ref	0.006	Ref	0.250	Ref	0.032	Ref	0.575
1	2.53 (1.31–4.87)		1.51 (0.75–3.05)		1.99 (1.06–3.72)		1.23 (0.60–2.52)
EPIC
No	Ref	<0.001	Ref	0.004	Ref	0.001	Ref	0.021
Yes	0.31 (0.18–0.53)		0.39 (0.21–0.73)		0.40 (0.24–0.67)		0.48 (0.26–0.89)
Preoperative CEA
Normal	Ref	0.05	Ref	0.708	Ref	0.237	Ref	–
Elevated	0.59 (0.35–1.00)		0.86 (0.38–1.93)		0.73 (0.43–1.23)		–	–
Preoperative CA125
Normal	Ref	–	–	–	Ref	0.049	Ref	0.021
Elevated	1.44 (0.73–2.85)	0.297	–	–	1.98 (1.00–3.92)		2.35 (1.14–4.85)
Preoperative CA19.9
Normal	Ref	0.889	–	–	Ref	0.494	–	–
Elevated	1.04 (0.63–1.71)		–	–	1.19 (0.72–1.97)		–	–
Elevated CEA, CA19.9, CA125								–
No	Ref	0.713	–	–	Ref	0.237	–	–
Yes	1.10 (0.67–1.81)		–	–	1.36 (0.82–2.28)		–
Blood transfusion
≤8 units	Ref	0.028	Ref	0.038	Ref	0.001	Ref	0.042
>8 units	1.75 (1.06–2.87)		1.77 (1.03–3.03)		2.29 (1.38–3.78)		2.11 (1.03–4.31)
FFP transfusion
≤10 units	Ref	0.226	–	–	Ref	0.013	Ref	0.578
>10 units	1.37 (0.82–2.27)		–	–	1.89 (1.14–3.11)		1.23 (0.59–2.55)
Morbidity
Grade 0–2	Ref	0.177	–	–	Ref	0.053	Ref	0.336
Grade 3–4	1.47 (0.84–2.55)		–	–	1.74 (0.99–3.04)		1.37 (0.72–2.61)

Ref: reference; CI: confidence interval; LAMN: low-grade appendiceal mucinous neoplasm; HAMN: high-grade appendiceal mucinous neoplasm; CC: completeness of cytoreduction; PCI: peritoneal carcinomatosis index; FFP: fresh frozen plasma; EPIC: early postoperative intraperitoneal chemotherapy.