Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy for the treatment of primary peritoneal serous carcinoma: Results of a Chinese retrospective study

Figures & data

Figure 1. Flow chart of the study procedure. Patients with primary peritoneal serous carcinoma (PPSC) were included in this study and were divided into group A and group B. Patients in group A were treated with CRS + HIPEC at first hospitalization or after 2 cycles of neoadjuvant chemotherapy. Patients in group B were first treated with conventional surgery and post-operative adjuvant chemotherapy. CRS + HIPEC was performed at the time of first recurrence.

Table 1. Major clinico-pathologic characteristics of the 22 PPSC patients^a.

Items	Value n (%)
Age in years
Median age (range)	61 (43–70)
<60	10 (45.5)
≥60	12 (54.5)
Median KPS score (range)	70 (60–90)
CRS + HIPEC timing
Upfront	6 (27.3)
Interval	6 (27.3)
Salvage	10 (45.4)
Histopathology differentiation
Well/moderately differentiated	12 (54.5)
Poorly differentiated	10 (45.5)
SAE
Yes	2 (9.1)
No	20 (90.9)
Post-operative chemotherapy cycles
Median post-operative chemotherapy cycles (range)	7 (0–26)
<6	7 (31.8)
≥6	15 (68.2)
Post-operative intraperitoneal chemotherapy cycles	4 (0–7)
Median hospital stay in days (range)	18 (12–39)
Median post-operative hospital stay in days (range)	11 (7–30)
Median ICU stay in h (range)	17 (0–51)
Median gastric tube removal time in days (range)	5 (3–10)
Median follow-up in months (range)	45.9 (13.5–106.3)
CA125 level (median, range) in U/mL
Preoperative	387.9 (7.8–4881.0)
Post-operative	213.8 (12.6–1970.1)
PCI
Median PCI (range)	14 (7–27)
≤15	12 (54.5)
>15	10 (45.5)
CC scores
0–1	15 (68.2)
2–3	7 (31.8)
Number of organs resected
0–1 resection	15 (68.2)
2–4 resections	7 (31.8)
Peritoneal regions resected
1–3 regions	7 (31.8)
4–6 regions	8 (36.4)
7–9 regions	7 (31.8)
Median fluid output volume at surgery in mL (range)
Blood loss	650 (150–1200)
Urine output	1000 (450–3350)
Ascites	1250 (0–4000)
≤1000	10 (45.5)
>1000	12 (54.5)
Median fluid intake volume at surgery (range)
Plasma in mL	500 (0–1550)
RBC (U)^b	3 (0–7)
Cryoprecipitation (U)^c	4 (0–8)
Other fluids (ml)	4000 (2000–7500)
CRS + HIPEC duration (median, range) in h	7.8 (4.5–11.7)
HIPEC duration in min	60–90

^aFor the first CRS + HIPEC of the 22 patients; ^b1U = 200 ml; ^c1U = 25 ml.

KPS, Karnofsky performance status; CRS, cytoreductive surgery; HIPEC, hyperthermic intraperitoneal chemotherapy; SAE, serious adverse events; PCI, peritoneal cancer index; CC, completeness of cytoreduction.

Figure 2. The Kaplan–Meier overall survival curve of the patients in this study (A). The Kaplan–Meier overall survival curve by treatment time from first treatment (B), by PCI (C) and by CC (D) for primary advanced and recurrent PPSC patients. mo, months.

Table 2. Major clinico-pathological parameters, treatment course and outcome information of the 22 PPSC^a.

No.	Age (years)	P/R	Histopathology	CRS^b	HIPEC	PCI	CC	Survival (months)	Comments
1	64	R	Serous adenocarcinoma, poorly differentiated	Resection of right diaphragmatic copula peritoneum, left/right paracolic sulci peritoneum, pelvic peritoneum, ileectomy, resection of ileocecum	Lobaplatin 100 mg, PTX 120 mg, 43 °C, 60 min	12	1	47.0, SWT
2	61	P	Serous papillary adenocarcinoma, poorly differentiated	Resection of right diaphragmatic copula peritoneum, right paracolic sulci peritoneum, pelvic peritoneum, appendectomy, rectectomy and TAH + BSO	Lobaplatin 100 mg, PTX 120 mg, 43 °C, 60 min	7	0	13.8, D
3	66	R	Serous papillary adenocarcinoma, moderately differentiated	Resection of right diaphragmatic copula peritoneum, left/right paracolic sulci peritoneum, pelvic peritoneum	Lobaplatin 100 mg, PTX 120 mg, 43 °C, 60 min	25	2	20.3, D
4	56	R	Serous cystadenocarcinoma, well differentiated	Resection of left/right paracolic sulci peritoneum, pelvic peritoneum	DDP 120 mg, MMC 30 mg, 43 °C, 60 min	25	2	13.5, D
5	62	P	Serous papillary adenocarcinoma moderately differentiated	Resection of right diaphragmatic copula peritoneum, left/right paracolic sulci peritoneum, pelvic peritoneum	DDP 120 mg, MMC 30 mg, 43 °C, 90 min	8	1	76.5, SWT
6	62	P	Serous papillary adenocarcinoma, poorly differentiated	Resection of pelvic peritoneum, bilateral fossa iliac peritoneum and BSO	DDP 120 mg, MMC 30 mg, 43 °C, 90 min	9	2	74.0, D
7	52	P	Serous papillary adenocarcinoma, well differentiated	Resection of right/left diaphragmatic copula peritoneum, right/left paracolic sulci peritoneum, pelvic peritoneum, anterior wall peritoneum and BSO	DDP 120 mg, TXT 120 mg, 43 °C, 60 min	26	1	24.3, D
8	70	R	Serous papillary adenocarcinoma, poorly differentiated	Resection of right diaphragmatic copula peritoneum, left/right paracolic sulci, pelvic peritoneum and bilateral fossa iliac peritoneum, splenectomy	Lobaplatin 100 mg, PTX 120 mg, 43 °C, 60 min	13	1	51.5, SWOT
9	68	P	Serous cystadenocarcinoma, well differentiated	Resection of right diaphragmatic copula peritoneum, pelvic peritoneum, bilateral fossa iliac peritoneum, cholecystotomy and TAH + BSO	DDP 120 mg, MMC 30 mg, 43 °C, 90 min	11	0	41.6, D	SAE 1
10	46	P	Serous papillary adenocarcinoma, poorly differentiated	Resection of right diaphragmatic copula peritoneum, pelvic peritoneum and BSO	DDP 120 mg, TXT 120 mg, 43 °C, 60 min	17	1	31.0, D
11	66	P	Serous adenocarcinoma, poorly differentiated	Resection of right diaphragmatic copula peritoneum, pelvic peritoneum, left hemicolectomy and BSO	DDP 120 mg, TXT 120 mg, 43 °C, 60 min	14	1	31.0, D
12	70	P	Serous papillary adenocarcinoma, well differentiated	Resection of right/left diaphragmatic copula peritoneum, right/left paracolic sulci peritoneum, pelvic peritoneum and BSO	DDP 120 mg, TXT 120 mg, 43 °C, 60 min	16	1	15.0, D
13	50	R	Serous papillary adenocarcinoma, poorly differentiated	Resection of right diaphragmatic copula peritoneum, left/right paracolic sulci peritoneum, pelvic peritoneum, anterior wall peritoneum, ileectomy	DDP 120 mg, TXT 120 mg, 43 °C, 90 min	11	1	65.3, D	Twice CRS + HIPEC
14	43	R	Serous adenocarcinoma, well differentiated	Resection of pelvic peritoneum, left/right paracolic sulci peritoneum, anterior wall peritoneum	DDP 120 mg, TXT 120 mg, 43 °C, 60 min	18	1	18.5, D
15	58	P	Serous adenocarcinoma, moderately differentiated	Resection of right/left diaphragmatic copula peritoneum, left/right paracolic sulci peritoneum, pelvic peritoneum and BSO	DDP 120 mg, MMC 30 mg, 43 °C, 60 min	20	3	23.5, D	SAE 2
16	55	R	Serous papillary adenocarcinoma, moderately differentiated	Resection of left/right paracolic sulci peritoneum, pelvic peritoneum	DDP 120 mg, TXT 120 mg, 43 °C, 60 min	22	3	28.5, D
17	61	P	Serous adenocarcinoma, well differentiated	Resection of pelvic peritoneum, bilateral fossa iliac peritoneum	DDP 120 mg, TXT 120 mg, 43 °C, 60 min	27	2	16.1, D
18	69	R	Serous adenocarcinoma, poorly differentiated	Transverse colectomy	DDP 120 mg, MMC 30 mg, 43 °C, 60 min	13	1	38.5, D	Twice CRS + HIPEC
19	43	R	Serous papillary adenocarcinoma, moderately differentiated	Resection of right diaphragmatic copula peritoneum, right paracolic sulci peritoneum	DDP 120 mg, TXT 120 mg, 43 °C, 60 min	12	1	13.5, SWT
20	44	R	Serous adenocarcinoma, poorly differentiated	Resection of right paracolic sulci peritoneum, pelvic peritoneum	DDP 120 mg, TXT 120 mg, 43 °C, 90 min	14	1	39.7, D
21	50	P	Serous adenocarcinoma, moderately differentiated	Resection of right diaphragmatic copula peritoneum, left/right paracolic sulci peritoneum, pelvic peritoneum, right hemicolectomy, rectectomy and TAH + BSO	Lobaplatin 100 mg, PTX 120 mg, 43 °C, 60 min	18	2	34.3, D
22	61	P	Serous papillary adenocarcinoma, poorly differentiated	Resection of right diaphragmatic copula peritoneum, left/right paracolic sulci peritoneum, pelvic peritoneum, right hemicolectomy, cholecystotomy and TAH + BSO	Lobaplatin 100 mg, PTX 120 mg, 43 °C, 60 min	10	1	40.4, D	Twice CRS + HIPEC

^aFor the first CRS + HIPEC of 22 patients; ^bAll 22 patients underwent liver round ligament resection, greater and lesser omentectomy and mesenteric fulguration during CRS.

PPSC, primary peritoneal serous carcinoma; PCI, peritoneal cancer index; CRS, cytoreductive surgery; HIPEC, hyperthermic intraperitoneal chemotherapy; CC, completeness of cytoreduction; R, recurrent; P, primary; TAH, total abdominal hysterectomy; BSO, bilateral salpingo-oophorectomy; SAE, serious adverse events; SWT, survival with tumour; SWOT, survival without tumour; D, dead; DDP, cisplatin; MMC, mitomycin C; TXT, docetaxel; PTX, paclitaxel; SAE 1, pneumonia and septicaemia; SAE 2, anastomotic haemorrhage.

Table 3. The overall survival information from different studies for primary peritoneal serious carcinoma.

										Survival rate (%)
References	Country	N	Median age	Study design	Treatment	Optimal surgery (%)	Median preoperative CA125 (U/mL)	Median OS (months)	Median PFS (months)	1 year	2 years	5 years
Gershenson et al. [11]	USA	350	46.5	Retrospective	CRS + IV CT + HT	NR	146.3	101.7	28.1	NR	NR	NR
Unal et al. [3]	Turkey	79	63.0	Retrospective	CRS + IV/IP CT	49.5^a	954.0	31.1	16.3	93.5	85.7	48.1
Ifthikar et al. [32]	India	10	56.0	Retrospective	CRS + IV CT	75.0^a	Mean 566.0	NR	22.0	NR	NR	18.0 (PFS)
Kawaguchi et al. [29]	Japan	22	67.0	Retrospective	NACT + CRS + IV CT	54.5^a	638.0	26.5	12.7	NR	NR	NR
Liu et al. [27]	China	22	56.0	Retrospective	NACT + CRS + IV CT	81.8^a	90% elevated	21.0	NR	NR	NR	34.4
Zhang et al. [30]	China	24	59.0	Retrospective	CRS + IV CT	12.5^b	95.8% elevated	42.0	NR	NR	63.0	NR
Bloss et al. [4]	USA	36	65.8	Prospective	CRS + IV CT	NR	NR	22.0	11.0	NR	NR	NR
Ben-Baruch et al. [33]	Israel	22	61.0	Retrospective	CRS + IV CT	28.0^b	NR	21.0	DFS 15.0	NR	NR	18.0
Piver et al. [35]	USA	46	62.0	Prospective	CRS + PAC IV CT 25; CRS + TP IV CT 21	PAC 60.0 TP 81.0^a	PAC 1350.0 TP 1280.0	23.1 TP 21.5 PAC 24.0	TP 17.3; PAC 24.0	NR	NR	NR
Halperin et al. [28]	Israel	28	59.8	Retrospective	CRS + IV CT	39.3^a	Mean 5284.0	17.0	NR	NR	NR	NR
Dubernard et al. [9]	France	37	60.0	Retrospective	NACT + CRS + IV CT	89.2^b	833.0	Not reached	3-year DFS 29%	NR	NR	NR
Eltabbakh et al. [34]	USA	75	65.0	Retrospective	CRS + IV CT	65.3^a	1320.0	23.5	NR	NR	NR	26.5
Bakrin et al. [31]	France	36	60.5	Retrospective	NACT + CRS + HIPEC	88.9^c	NR	Not reached	DFS: 16.7	93.6	NR	57.4
This study	China	22	61.0	Retrospective	NACT + CRS + HIPEC + IV/IP CT	68.2^c	387.9	31.0	NR	100	NR	31.8

Optimal surgery: ^aresidual tumour ≤ 1 cm; ^bresidual tumour ≤ 2 cm; ^cresidual tumour ≤ 0.25 cm.

OS, overall survival; PFS, progression-free survival; CRS, cytoreductive surgery; IV, intravenous; IP, intraperitoneal; CT, chemotherapy; HT, hormonal therapy; NACT, neoadjuvant chemotherapy; PAC, cisplatin, doxorubicin, and cyclophosphamide; TP, paclitaxel and cisplatin; NR, not reported.

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