Comparison of Outcomes Following Complete and Selective Parietal Peritonectomy During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Advanced Epithelial Ovarian Cancer: A Study by Indian Society of Peritoneal Surface Malignancies (ISPSM)
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Peritonectomy is an important component in surgical treatment for peritoneal surface malignancies. Visual inspection and palpation to estimate the extent of tumor involvement are unreliable. Most gynecologic oncologists are skeptical regarding the benefits of complete peritonectomy and do not perform them, worrying about the benefit and associated morbidity. They believe it is the inherent tumor biology that determines the resectability of the tumor, not surgical aggressiveness. The aim of this study was to assess the recurrence pattern, oncological outcomes, morbidity and mortality based on the extent of parietal peritonectomy performed during CRS and HIPEC in stage IIIc epithelial ovarian cancers.
Patients diagnosed with stage IIIc epithelial carcinoma ovary underwent selective parietal peritonectomy (SPP) or complete parietal peritonectomy (CPP) with CRS–HIPEC. All pre- and intraoperative data were compared and analyzed with main focus on postoperative morbidity, mortality, recurrence pattern and oncological outcomes.
From February 2013 to December 2017, 110 patients with stage IIIc epithelial ovarian cancers underwent CRS–HIPEC of which 20 were upfront primary, 55 had interval surgery and 35 were recurrent cases. Forty and 70 patients underwent CPP and SPP, respectively. The median peritoneal cancer index was 14 for CPP and 10 for SPP. CPP group had longer duration of surgery (10.7 vs. 8.9 h) and more blood loss (1062 vs. 653 ml) when compared to SPP group. The morbidity was more common in SPP group 26 (37%) than CPP group 20 (50%), and it was not statistically significant (p = 0.133). There was equal number of operative mortality in both groups: CPP versus SPP—3 (7.5%) versus 3 (4.2%), p = 0.406. With a median follow-up of 45 months, progression-free survival (PFS) was significantly higher in CPP group (33 months vs. 25 months, p < 0.05) and median overall survival (OS) was 48 months in SPP group (yet to be achieved in CPP group). The 3-year PFS was 42% versus 38%. The 3-year OS was 80% for CPP and 75% for SPP. In 30% (12 of 40 patients) undergoing CPP, pathologic examination detected microscopic disease involvement in parietal peritoneum with no visually evident tumor at surgery by the surgeon.
Patients who underwent complete peritonectomy had significantly higher PFS. This indicates aggressive surgical resection has a benefit with manageable postoperative morbidity. However, longer follow-up and a prospective randomized study need to be designed for more evidence of the same.
KeywordsPeritonectomy Cytoreductive surgery Hyperthermic intraperitoneal chemotherapy Ovarian cancer Peritoneal surface malignancies
The authors thank Dr. Arun Kumar, Consultant Biostatistician, for statistical analysis and sample size calculation.
Compliance with Ethical Standards
conflict of interest
The authors declare that they have no competing interests.
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