Dense Hyperthermic Intraperitoneal Chemotherapy with Cisplatin In

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Dense Hyperthermic Intraperitoneal Chemotherapy with Cisplatin In He et al. BMC Cancer (2021) 21:738 https://doi.org/10.1186/s12885-021-08507-y RESEARCH ARTICLE Open Access Dense hyperthermic intraperitoneal chemotherapy with cisplatin in patients with stage III serous epithelial ovarian cancer: a retrospective study Xiaoli He1†, Li Wei1†, Rui Li1, Shuang Jing1, Linlin Jia1, Danwei Ji2, Yali Li1, Yue Wang1* and Yongxia Zhu1* Abstract Background: To investigate the efficacy and safety of interval debulking surgery (IDS) combined with dense hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin in Chinese patients with FIGO stage III serous epithelial ovarian cancer (EOC). Methods: This retrospective single-center study reviewed the demographic and clinical data of 197 patients with primary FIGO stage III serous EOC who were treated with IDS with (n = 121) or without (n = 76, control group) dense HIPEC between January 2012 and April 2017. The co-primary endpoints were progression-free survival (PFS) and overall survival (OS), and the secondary endpoint was the occurrence of adverse events. Results: The median PFS was 24 months in the IDS plus dense HIPEC group, whereas it was 19 months in the IDS alone group (hazard ratio [HR] 0.46, 95% confidence interval [CI]: 0.33–0.65, p = 0.000). The median OS in patients treated with IDS plus dense HIPEC (51 months) was significantly longer than that in patients treated with IDS alone (40 months, HR 0.52, 95% CI: 0.35–0.78, p = 0.001). The demographic and preoperative clinical characteristics of these two groups were comparable (p > 0.05). In the IDS alone group, no adverse events were recorded in 42 (55.3%) of the 76 patients, and 14 (18.4%) patients were reported to have grade III/IV adverse events. In the IDS plus dense HIPEC group, no adverse events were recorded in 55 (45.5%) of the 121 patients, and 23 (19.0%) patients were reported to have grade III/IV adverse events. No postoperative deaths occurred within 30 days in either group and neither did severe fatal complications in the IDS plus dense HIPEC group. Conclusions: IDS plus dense HIPEC with cisplatin in Chinese patients with FIGO stage III serous EOC is associated with improved survival and is reasonably well tolerated by patients. Keywords: Dense hyperthermic intraperitoneal chemotherapy, Serous epithelial ovarian cancer, Survival, Interval debulking surgery * Correspondence: [email protected]; [email protected] †Xiaoli He and Li Wei contributed equally to this work. 1Department of Gynecology, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, People’s Hospital of Henan University, No.7, Weiwu Road, Jinshui District, Zhengzhou 450003, China Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. He et al. BMC Cancer (2021) 21:738 Page 2 of 9 Background in China, and written informed consent was obtained Epithelial ovarian cancer (EOC) has the highest mortal- from each patient prior to all treatment procedures. All ity rate among all gynecological tumors worldwide, caus- patients in this study were diagnosed with FIGO stage ing nearly 22,500 deaths in China in 2015 and 14,335 III high-grade serous ovarian cancer, which based on deaths in the United States in 2018 [1, 2]. The most ef- surgical findings and histopathological results, between fective treatment for advanced EOC remains primary January 1, 2012 and April 31, 2017 at the Department of cytoreductive surgery (CRS) followed by intravenous Gynecology, Henan Provincial People’s Hospital. Staging chemotherapy with carboplatin and paclitaxel [3, 4]. In was done based on the 1988 International FIGO staging patients where complete primary cytoreduction is im- system between January 1, 2012 and December 31, 2012, possible, interval debulking surgery (IDS) can be per- the 2013 International FIGO staging system between formed after 2–4 cycles of neoadjuvant chemotherapy January 1, 2013 and December 31, 2013, and the 2014 (NACT) [5–7]. Peritoneum is the primary site of metas- International FIGO staging system between January 1, tasis of tumor cells from the ovary in advanced EOC pa- 2014 and April 31, 2017 [24]. The medical records of all tients [8, 9]. Therefore, intraperitoneal chemotherapy is patients were reviewed, and all patients were followed used to improve outcomes and minimize tumor dissem- up until March 31, 2020. ination and implantation [10, 11]. All patients who demonstrated an Eastern Cooperative Hyperthermic intraperitoneal chemotherapy (HIPEC) Oncology Group (ECOG) score 0–1[25, 26] in our is delivered under hyperthermic conditions and used to study underwent 2–4 cycles of NACT with a combin- increase chemotherapy penetration into peritoneal tu- ation of carboplatin (area under the curve of 5–6 mg per mors, including advanced EOC [12]. Randomized trials, milliliter per minute, AUC 5–6) and paclitaxel (175 mg meta-analyses, and retrospective studies have all shown per square meter of body-surface area, 175 mg/m2). that HIPEC is feasible and associated with prolonged After NACT, IDS was performed using peritonectomy. ovarian cancer survival rates [13–15]. Some studies have Complete cytoreductive surgery was defined as surgery demonstrated that despite the promise of HIPEC, HIPE that resulted in no visible disease (residual disease classi- C did not improve patient survival data compared with fication, R0), optimal cytoreductive surgery as surgery therapy without HIPEC [3, 14, 16]. Interestingly, in a that resulted in the presence of one or more residual tu- meta-analysis of patients with primary EOC, Huo et al. mors measuring ≤1 cm in diameter (R1), and incomplete showed that HIPEC combined with CRS was associated cytoreductive surgery as surgery that resulted in the with a significantly improved 2-, 3-, 4-, 5-, and 8-year presence of one or more residual lesions measuring > 1 OS compared with CRS alone [17]. cm in diameter (R2) [27]. In this study, regardless of In those studies, different drug and dose ranges of whether satisfactory tumor cell reduction is achieved HIPEC were used, which resulted in dissimilar survival after IDS (single or more residual lesions ≤1 cm), HIPEC times. In some studies, HIPEC was administered only was performed with the consent of patients and family after optimal cytoreductive surgery using cisplatin or a members. According to the patient’s request and a combination of doxorubicin, paclitaxel, or mitomycin C multidisciplinary discussion among general surgeons, gy- [8, 18–20]. In other studies, patients received HIPEC necologists, and physicians, patients were divided into with different doses of cisplatin [14, 21–23]. Numerous two groups: an IDS plus dense HIPEC group and an IDS investigations conducted to assess dose dense chemo- alone control group. therapy have shown clinical benefits. For instance, Ba M, et al. showed that HIPEC procedures with three sessions Inclusion and exclusion criteria were performed on the first, third, and fifth days after The inclusion criteria were as follows. (1) Patients aged CRS was comparable to other HIPEC procedures [22]. ≥18 years. (2) Patients that underwent pretreatment and Therefore, we referenced the procedure that have three preoperative evaluation with computed tomography sessions and defined them as Dense HIPEC with (CT) or magnetic resonance imaging (MRI), pelvic ultra- cisplatin. sound, and had tumor markers (including cancer antigen In this single-center study, we sought to retrospect- 125 [CA125] and human epididymis protein 4 [HE4]) as ively analyze the role of IDS combined with dense HIPE well as routine blood tests. (3) A pathologic diagnosis C with cisplatin in patients with primary FIGO stage III confirmed by ascites cytology or biopsy pathology. (4) serous EOC after NACT compared with IDS alone. Patients diagnosed with FIGO stage III serous EOC (high-grade serous ovarian cancer). (5) Patients with Methods normal blood counts, and adequate renal function. (6) Patients Patients with an ECOG performance status of 0–1. This retrospective study was approved by the Human The exclusion criteria were as follows. (1) Recurrent Ethics Committee of Henan Provincial People’s Hospital peritoneal ovarian cancer patients. (2) Patients with He et al. BMC Cancer (2021) 21:738 Page 3 of 9 previous primary cytoreductive surgery. (3) Patients with Study variables the presence of extra-abdominal metastasis. (4) Patients The following information was reviewed and collected. that treated with bevacizumab or poly ADP-ribose poly- Patient demographics, medical history, tumor markers, merase inhibitors. (5) Patients that with poor general pathologic characteristics, chemotherapy regime includ- health, renal insufficiency, heart failure, or the existence ing the dose, surgical procedures, tumor debulking sta- of a lesion in the central nervous system. tus according to the visible residual disease classification [28], the pre- and post-HIPEC lab values (absolute neu- trophil count, platelets, hematocrit, and hemoglobin), IDS plus dense HIPEC group and HIPEC techniques and drugs, patient adverse events, After the IDS procedure, dense HIPEC was administered length of hospital stay, and the cost of hospital data.
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