Department of Peritoneal Cancer Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, PR China.
Department of Peritoneal Cancer Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, PR China.
Eur J Surg Oncol. 2021 Jun;47(6):1411-1419. doi: 10.1016/j.ejso.2020.11.139. Epub 2020 Dec 1.
The role of cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) in gastric cancer with peritoneal metastasis (GCPM) is still controversial, mainly due to the limited survival benefit and uncertain patient selection. This study aims to construct a selecting strategy in GCPM for CRS + HIPEC.
From a prospective established database, 125 patients were enrolled. All these patients were pathologically confirmed as GCPM and treated with CRS + HIPEC with or without preoperative or postoperative chemotherapy. The clinical documents and follow-up results were collected and analyzed with the primary endpoint of overall survival (OS) and the secondary endpoint of perioperative serious adverse events (SAEs).
The median OS of 125 GCPM patients treated with CRS + HIPEC was 10.7 months, with 1-, 2-, 3-, and 5-year survival rates of 43.8%, 24.7%, 18.6%, and 15.7%, respectively. The multivariate analysis identified completeness of cytoreduction (CC), SAEs, HIPEC drugs, and adjuvant chemotherapy as independent prognostic factors on OS. The median OS was 30.0 (95%CI: 16.8-43.3) months in CC-0 group, significantly better than 7.3 (95%CI: 5.8-8.8) months in CC1-3 group (P < 0.001). The median OS showed no significant difference among CC-1 (8.5, 95%CI: 6.7-10.2, months), CC-2 (5.6, 95%CI: 3.0-8.2, months) and CC-3 (6.5, 95%CI: 5.2-7.7, months) groups (P > 0.05 for all pairwise comparations). The nomogram based on peritoneal metastasis timing, preoperative tumor marker (TM), and peritoneal cancer index (PCI), with AUC of 0.985, showed a good accuracy and consistency between actual observation and prediction of the probability of complete CRS. The cutoffs of PCI were 16 for synchronous GCPM with normal TM, 12 for synchronous GCPM with abnormal TM, 10 for metachronous GCPM with normal TM, and 5 for metachronous GCPM with abnormal TM, setting the probability to achieve complete CRS as 50%.
Only complete CRS + HIPEC (CC-0) could improve survival for high selected GCPM patients with acceptable safety. An incomplete CRS (CC1-3) should be avoided for GCPM patients. Synchronous GCPM with PCI ≤16 and normal TM, synchronous GCPM with PCI ≤12 and abnormal TM, metachronous GCPM with PCI ≤10 and normal TM, or metachronous GCPM with PCI ≤5 and abnormal TM maybe potential indications for complete CRS + HIPEC treatment.
细胞减灭术（CRS）加腹腔热灌注化疗（HIPEC）在胃癌伴腹膜转移（GCPM）中的作用仍存在争议，主要是因为生存获益有限且患者选择不确定。本研究旨在为 GCPM 患者的 CRS+HIPEC 制定选择策略。
从前瞻性建立的数据库中纳入 125 例经病理证实为 GCPM 且接受 CRS+HIPEC 治疗的患者，无论是否接受术前或术后化疗。收集并分析这些患者的临床资料和随访结果，主要终点为总生存期（OS），次要终点为围手术期严重不良事件（SAEs）。
125 例 GCPM 患者接受 CRS+HIPEC 治疗的中位 OS 为 10.7 个月，1、2、3 和 5 年生存率分别为 43.8%、24.7%、18.6%和 15.7%。多因素分析显示，肿瘤细胞减灭术完全程度（CC）、SAEs、HIPEC 药物和辅助化疗是 OS 的独立预后因素。CC-0 组的中位 OS 为 30.0（95%CI：16.8-43.3）个月，明显优于 CC1-3 组的 7.3（95%CI：5.8-8.8）个月（P<0.001）。CC-1（8.5，95%CI：6.7-10.2 个月）、CC-2（5.6，95%CI：3.0-8.2 个月）和 CC-3（6.5，95%CI：5.2-7.7 个月）组之间的中位 OS 无显著差异（所有两两比较 P>0.05）。基于腹膜转移时间、术前肿瘤标志物（TM）和腹膜癌症指数（PCI）的列线图，AUC 为 0.985，对完全 CRS 的概率具有良好的准确性和一致性。同步 GCPM 伴正常 TM 的 PCI 截断值为 16，同步 GCPM 伴异常 TM 的 PCI 截断值为 12，同步 GCPM 伴正常 TM 的异时性 GCPM 的 PCI 截断值为 10，同步 GCPM 伴异常 TM 的异时性 GCPM 的 PCI 截断值为 5，将实现完全 CRS 的概率设定为 50%。
只有完全的 CRS+HIPEC（CC-0）才能提高高选择 GCPM 患者的生存，而不完全的 CRS（CC1-3）应避免用于 GCPM 患者。同步 GCPM 伴 PCI≤16 和正常 TM、同步 GCPM 伴 PCI≤12 和异常 TM、异时性 GCPM 伴 PCI≤10 和正常 TM 或异时性 GCPM 伴 PCI≤5 和异常 TM 可能是完全 CRS+HIPEC 治疗的潜在适应证。
