Available online at www.sciencedirect.com
ScienceDirect EJSO xx (2013) 1e2
www.ejso.com
Correspondence
Reply letter to: Combined resection of colorectal liver metastases with peritoneal deposits discovered intraoperatively We thank Graziosi et al. for their constructive comments on our recent article.1 Regarding the comment concerning the predictors of unexpected peritoneal carcinomatosis (PC), studying others risk factors for unexpected PC would have been interesting, indeed. Unfortunately, these data were not available in all our patients because, in the vast majority of them, the primary tumor had been resected in another center. However, in a study of Elias,2 a systematic second-look surgery performed in patients who had either synchronous PC, ovarian metastases or perforated tumor at the time of the primary tumor resection revealed the presence of macroscopic PC in 56% of cases. The risk of PC was not different between these subgroups, suggesting that the risk related to each of these risk factors is similar. The risk in patients with occlusive tumor, pT4 tumor, or a positive peritoneal cytology is less obvious.3 Regarding the place of HIPEC, Graziosi et al. mention the long term outcome of cytoreductive surgery (CS) þ intraperitoneal chemotherapy and colorectal liver metastases (CLM) resection reported by the group of Elias.4 Overall survival was good in patients with 1 or 2 LM and a peritoneal cancer index (PCI) 12 (median survival: 27 months). Our study population is characterized by an advanced hepatic disease (57% with 3 CLM) but a very limited peritoneal disease (median PCI ¼ 2, range [1e6]). This particular subgroup has not been identified in the study of Elias group, probably because of a limited number of patients meeting these criteria and the usual contraindication represented by the presence of more than 3 metastases. Although this group had adverse prognosis factors, we were surprised to observe a median survival of 42 months after resection without HIPEC. Whether this group of patients with advanced liver disease and very limited PC may benefit of additional HIPEC
DOI of original article: http://dx.doi.org/10.1016/j.ejso.2013.08.033
has not really been explored in the literature. In most of these patients, HIPEC reference centers would not have considered HIPEC because of hepatic disease extent (if not because of age or general condition.). In these patients, the positive effect of complete resection alone, on survival is supported by the relatively good median survival observed in our study (compared to that of best chemotherapy alone). In the other patients presenting limited PC and limited CLM, potentially eligible for HIPEC, we would agree to postpone resection and to refer them for CS þ HIPEC. Regarding the question of morbidity related to simultaneous major hepatectomy and HIPEC, it is important to note that data are seriously lacking. In the study of Elias4 taken as reference by Graziosi et al., only 3 patients underwent simultaneous major liver resection and HIPEC over a 17 year-period. The 9 other patients who underwent major liver resection received early postoperative intraperitoneal chemotherapy (i.e. without hyperthermia). Therefore, it is not possible to conclude that “postoperative complications are not related to major liver surgery” with such a limited number of patients. We share with Graziosi et al., the opinion that CS and HIPEC is a major therapeutic advance in the treatment of colorectal PC. However, we think that more experience is needed to better refine the indications of simultaneous HIPEC and hepatectomy, and to assess its postoperative risk to benefit ratio. Conflict of interest statement No conflicts of interest to declare. References 1. Allard MA, Adam R, Ruiz A, et al. Is unexpected peritoneal carcinomatosis still a contraindication for resection of colorectal liver metastases? Combined resection of colorectal liver metastases with peritoneal deposits discovered intra-operatively. Eur J Surg Oncol 2013;39:981–7. 2. Elias D, Honore C, Dumont F, et al. Results of systematic second-look surgery plus HIPEC in asymptomatic patients presenting a high risk of developing colorectal peritoneal carcinomatosis. Ann Surg 2011;254: 289–93. 3. Honore C, Goere D, Souadka A, Dumont F, Elias D. Definition of patients presenting a high risk of developing peritoneal carcinomatosis
0748-7983/$ - see front matter Ó 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.ejso.2013.11.020 Please cite this article in press as: Allard MA, Reply letter to: Combined resection of colorectal liver metastases with peritoneal deposits discovered intraoperatively, Eur J Surg Oncol (2013), http://dx.doi.org/10.1016/j.ejso.2013.11.020
2
Correspondence / EJSO xx (2013) 1e2
after curative surgery for colorectal cancer: a systematic review. Ann Surg Oncol 2013;20:183–92. 4. Maggiori L, Goere D, Viana B, et al. Should patients with peritoneal carcinomatosis of colorectal origin with synchronous liver metastases be treated with a curative intent? A case-control study. Ann Surg 2013;258:116–21.
M.A. Allard Centre Hepato-biliaire, Paul Brousse Hospital, Assistance Publique-H^ opitaux de Paris, Univ Paris-Sud, Villejuif, France
R. Adam* Centre Hepato-biliaire, Paul Brousse Hospital, Assistance Publique-H^opitaux de Paris, Univ Paris-Sud, Villejuif, France UMR-S776 Inserm, Villejuif, France *Corresponding author. Centre Hepato-biliaire, H^opital Paul Brousse, 9 Avenue Paul Vaillant Couturier, 94804 Villejuif, France. Tel.: þ33 1 45 59 30 49; fax: þ33 1 45 59 38 57. E-mail address: [email protected]
Please cite this article in press as: Allard MA, Reply letter to: Combined resection of colorectal liver metastases with peritoneal deposits discovered intraoperatively, Eur J Surg Oncol (2013), http://dx.doi.org/10.1016/j.ejso.2013.11.020
ScienceDirect EJSO xx (2013) 1e2
www.ejso.com
Correspondence
Reply letter to: Combined resection of colorectal liver metastases with peritoneal deposits discovered intraoperatively We thank Graziosi et al. for their constructive comments on our recent article.1 Regarding the comment concerning the predictors of unexpected peritoneal carcinomatosis (PC), studying others risk factors for unexpected PC would have been interesting, indeed. Unfortunately, these data were not available in all our patients because, in the vast majority of them, the primary tumor had been resected in another center. However, in a study of Elias,2 a systematic second-look surgery performed in patients who had either synchronous PC, ovarian metastases or perforated tumor at the time of the primary tumor resection revealed the presence of macroscopic PC in 56% of cases. The risk of PC was not different between these subgroups, suggesting that the risk related to each of these risk factors is similar. The risk in patients with occlusive tumor, pT4 tumor, or a positive peritoneal cytology is less obvious.3 Regarding the place of HIPEC, Graziosi et al. mention the long term outcome of cytoreductive surgery (CS) þ intraperitoneal chemotherapy and colorectal liver metastases (CLM) resection reported by the group of Elias.4 Overall survival was good in patients with 1 or 2 LM and a peritoneal cancer index (PCI) 12 (median survival: 27 months). Our study population is characterized by an advanced hepatic disease (57% with 3 CLM) but a very limited peritoneal disease (median PCI ¼ 2, range [1e6]). This particular subgroup has not been identified in the study of Elias group, probably because of a limited number of patients meeting these criteria and the usual contraindication represented by the presence of more than 3 metastases. Although this group had adverse prognosis factors, we were surprised to observe a median survival of 42 months after resection without HIPEC. Whether this group of patients with advanced liver disease and very limited PC may benefit of additional HIPEC
DOI of original article: http://dx.doi.org/10.1016/j.ejso.2013.08.033
has not really been explored in the literature. In most of these patients, HIPEC reference centers would not have considered HIPEC because of hepatic disease extent (if not because of age or general condition.). In these patients, the positive effect of complete resection alone, on survival is supported by the relatively good median survival observed in our study (compared to that of best chemotherapy alone). In the other patients presenting limited PC and limited CLM, potentially eligible for HIPEC, we would agree to postpone resection and to refer them for CS þ HIPEC. Regarding the question of morbidity related to simultaneous major hepatectomy and HIPEC, it is important to note that data are seriously lacking. In the study of Elias4 taken as reference by Graziosi et al., only 3 patients underwent simultaneous major liver resection and HIPEC over a 17 year-period. The 9 other patients who underwent major liver resection received early postoperative intraperitoneal chemotherapy (i.e. without hyperthermia). Therefore, it is not possible to conclude that “postoperative complications are not related to major liver surgery” with such a limited number of patients. We share with Graziosi et al., the opinion that CS and HIPEC is a major therapeutic advance in the treatment of colorectal PC. However, we think that more experience is needed to better refine the indications of simultaneous HIPEC and hepatectomy, and to assess its postoperative risk to benefit ratio. Conflict of interest statement No conflicts of interest to declare. References 1. Allard MA, Adam R, Ruiz A, et al. Is unexpected peritoneal carcinomatosis still a contraindication for resection of colorectal liver metastases? Combined resection of colorectal liver metastases with peritoneal deposits discovered intra-operatively. Eur J Surg Oncol 2013;39:981–7. 2. Elias D, Honore C, Dumont F, et al. Results of systematic second-look surgery plus HIPEC in asymptomatic patients presenting a high risk of developing colorectal peritoneal carcinomatosis. Ann Surg 2011;254: 289–93. 3. Honore C, Goere D, Souadka A, Dumont F, Elias D. Definition of patients presenting a high risk of developing peritoneal carcinomatosis
0748-7983/$ - see front matter Ó 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.ejso.2013.11.020 Please cite this article in press as: Allard MA, Reply letter to: Combined resection of colorectal liver metastases with peritoneal deposits discovered intraoperatively, Eur J Surg Oncol (2013), http://dx.doi.org/10.1016/j.ejso.2013.11.020
2
Correspondence / EJSO xx (2013) 1e2
after curative surgery for colorectal cancer: a systematic review. Ann Surg Oncol 2013;20:183–92. 4. Maggiori L, Goere D, Viana B, et al. Should patients with peritoneal carcinomatosis of colorectal origin with synchronous liver metastases be treated with a curative intent? A case-control study. Ann Surg 2013;258:116–21.
M.A. Allard Centre Hepato-biliaire, Paul Brousse Hospital, Assistance Publique-H^ opitaux de Paris, Univ Paris-Sud, Villejuif, France
R. Adam* Centre Hepato-biliaire, Paul Brousse Hospital, Assistance Publique-H^opitaux de Paris, Univ Paris-Sud, Villejuif, France UMR-S776 Inserm, Villejuif, France *Corresponding author. Centre Hepato-biliaire, H^opital Paul Brousse, 9 Avenue Paul Vaillant Couturier, 94804 Villejuif, France. Tel.: þ33 1 45 59 30 49; fax: þ33 1 45 59 38 57. E-mail address: [email protected]
Please cite this article in press as: Allard MA, Reply letter to: Combined resection of colorectal liver metastases with peritoneal deposits discovered intraoperatively, Eur J Surg Oncol (2013), http://dx.doi.org/10.1016/j.ejso.2013.11.020
