Are We Ready for Hyperthermic Intraperitoneal Chemotherapy in the Upfront Treatment of Ovarian Cancer?
Mené sur 584 patientes atteintes d'un cancer épithélial de l'ovaire (durée médiane de suivi : 42,2 mois), cet essai évalue l'intérêt, du point de vue de la durée médiane de survie et de la survie globale à 3 ans, d'ajouter une chimiothérapie intrapéritonéale hyperthermique à une chirurgie cytoréductive
Advanced epithelial ovarian cancer (EOC) has a well-characterized pattern of spread; the cancer cells tend to stay within the peritoneal cavity, attaching to organ surfaces and only invading superficial layers. This pattern makes intraperitoneal chemotherapy an attractive alternative to conventional systemic chemotherapy in select patients with EOC, although it can be poorly tolerated. Hyperthermic intraperitoneal chemotherapy (HIPEC) performed at the time of cytoreductive surgery is a method of delivering intraperitoneal chemotherapy that can mitigate the concerns of patient tolerance and catheter-related issues seen in normothermic intraperitoneal chemotherapy. Hyperthermia is thought to synergize with chemotherapy by increasing activity of the agent, as well as promoting deeper penetration of the drug into tumor implants. Previous studies of HIPEC in advanced EOC have generally examined its use in the interval or recurrent setting. The first randomized trial, published by Spiliotis et al in 2015, found 13-month improvement in survival with the addition of HIPEC to secondary cytoreductive surgery, a benefit found in both platinum-sensitive and platinum-resistant cohorts. More recently, van Driel et al randomized women with stage III EOC undergoing neoadjuvant chemotherapy to interval debulking surgery (IDS) with and without HIPEC with cisplatin at a dose of 100 mg/m2. The women who underwent IDS with HIPEC demonstrated a 3.5-month improvement in progression-free survival and a 12-month improvement in overall survival. These findings support the use of HIPEC in this setting, although the trial had significant limitations, including the lack of stratification by International Federation of Gynecgology and Obstetrics or BRCA mutation status, imbalance in the 2 groups, and randomization prior to surgery. Despite these limitations, we now routinely discuss HIPEC with cisplatin at a dose of 100 mg/m2 in the interval setting with the subset of patients with abdominally confined disease, whom we anticipate will experience optimal IDS (the removal of all tumor to microscopic disease).