Total parietal peritonectomy for 61 patients: a retrospective study

Objective: To evaluate the morbidity of total parietal peritonectomy (TPP) during cytoreduction surgery, and its impact on the site of recurrence of different peritoneal surface malignancies (PSM). Methods: We led a retrospective study in a French tertiary cancer institution (Centre Oscar Lambret - Lille) experienced in treating PSM over a 6-year period from 2012 to 2018. All patients underwent a total parietal peritonectomy during a debulking surgery for PSM including ovarian cancer, appendiceal pseudomyxoma peritonei or peritoneal mesothelioma. Results: Among the 61 patients included in this study, 49 patients(80.3%) had an ovarian cancer. The rate of complete tumor resection reached 86.9% with almost 69% of surgeries being highly complex. 73.8% were transfused during the surgical procedure. The median length of hospital stay was 10 days including 7 days in Intensive Care Unit. Overall, 19 patients (31.1%) had an early postoperative complication, including 3 with a grade IIIB complication of Clavien Dindo classification. With a median follow-up of 30 months, the estimated disease-free survival in the ovarian cancer subgroup who had an initial peritonectomy (n = 42) was 84.7% at 1 year and 12.0% at 3 year. The main site of first and second recurrence was peritoneal (42% and 14%). Conclusion: TPP is a safe surgical procedure to treat peritoneal surface malignancies and their recurrences with a low rate of grade IIIB morbidity and no treatment-related death and allow optimal surgery. In this study there is no atypical recurrence site, such as abdominal muscle involvement.

Ovarian cancer; Peritonectomy; Primary surgery debulking; Interval debulking surgery; Neo-adjuvant chemotherapy

[1] Cashin PH, Mahteme H, Spång N, Syk I, Frödin JE, Torkzad M, et al. Cytoreductive surgery and intraperitoneal chemotherapy versus systemic chemotherapy for colorectal peritoneal metastases: a randomised trial. European Journal of Cancer. 2016; 53: 155–162.

[2] Verwaal VJ, Bruin S, Boot H, van Slooten G, van Tinteren H. 8-Year Follow-up of Randomized Trial: Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy Versus Systemic Chemotherapy in Patients with Peritoneal Carcinomatosis of Colorectal Cancer. Annals of Surgical Oncology. 2008; 15: 2426–2432.

[3] Ansari N, Chandrakumaran K, Dayal S, Mohamed F, Cecil TD, Moran BJ. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1000 patients with perforated appendiceal epithelial tumours. European Journal of Surgical Oncology. 2016; 42: 1035–1041.

[4] Baratti D, Kusamura S, Cabras AD, Bertulli R, Hutanu I, Deraco M. Diffuse malignant peritoneal mesothelioma: Long-term survival with complete cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC). European Journal of Cancer. 2013; 49: 3140–3148.

[5] Baratti D, Kusamura S, Cabras AD, Deraco M. Cytoreductive Surgery with Selective Versus Complete Parietal Peritonectomy Followed by Hyperthermic Intraperitoneal Chemotherapy in Patients with Diffuse Malignant Peritoneal Mesothelioma: a Controlled Study. Annals of Surgical Oncology. 2012; 19: 1416–1424.

[6] Chang SJ, Bristow RE, Chi DS, Cliby WA. Role of aggressive surgical cytoreduction in advanced ovarian cancer. Journal of Gynecologic Oncology. 2015; 26: 336–342.

[7] acquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. Cancer Treatment and Research. 1996; 82: 359–374.

[8] Deraco M, Baratti D, Kusamura S, Laterza B, Balestra MR. Surgical technique of parietal and visceral peritonectomy for peritoneal surface malignancies. Journal of Surgical Oncology. 2009; 100: 321–328.

[9] Sugarbaker PH. Management of peritoneal metastases - Basic concepts. Journal of B.U.ON. 2015; 20 Suppl 1: S2–11.

[10] Kyriazanos I, Papageorgiou D, Zoulamoglou M, Marougkas M, Stamos N, Ivros N, et al. Total extraperitoneal access for parietal peritonectomy for peritoneal surface malignancy: The ‘cocoon’ technique. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2020; 251: 258–262.

[11] Mohamed F, Cecil T, Moran B, Sugarbaker P. A new standard of care for the management of peritoneal surface malignancy. Current Oncology. 2011; 18: e84–96.

[12] Harter P, Muallem ZM, Buhrmann C, Lorenz D, Kaub C, Hils R, et al. Impact of a structured quality management program on surgical outcome in primary advanced ovarian cancer. Gynecologic Oncology. 2011; 121: 615–619.

[13] Chi DS, Eisenhauer EL, Zivanovic O, Sonoda Y, AbuRustum NR, Levine DA, et al. Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm. Gynecologic Oncology. 2009; 114: 26–31.

[14] Ferrandina G, Legge F, Salutari V, Paglia A, Testa A, Scambia G. Impact of pattern of recurrence on clinical outcome of ovarian cancer patients: Clinical considerations. European Journal of Cancer. 2006; 42: 2296–302.

[15] Meinhold-Heerlein I, Fotopoulou C, Harter P, Kurzeder C, Mustea A, Wimberger P, et al. Statement by the Kommission Ovar of the AGO: The New FIGO and WHO Classifications of Ovarian, Fallopian Tube and Primary Peritoneal Cancer. Geburtshilfe und Frauenheilkunde. 2015; 75: 1021–1027.

[16] Yokosu K, Tanabe H, Nomura S, Ozone H, Saito M, Takano H, et al. Total parietal peritonectomy in primary debulking surgery for advanced ovarian cancer. Gynecologic Oncology Reports. 2021; 37: 100805.

[17] Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, Mc-Fadden ET, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. American Journal of Clinical Oncology. 1982; 5: 649–655.

[18] Mutch DG, Prat J. 2014 FIGO staging for ovarian, fallopian tube and peritoneal cancer. Gynecologic Oncology. 2014; 133: 401–404.

[19] Aletti G, Santillan A, Eisenhauer E, Hu J, Aletti G, Podratz K, et al. A new frontier for quality of care in gynecologic oncology surgery: Multiinstitutional assessment of short-term outcomes for ovarian cancer using a risk-adjusted model. Gynecologic Oncology. 2007; 107: 99–106.

[20] Dindo D, Demartines N, Clavien P. Classification of Surgical Complications. Annals of Surgery. 2004; 240: 205–213.

[21] Hoskins WJ, Bundy BN, Thigpen JT, Omura GA. The influence of cytoreductive surgery on recurrence-free interval and survival in small-volume Stage III epithelial ovarian cancer: a gynec-logic oncology group study. Gynecologic Oncology. 1992; 47: 159–166.

[22] Elattar A, Bryant A, Winter-Roach BA, Hatem M, Naik R. Optimal primary surgical treatment for advanced epithelial ovarian cancer. The Cochrane Database of Systematic Reviews. 2011; 2011: CD007565.

[23] Chang S, Hodeib M, Chang J, Bristow RE. Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: a meta-analysis. Gynecologic Oncology. 2013; 130: 493–498.

[24] Chi DS, McCaughty K, Diaz JP, Huh J, Schwabenbauer S, Hum-mer AJ, et al. Guidelines and selection criteria for secondary cytoreductive surgery in patients with recurrent, platinum-sensitive epithelial ovarian carcinoma. Cancer. 2006; 106: 1933–1939.

[25] Du Bois A, Vergote I, Ferron G, Reuss A, Meier W, Greggi S, et al. Randomized controlled phase III study evaluating the impact of secondary cytoreductive surgery in recurrent ovarian cancer: AGO DESKTOP III/ENGOT ov20. Journal of Clinical Oncology. 2017; 35: 5501–5501.

[26] Bhatt A, Kammar P, Sinukumar S, Parikh L, Jumle N, Shaikh S, et al. Total Parietal Peritonectomy can be Performed with Acceptable Morbidity for Patients with Advanced Ovarian Cancer after Neoadjuvant Chemotherapy: Results from a Prospective Multicentric Study. Annals of Surgical Oncology. 2021; 28: 1118–1129.

[27] Sinukumar S, Rajan F, Mehta S, Damodaran D, Zaveri S, Kammar P, et al. A comparison of outcomes following total and selective peritonectomy performed at the time of interval cytoreductive surgery for advanced serous epithelial ovarian, fallopian tube and primary peritoneal cancer – a study by INDEPSO. European Journal of Surgical Oncology. 2021; 47: 75–81.

[28] Muallem MZ, Sehouli J, Miranda A, Richter R, Muallem J. Total retroperitoneal en bloc resection of multivisceral-peritoneal packet (TROMP operation): a novel surgical technique for advanced ovarian cancer. International Journal of Gynecologic Cancer. 2020; 30: 648–653.

[29] Vergote I, Tropé CG, Amant F, Kristensen GB, Ehlen T, Johnson N, et al. Neoadjuvant Chemotherapy or Primary Surgery in Stage IIIC or IV Ovarian Cancer. New England Journal of Medicine. 2010; 363: 943–953.

[30] Bakrin N, Bereder JM, Decullier E, Classe JM, Msika S, Lorimier G, et al. Peritoneal carcinomatosis treated with cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for advanced ovarian carcinoma: a French multicentre retrospective cohort study of 566 patients. European Journal of Surgical Oncology. 2013; 39: 1435–1443.

[31] Harter P, Sehouli J, Lorusso D, Reuss A, Vergote I, Marth C, et al. A Randomized Trial of Lymphadenectomy in Patients with Advanced Ovarian Neoplasms. New England Journal of Medicine. 2019; 380: 822–832.

[32] Vergote I, Coens C, Nankivell M, Kristensen GB, Parmar MKB, Ehlen T, et al. Neoadjuvant Chemotherapy Versus Debulking Surgery in Advanced Tubo-Ovarian Cancers: Pooled Analysis of Individual Patient Data from the EORTC 55971 and CHORUS Trials. The Lancet. Oncology. 2018; 19: 1680–1687.

[33] Akaishi E, Teixeira F, Katayama M, Mizumoto N, Costa FP, Buzaid AC, et al. Peritonectomy for Peritoneal Carcinomatosis: Long-Term Outcomes from a Single Brazilian Institution. World Journal of Surgery. 2009; 33: 835–839.

[34] Spratt JS, Adcock RA, Muskovin M, Sherrill W, McKeown J. Clinical delivery system for intraperitoneal hyperthermic chemotherapy. Cancer Research. 1980; 40: 256–260.

[35] van Driel WJ, Koole SN, Sikorska K, Schagen van Leeuwen JH, Schreuder HWR, Hermans RHM, et al. Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer. New England Journal of Medicine. 2018; 378: 230–240.

[36] Youssef H, Newman C, Chandrakumaran K, Mohamed F, Cecil TD, Moran BJ. Operative Findings, Early Complications, and Long-Term Survival in 456 Patients with Pseudomyxoma Peritonei Syndrome of Appendiceal Origin. Diseases of the Colon & Rectum. 2011; 54: 293–299.

[37] Moran B, Baratti D, Yan TD, Kusamura S, Deraco M. Consensus statement on the locoregional treatment of appendiceal mucinous neoplasms with peritoneal dissemination (pseudomyxoma peritonei). Journal of Surgical Oncology. 2008; 98: 277–282.