Overall survival post secondary cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent colorectal cancer with peritoneal metastases.

Background: Colorectal cancer is the third-most common malignancy worldwide. It has the potential to develop peritoneal metastases (CRPM), which can be treated using cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). There is limited literature on outcomes of secondary CRS/HIPEC for CRPM recurrence.

Methods: All patients with CRPM who had secondary CRS/HIPEC between 2000 and 2023 were included. Clinical information regarding histological grade, peritoneal cancer index (PCI), completion of cytoreduction (CC), other metastases and their treatments, morbidity grade and demographics including sex, age and death were collected. The outcome of interest was peri-operative morbidity measured using Clavien-Dindo classification comparing with index CRS/HIPEC and survivals (disease-free survival (DFS) and overall survival (OS)). Secondary analyses were conducted to compare concurrent treatments and variables correlated with survivals.

Results: Out of 435 patients who underwent CRS/HIPEC for colorectal cancer, 65 underwent secondary CRS/HIPEC. The median PCI score at secondary CRS/HIPEC was 6 (range 0-18) compared to 8 at index CRS/HIPEC (p < 0.01), and the median CC score at secondary CRS/HIPEC was 0 (n = 59, 91%) compared to 0 (n = 65, 100%) at index CRS/HIPEC (mean 0.0 v 0.12, p = 0.02). HIPEC was given in 59/65 patients (90%). Ten patients (15%) had radio- or microwave ablation to lung/liver metastases. Significant Clavien-Dindo morbidity (≥ 3) was similar between index and secondary operation with 13 (23%) of patients and 12 (19%) respectively. Median length of stay was 17 days. Median DFS after secondary CRS/HIPEC was 10.7 months, with an OS of 31.1 months. From index CRS/HIPEC, OS was 65.2 months. There was no difference by histological grade and no difference in DFS or OS in those who had had ablation. PCI at secondary operation was negatively associated with OS (r=-0.32, p = 0.009).

Conclusion: Secondary CRS/HIPEC for patients with CRC recurrence has comparable perioperative morbidity and mortality to index CRS/HIPEC, with significant disease-free and overall survival. Ablation of oligometastatic or extra-abdominal disease allows for comparable survival post-secondary CRS/HIPEC. Secondary CRS/HIPEC should be considered in selected patients.