Patients With Peritoneal Hepatocellular Carcinoma May Benefit From Cytoreductive Surgery With or Without Intraperitoneal Chemotherapy


Key Points

  • People with peritoneal hepatocellular carcinoma represent a challenging group to treat, with the benefits of sorafenib not well described in these patients.
  • In a small retrospective study, cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy extended survival compared with systemic therapy alone.

Cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy extended survival over systemic therapy alone in well-selected candidates with peritoneal hepatocellular carcinoma, according to the results of a small retrospective trial reported by Tabrizian et al in the Journal of Surgical Oncology. Although peritoneal carcinomatosis traditionally has been considered a lethal endpoint for various intra-abdominal tumors, the role of this therapeutic approach in this patient population may warrant further study.

Up to 85% of primary liver tumors are hepatocellular carcinomas. A small subgroup of people with this type of liver cancer present with peritoneal metastasis, which is associated with a poor prognosis and few effective therapeutic options.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy have shown promise in certain malignancies. Thus, Tabrizian and colleagues evaluated the role of this treatment approach in a series of patients with peritoneal hepatocellular carcinoma.

Study Details

Over a 5-year period (from July 2007 to August 2012), 14 patients with hepatocellular carcinoma developed limited disease to the peritoneum (12 after hepatic resection and 2 after orthotopic liver transplantation). The investigators defined peritoneal metastasis as metachronous (after surgery for primary disease) or synchronous. Patients with at least Child’s A liver disease and no clinical evidence of significant portal hypertension were included in the study.

To quantify the peritoneal disease burden and to rule out extra-abdominal tumor spread, contrast-enhanced cross-sectional imaging (either with computed tomography or magnetic resonance imaging) of the chest, abdomen, and pelvis was performed. All 14 patients underwent cytoreductive surgery.

After surgery, half of the patients received additional treatment with hyperthermic intraperitoneal chemotherapy. In all cases, the closed-abdomen technique was employed for administration of chemotherapy. Two doses of mitomycin C (for a 90-minute perfusion period) were given.

In addition, after 2008, 12 patients in this series received treatment with sorafenib (Nexavar). (Two patients did not receive sorafenib because they were treated prior to 2008.) A daily dose of 400 mg of sorafenib was given 6 weeks after surgery and hyperthermic intraperitoneal chemotherapy.

Patients were followed every 3 months for the first year, every 4 months for the second year, and then twice a year thereafter. Surveillance included contrast-enhanced imaging, complete blood cell counts, alpha-fetoprotein measurement, and physical examination.

Clinicopathologic Characteristics and Outcomes

The average age of patients at diagnosis of peritoneal tumor spread was 54.5 years, and most patients (86%) were men. In addition, all patients had an adequate performance status and well-preserved liver function.

In the majority of patients (93%), operative treatment was performed for metachronous peritoneal disease. The most common site of tumor spread was the omentum (86%). In all but one patient, complete macroscopic cytoreduction was achieved. One patient with an extensive tumor burden died after surgery and intraperitoneal chemotherapy, although the investigators noted that his disease course was complicated by an acute cardiac event.

After peritoneal resection, the 3-year recurrence rate was 100%. The median survival for patients treated with both cytoreductive surgery and hyperthermic intraperitoneal chemotherapy was 42.1 months, compared with 35.6 months for those who had complete macroscopic cytoreduction alone. Both survival times were longer than that with systemic therapy alone.

Closing Thoughts

“Over the past decade, aggressive cytoreduction with hyperthermic intraperitoneal chemotherapy has altered the treatment of peritoneal carcinomatosis from diverse visceral malignancies,” declared the investigators. “Since peritoneal disease reflects locoregional spread rather than systemic dissemination, it would be interesting to further investigate the role of hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal hepatocellular carcinoma.”

Parissa Tabrizian, MD, of Mount Sinai School of Medicine, New York, is the corresponding author of the article in the Journal of Surgical Oncology.

The authors disclosed no potential conflicts of interest.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.