Miguel Cunha interviewed Professor Diane Goéré ahead of her talk on ‘Cytoreduction with or without HIPEC for peritoneal carcinomatosis’ at #ESCP2020.
Diane teaches digestive surgery at University of Paris and works at Saint-Louis hospital in Paris. Professor Goéré specialises in digestive oncological surgery and in particular in the treatment of liver metastases and peritoneal diseases.
Miguel Cunha: Firstly, let me say it is a pleasure to interview you prior to your Vilnius session on cytoreduction for peritoneal carcinomatosis. I hope this interview works as a teaser for our colleagues to tune in on the 23 of September.
Can you start off by telling us a bit about the subject?
Diane Goéré: Thanks. Advanced primary or recurrent colorectal cancer commonly involves the peritoneum via a process best described as synchronous or metachronous colorectal peritoneal metastasis. Conventional treatment of these patients using systemic chemotherapy with or without palliative surgery has been reported to result in a poor median survival. The evidence shows that select patients with colorectal peritoneal metastatic disease may be cured by a combination of what is termed cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Recent papers showed interesting results about cytoreductive surgery also without hyperthermic intraperitoneal chemotherapy. During my 23rd September presentation, I will discuss the best options for this pathology towards current knowledge.
MC: We can say one of your research subjects concerns finding the best approach for peritoneal metastasis. You are definitely in the forefront of investigation on this subject. I believe my first question is challenging, though important to introduce the topic for our readers. In a short sentence, what is the established knowledge concerning colorectal peritoneal metastasis diagnosis, treatment and survival benefits?
DG: Diagnosis of colorectal peritoneal metastases is mostly done at a very advanced stage because no symptoms are fully specific of peritoneal metastases, and because of the low sensitivity of the imaging exams. The prognosis of patients with peritoneal metastases from CRC has been widely improved with the development of a new therapeutic approach consisting in a complete cytoreductive surgery (CRS) of the peritoneal metastases followed with hyperthermic intraperitoneal chemotherapy (HIPEC). This strategy allows obtaining an overall 5-year survival rates close to 40-45%, in selected patients, provided there is complete removal of macroscopic disease.
MC: What would you say are yet the most challenging questions about colorectal peritoneal metastasis?
DG: Results of the randomised trial PRODIGE 7 have shown that the addition of oxaliplatin-HIPEC after cytoreductive surgery (R0/R1 in 90% of the patients) does not influence both OS and RFS, compared to cytreductive surgery alone. So, the place of HIPEC associated to complete cytoreductive surgery has recently been challenged, and more studies have to be done to first define patients who could benefit from HIPEC, and second to define the best protocol for HIPEC.
MC: Regarding colorectal cancer, in your opinion, can we look at resectable peritoneal metastasis as we look at resectable liver metastasis?
DG: Prolonged survival can be obtained in selected patients, after complete cytoreductive surgery and HIPEC. Studies have demonstrated that survival (with 5-y OS of 40-45%) could be closed to that obtained after resection of colorectal liver metastases. Aggressive treatment including complete resection of peritoneal metastases has always to be discussed, and to be proposed for patients in good general status, with a low tumour burden (peritoneal cancer index less than 17), without extra-peritoneal metastases.
MC: Do you see the laparoscopic and robotic approaches as an option in colorectal peritoneal metastasis treatment?
DG: Complete cytoreductive surgery means complete exploration of the peritoneal cavity, that must be very careful. Laparoscopy does not offer the possibility of examining the entire cavity, it has been shown that the extension of peritoneal disease was underestimated in laparoscopy.
MC: Looking at the broader range of gastrointestinal carcinomas, who may benefit the most from cytoreduction surgery with HIPEC?
DG: Prolonged survival has been reported after CRS and HIPEC for peritoneal pseudomyxoma (up to 8 years for median survival), for peritoneal malignant mesothelioma and for peritoneal metastases from gastric carcinoma with a very limited extension (PCI less than 7).
MC: From a surgical point of view, what developments do you think we can expect in the future for peritoneal carcinomatosis treatment?
DG: Progress can be of several types. One of the major points is to treat patients at an early stage before the disease is not accessible to complete resection, which means diagnostic progress (imaging). Therapeutic progress in order to improve the tumour response is also necessary: choice of chemotherapy, type of administration (systemic and/or intraperitoneal), pre- and/or postoperative, and harmonisation of HIPEC protocols around the world is necessary.
MC: Thank you so much for sharing your knowledge with us. We have great expectations for your talk at the upcoming ESCP meeting, and are looking forward to it! We’ll all be tuned in next week!
Diane’s session on ‘Cytoreduction with or without HIPEC for peritoneal carcinomatosis’ will take place at ESCP Virtually Vilnius 2020 at 18:00 on Wednesday 23 September.
