[Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal colorectal carcinomatosis: a newly validated standard whose contribution remains to be assessed]

Peritoneal carcinomatosis represent an advanced form of colorectal cancer but different of others metastatic pathways. However carcinomatosis was associated with stage M in the TNM classification, because of a very poor prognosis, actually resulting despite new chemotherapeutic agents of a single year of survival. In an estimated 30% of patients, no other tumour location can be found. Usually complete tumour resection can not be perform, resulting in the best time with a R1 procedure associated with microscopic residual disease. This is to eradicate microscopic residual disease that hyperthermic intraperitoneal chemotherapy (HIPEC) was proposed. First results of single unit published reported survival after 5 years and that the most important prognosis factor of survival was complete resection of the carcinomatosis (R1 resection). A phase III study publish in 2003 in the Journal of Surgical Oncology by the Zoetmulder's team confirm the phase II results and offer for the first time a factual impact with a level II of demonstration. Between 1998 and 2001, 105 patients were randomly assigned to receive either standard treatment consisting of systemic chemotherapy (fluorouracil-leucovorin) or aggressive cytoreduction (incomplete for some patients) with HIPEC (mitomycin C during 90 minutes) followed by the same systemic chemotherapy regime. In the HIPEC arms, mortality was at 8 % and the median hospital admission was near one month. After a median follow-up period of 21 months, the median survival was 12 months in the standard therapy arm and 22 months in the HIPEC arm (p = 0.032). These results confirm prior reported non randomised study reporting median survival of 12 to 40 months. We had recently published the results of a phase II study including only patient with a R1 resection associated with HIPEC with oxaliplatin. This study had include 24 patients with an overall survival of 65% at 3 years. These survival result was the most prolonged never reported in the treatment of peritoneal colorectal carcinomatosis. HIPEC can be considered as a new standard even the exact place in clinical practice had to be more define because of alls recent progress are publish giving an important number of publications during the 2003-2004 years, some of them coming from French groups.