Optimizing patient selection for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Carefully selected patients with resectable and limited colorectal peritoneal metastases (PM) can be treated with curative intent by cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS+HIPEC). It remains a serious challenge to weigh the potential survival benefit from this extensive treatment against the risks of substantial treatment−related morbidity, mortality, and potential diminished QoL. We identified some new and promising preoperative factors that can predict postoperative morbidity and survival outcomes after CRS+HIPEC. Performing a diagnostic laparoscopy (DLS) routinely during the preoperative workup for CRS+HIPEC prevents non−therapeutic laparotomies (i.e., open−close procedures). DLS is feasible and safe and we recommend performing this laparoscopic screening in an experienced HIPEC center. The extent of surgery (ES) during cytoreductive surgery is a well−known risk factor for major postoperative morbidity. For the first time, we discovered that experienced HIPEC surgeons in most cases fail to predict the resections that are necessary to achieve a complete cytoreduction, with an underestimation of the ES in almost 40% of the cases. At this moment, two investigations are still ongoing (i.e., SELECT trial and MUSCLE POWER study) to further optimize patient selection for CRS+HIPEC. The SELECT trial aims to improve the staging of colorectal PM during DLS by using the fluorescent tracer bevacizumab−IRDye800CW. The MUSCLE POWER study focusses on (the prevention of) clinically relevant surgery−related muscle loss (SRML) in cancer patients after major abdominal surgery. Ultimately, these new strategies might reduce overtreatment, morbidity, and costs while maintaining the same or better effectiveness with a lower recurrence rate and improved QoL.