Comparison of Outcomes Following Complete and Selective Parietal Peritonectomy During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Advanced Epithelial Ovarian Cancer: A Study by Indian Society of Peritoneal Surface Malignancies (ISPSM)

  • S. P. Somashekhar
  • K. R. AshwinEmail author
  • Rohit Kumar
  • Y. Ramya
  • Shabber S. Zaveri
  • Amit Rauthan
Original Article



Peritonectomy is an important component in surgical treatment for peritoneal surface malignancies. Visual inspection and palpation to estimate the extent of tumor involvement are unreliable. Most gynecologic oncologists are skeptical regarding the benefits of complete peritonectomy and do not perform them, worrying about the benefit and associated morbidity. They believe it is the inherent tumor biology that determines the resectability of the tumor, not surgical aggressiveness. The aim of this study was to assess the recurrence pattern, oncological outcomes, morbidity and mortality based on the extent of parietal peritonectomy performed during CRS and HIPEC in stage IIIc epithelial ovarian cancers.


Patients diagnosed with stage IIIc epithelial carcinoma ovary underwent selective parietal peritonectomy (SPP) or complete parietal peritonectomy (CPP) with CRS–HIPEC. All pre- and intraoperative data were compared and analyzed with main focus on postoperative morbidity, mortality, recurrence pattern and oncological outcomes.


From February 2013 to December 2017, 110 patients with stage IIIc epithelial ovarian cancers underwent CRS–HIPEC of which 20 were upfront primary, 55 had interval surgery and 35 were recurrent cases. Forty and 70 patients underwent CPP and SPP, respectively. The median peritoneal cancer index was 14 for CPP and 10 for SPP. CPP group had longer duration of surgery (10.7 vs. 8.9 h) and more blood loss (1062 vs. 653 ml) when compared to SPP group. The morbidity was more common in SPP group 26 (37%) than CPP group 20 (50%), and it was not statistically significant (p = 0.133). There was equal number of operative mortality in both groups: CPP versus SPP—3 (7.5%) versus 3 (4.2%), p = 0.406. With a median follow-up of 45 months, progression-free survival (PFS) was significantly higher in CPP group (33 months vs. 25 months, p < 0.05) and median overall survival (OS) was 48 months in SPP group (yet to be achieved in CPP group). The 3-year PFS was 42% versus 38%. The 3-year OS was 80% for CPP and 75% for SPP. In 30% (12 of 40 patients) undergoing CPP, pathologic examination detected microscopic disease involvement in parietal peritoneum with no visually evident tumor at surgery by the surgeon.


Patients who underwent complete peritonectomy had significantly higher PFS. This indicates aggressive surgical resection has a benefit with manageable postoperative morbidity. However, longer follow-up and a prospective randomized study need to be designed for more evidence of the same.


Peritonectomy Cytoreductive surgery Hyperthermic intraperitoneal chemotherapy Ovarian cancer Peritoneal surface malignancies 



The authors thank Dr. Arun Kumar, Consultant Biostatistician, for statistical analysis and sample size calculation.

Compliance with Ethical Standards

conflict of interest

The authors declare that they have no competing interests.

Supplementary material

Complete parietal peritonectomy

40944_2018_241_MOESM1_ESM.jpg (2.5 mb)
Supplementary material 1 (JPEG 2543 kb)

Selective parietal peritonectomy

40944_2018_241_MOESM2_ESM.jpg (138 kb)
Supplementary material 2 (JPEG 139 kb)


  1. 1.
    van Driel WJ, Koole SN, Sikorska K, Schagen van Leeuwen JH, Schreuder HW, Hermans RH, et al. Hyperthermic intraperitoneal chemotherapy in ovarian cancer. N Engl J Med. 2018;378:230–40.CrossRefPubMedGoogle Scholar
  2. 2.
    Griffiths CT. Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma. Natl Cancer Inst Monogr. 1975;42:101–4.PubMedGoogle Scholar
  3. 3.
    Hoskins WJ, McGuire WP, Brady MF, Homesley HD, CreasmanWT Berman M, et al. The effect of diameter of largest residual disease on survival after primary cytoreductive surgery in patients with suboptimal residual epithelial ovarian carcinoma. Am J Obstet Gynecol. 1994;170:974–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Bookman MA. Optimal primary therapy of ovarian cancer. Ann Oncol. 2016;27(Suppl 1):i58–62.CrossRefPubMedGoogle Scholar
  5. 5.
    Chi DS, Eisenhauer EL, Zivanovic O, et al. Improved progression- free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm. Gynecol Oncol. 2009;114:26–31.CrossRefPubMedGoogle Scholar
  6. 6.
    Bristow RE, Chi DS. Platinum-based neoadjuvant chemotherapy and interval surgical cytoreduction for advanced ovarian cancer: a meta-analysis. Gynecol Oncol. 2006;103:1070–6.CrossRefPubMedGoogle Scholar
  7. 7.
    Eisenkop SM, Spirtos NM, Friedman RL, Lin WC, Pisani AL, Perticucci S. Relative influences of tumor volume before surgery and the cytoreductive outcome on survival for patients with advanced ovarian cancer: a prospective study. Gynecol Oncol. 2003;90:390–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Baratti D, Kusamura S, Cabras AD, Deraco M. Cytoreductive surgery with selective versus complete parietal peritonectomy followed by hyperthermic intraperitoneal chemotherapy in patients with diffuse malignant peritoneal mesothelioma: a controlled study. Ann Surg Oncol. 2012;19:1416–24.CrossRefPubMedGoogle Scholar
  9. 9.
    Sugarbaker PH, editor. Peritoneal carcinomatosis: principles of management. Boston: Kluwer Academic; 1996.Google Scholar
  10. 10.
    Somashekhar SP, Ashwin KR, Kumar R, Natraj N, Ramya Y, Shabber SZ, et al. Standardization of patient selection and hyperthermic intraperitoneal chemotherapy protocol for peritoneal surface malignancy in Indian patients IJGO; 2017.
  11. 11.
    Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 (v4.03: June 14, 2010). U.S. Department of Health and Human Services, National Institutes of Health. Bethesda: National Cancer Institute; 2009.Google Scholar
  12. 12.
    Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien–Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96.CrossRefPubMedGoogle Scholar
  13. 13.
    Hynninen J, Laasik M, Vallius T, Kemppainen J, Grönroos S, Virtanen J, et al. Clinical value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in response evaluation after primary treatment of advanced epithelial ovarian cancer. Clin Oncol. 2018;30(8):507–14.CrossRefGoogle Scholar
  14. 14.
    Hillemanns P, Wimberger P, Reif J, Stepp H, Klapdor R. Photodynamic diagnosis with 5-aminolevulinic acid for intraoperative detection of peritoneal metastases of ovarian cancer: a feasibility and dose finding study. Lasers Surg Med. 2017;49:169–76. Scholar
  15. 15.
    Hynninen Johanna, Lavonius Maija, Oksa Sinikka, Grénman Seija, Carpén Olli, Auranen Annika. Is perioperative visual estimation of intra-abdominal tumor spread reliable in ovarian cancer surgery after neoadjuvant chemotherapy? Gynecol Oncol. 2013;128(2):229–32. Scholar

Copyright information

© Association of Gynecologic Oncologists of India 2018

Authors and Affiliations

  • S. P. Somashekhar
    • 1
  • K. R. Ashwin
    • 1
    Email author
  • Rohit Kumar
    • 1
  • Y. Ramya
    • 1
  • Shabber S. Zaveri
    • 1
  • Amit Rauthan
    • 2
  1. 1.Department of Surgical Oncology, Manipal Comprehensive Cancer CentreManipal HospitalBangaloreIndia
  2. 2.Department of Medical Oncology, Manipal Comprehensive Cancer CentreManipal HospitalBangaloreIndia

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