Annals of Surgical Oncology

, Volume 23, Issue 13, pp 4214–4221 | Cite as

Development of a Prognostic Nomogram for Patients with Peritoneally Metastasized Colorectal Cancer Treated with Cytoreductive Surgery and HIPEC

  • Geert A. SimkensEmail author
  • Thijs R. van Oudheusden
  • Daan Nieboer
  • Ewout W. Steyerberg
  • Harm J. Rutten
  • Misha D. Luyer
  • Simon W. Nienhuijs
  • Ignace H. de Hingh
Gastrointestinal Oncology



With the introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), long-term survival can be achieved in selected patients with colorectal peritoneal metastases (PM). Patient selection and outcome may be improved significantly with a tool that adequately predicts survival in these patients. This study was designed to validate the peritoneal surface disease severity score (PSDSS) in patients with colorectal PM treated with CRS + HIPEC. If performance of the PSDSS was suboptimal (c < 0.7), we aimed to develop a new prognostic model.


Patients were included if they had colorectal PM and underwent CRS + HIPEC with intended complete cytoreduction in a Dutch tertiary hospital between 2007 and 2015. Statistical analyses were performed with R-software.


A total of 200 patients underwent CRS + HIPEC. External validation of the PSDSS showed a Harrell’s c statistic of 0.62. After analysis, four parameters appeared prognostically relevant factors for overall survival: age, PCI score, locoregional lymph node status, and signet ring cell histology. The weighted relevance of these parameters was turned into a prognostic nomogram that we termed colorectal peritoneal metastases prognostic surgical score (COMPASS). The COMPASS differentiated well and showed a Harrell’s c statistic of 0.72 with a calibration plot showing good agreement.


This study externally validated the PSDSS and developed a new prognostic score, the COMPASS. This pre-cytoreduction nomogram was more accurate than PSDSS in predicting survival of patients undergoing CRS + HIPEC. It can be used as tool to assist in the decision about continuing cytoreduction and HIPEC and can provide valuable information in the follow-up period after CRS + HIPEC.


Peritoneal Metastasis Prognostic Model Discriminative Ability Short Bowel Syndrome Peritoneal Cancer Index 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.




Conflict of interest


Supplementary material

10434_2016_5211_MOESM1_ESM.docx (19 kb)
Supplementary material 1 (DOCX 19 kb)


  1. 1.
    Verwaal VJ, van Ruth S, de Bree E, et al. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol. 2003;21(20):3737–43.CrossRefPubMedGoogle Scholar
  2. 2.
    Razenberg LG, van Gestel YR, Creemers GJ, Verwaal VJ, Lemmens VE, de Hingh IH. Trends in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for the treatment of synchronous peritoneal carcinomatosis of colorectal origin in the Netherlands. Eur J Surg Oncol. 2015;41(4):466–71.CrossRefPubMedGoogle Scholar
  3. 3.
    Pelz JO, Stojadinovic A, Nissan A, Hohenberger W, Esquivel J. Evaluation of a peritoneal surface disease severity score in patients with colon cancer with peritoneal carcinomatosis. J Surg Oncol. 2009;99(1):9–15.CrossRefPubMedGoogle Scholar
  4. 4.
    Esquivel J, Lowy AM, Markman M, et al. The American Society of Peritoneal Surface Malignancies (ASPSM) multi institution evaluation of the peritoneal surface disease severity score (PSDSS) in 1,013 patients with colorectal cancer with peritoneal carcinomatosis. Ann Surg Oncol. 2014;21(13):4195–201.CrossRefPubMedGoogle Scholar
  5. 5.
    Chua TC, Morris DL, Saxena A, et al. Influence of modern systemic therapies as adjunct to cytoreduction and perioperative intraperitoneal chemotherapy for patients with colorectal peritoneal carcinomatosis: a multicenter study. Ann Surg Oncol. 2011;18(6):1560–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Chua TC, Morris DL, Esquivel J. Impact of the peritoneal surface disease severity score on survival in patients with colorectal cancer peritoneal carcinomatosis undergoing complete cytoreduction and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2010;17(5):1330–6.CrossRefPubMedGoogle Scholar
  7. 7.
    van Oudheusden TR, Braam HJ, Nienhuijs SW, et al. Cytoreduction and hyperthermic intraperitoneal chemotherapy: a feasible and effective option for colorectal cancer patients after emergency surgery in the presence of peritoneal carcinomatosis. Ann Surg Oncol. 2014;21(8):2621–6.PubMedGoogle Scholar
  8. 8.
    Sugarbaker PH. Management of peritoneal-surface malignancy: the surgeon’s role. Langenbecks Arch Surg. 1999;384(6):576–87.CrossRefPubMedGoogle Scholar
  9. 9.
    Harrell Jr FE. Rms: regression modeling strategies. R Package version 4.3-1.
  10. 10.
    Steyerberg EW. Clinical prediction models: a practical approach to development, validation, and updating. New York: Springer; 2009.CrossRefGoogle Scholar
  11. 11.
    Steyerberg EW, Vickers AJ, Cook NR, et al. Assessing the performance of prediction models: a framework for traditional and novel measures. Epidemiology. 2010;21(1):128–38.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Harrell FE. Regression modeling strategies: with applications to linear models, logistic regression, and survival analysis. New York: Springer; 2001.CrossRefGoogle Scholar
  13. 13.
    Hosmer DW, Lemeshow S. Applied logistic regression. 2nd edn. New York: Wiley; 2000.CrossRefGoogle Scholar
  14. 14.
    Efron B. Bootstrap methods: Another look at the Jackknife. Ann Statist. 1979;7(1):1–26.CrossRefGoogle Scholar
  15. 15.
    Steyerberg EW, Harrell FE, Jr., Borsboom GJ, Eijkemans MJ, Vergouwe Y, Habbema JD. Internal validation of predictive models: efficiency of some procedures for logistic regression analysis. J Clin Epidemiol. 2001;54(8):774–81.CrossRefPubMedGoogle Scholar
  16. 16.
    Verwaal VJ, van Tinteren H, van Ruth S, Zoetmulder FA. Predicting the survival of patients with peritoneal carcinomatosis of colorectal origin treated by aggressive cytoreduction and hyperthermic intraperitoneal chemotherapy. Br J Surg. 2004;91(6):739–46.CrossRefPubMedGoogle Scholar
  17. 17.
    Elias D, Faron M, Goere D, et al. A simple tumor load-based nomogram for surgery in patients with colorectal liver and peritoneal metastases. Ann Surg Oncol. 2014;21(6):2052–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Cashin PH, Graf W, Nygren P, Mahteme H. Comparison of prognostic scores for patients with colorectal cancer peritoneal metastases treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2013;20(13):4183–9.CrossRefPubMedGoogle Scholar
  19. 19.
    da Silva RG, Sugarbaker PH. Analysis of prognostic factors in seventy patients having a complete cytoreduction plus perioperative intraperitoneal chemotherapy for carcinomatosis from colorectal cancer. J Am Coll Surg. 2006;203(6):878–86.CrossRefPubMedGoogle Scholar
  20. 20.
    Elias D, Gilly F, Boutitie F, et al. Peritoneal colorectal carcinomatosis treated with surgery and perioperative intraperitoneal chemotherapy: retrospective analysis of 523 patients from a multicentric French study. J Clin Oncol. 2010;28(1):63–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Goere D, Souadka A, Faron M, et al. Extent of colorectal peritoneal carcinomatosis: attempt to define a threshold above which HIPEC does not offer survival benefit: a comparative study. Ann Surg Oncol. 2015;22(9):2958–64.CrossRefPubMedGoogle Scholar
  22. 22.
    Koh JL, Yan TD, Glenn D, Morris DL. Evaluation of preoperative computed tomography in estimating peritoneal cancer index in colorectal peritoneal carcinomatosis. Ann Surg Oncol. 2009;16(2):327–33.CrossRefPubMedGoogle Scholar
  23. 23.
    Rivard JD, Temple WJ, McConnell YJ, Sultan H, Mack LA. Preoperative computed tomography does not predict resectability in peritoneal carcinomatosis. Am J Surg. 2014;207(5):760–4; discussion 764–5.Google Scholar
  24. 24.
    Matsuda K, Hotta T, Takifuji K, et al. Lymph nodes ratio is associated with the survival of colorectal cancer patients with peritoneal carcinomatosis. Am Surg. 2011;77(5):602–7.PubMedGoogle Scholar
  25. 25.
    de Vries FE, da Costa DW, van der Mooren K, van Dorp TA, Vrouenraets BC. The value of preoperative computed tomography scanning for the assessment of lymph node status in patients with colon cancer. Eur J Surg Oncol. 2014;40(12):1777–81.CrossRefPubMedGoogle Scholar
  26. 26.
    van Oudheusden TR, Braam HJ, Nienhuijs SW, et al. Poor outcome after cytoreductive surgery and HIPEC for colorectal peritoneal carcinomatosis with signet ring cell histology. J Surg Oncol. 2015;111(2):237–42.CrossRefPubMedGoogle Scholar
  27. 27.
    Winer J, Zenati M, Ramalingam L, et al. Impact of aggressive histology and location of primary tumor on the efficacy of surgical therapy for peritoneal carcinomatosis of colorectal origin. Ann Surg Oncol. 2014;21(5):1456–62.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2016

Authors and Affiliations

  • Geert A. Simkens
    • 1
    Email author
  • Thijs R. van Oudheusden
    • 1
  • Daan Nieboer
    • 2
  • Ewout W. Steyerberg
    • 2
  • Harm J. Rutten
    • 1
  • Misha D. Luyer
    • 1
  • Simon W. Nienhuijs
    • 1
  • Ignace H. de Hingh
    • 1
  1. 1.Department of Surgical OncologyCatharina Hospital EindhovenEindhovenThe Netherlands
  2. 2.Department of Public HealthErasmus MC - University Medical CenterRotterdamThe Netherlands

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