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. Author manuscript; available in PMC: 2025 Dec 16.
Published in final edited form as: Ann Surg Oncol. 2025 Oct 8;32(13):9745–9746. doi: 10.1245/s10434-025-18522-z

Role of repeat cytoreductive surgery for patients with recurrent colorectal cancer-related peritoneal metastases

Paula Marincola Smith 1, Michael G White 1
PMCID: PMC12704155  NIHMSID: NIHMS2122846  PMID: 41060604

Past:

Colorectal cancer (CRC) is a leading cause of cancer and cancer-related death in the United States and around the world, with as many as 15% of patients developing peritoneal metastases (PM), or carcinomatosis, at some point in their disease course. While curative-intent surgery (including cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC)) is widely accepted to prolong overall- and peritoneal disease free-survival (OS and PDFS, respectively) compared to systemic chemotherapy alone, the majority of patients will eventually recur, and most commonly in the peritoneal cavity.1 The role of repeat CRS +/− HIPEC in the setting of recurrent CRC-related carcinomatosis is a common question encountered by peritoneal surgeons but one that is not well defined.

Present:

This retrospective review1 of one hundred and thirty-nine (139) patients who underwent CRS +/− HIPEC for CRC-related carcinomatosis systematically describes the outcomes of patients undergoing one or more repeat curative-intent operations for peritoneal recurrence(s). We observed that rates of recurrence similar to those published in a recent meta-analysis of repeat CRS for CRC and other peritoneal histologies.2,3 Moreover, and surprisingly, the outcomes were similar following first, second, and third CRS (81%, 80%, and 87%, respectively) as were rates of peritoneal-specific recurrence (73%, 75%, and 67%, respectively). Similarly, RFS/PDFS following index CRS was found to be largely predictive of RFS/PDFS following repeat CRS, suggesting that tumor biology is the dominant predictor of outcomes following curative-intent surgery for most patients. Importantly, complication rates were similar following index and re-do CRS, suggesting that re-do CRS is safe in skilled hands.

Interestingly, there were a small handful of individual patients who experienced long-term RFS/PDFS following repeat CRS who did not experience long-term RFS/PDFS after index CRS. Furthermore, patients who underwent at least one repeat CRS after peritoneal recurrence (versus those who were not offered a repeat operation after peritoneal recurrence) were more likely to have had their index operation performed outside our institution, not have undergone neoadjuvant chemotherapy prior to index CRS, have had an incomplete (“targeted”) first CRS, and not have experienced significant complications from their first CRS. It is unclear from this data whether these patients derived this benefit because of optimal surgical resection or improved systemic disease control with neoadjuvant chemotherapy. However, these observations may reflect that the operating surgeons at our institution were more inclined to offer a repeat curative-intent operation to individuals who they feel obtained sub-optimal treatment at index CRS, offering a second chance at curative-intent surgery for people they felt did not get an adequate index operation.

It is also important to note that while patients who underwent “targeted” index CRS had shorter RFS/PDFS compared to patients who had a “complete” index CRS, their OS from index operation was not significantly different. This suggests that while “targeted” CRS appears to be oncologically sub-optimal, it is possible to salvage patients with early recurrence after “targeted” CRS if they are ultimately candidates for and undergo a timely complete CRS after recurrence.

Future:

In the setting of limited level one evidence for a disease process that is classically challenging to study prospectively, these data suggests that offering re-do CRS for recurrent CRC-related carcinomatosis is reasonable in appropriately selected patients who either 1) attained long-term benefit from their index operation or 2) are felt to have had a sub-optimal index operation. The authors advocate for systematic abdominal exploration and complete CRS (rather than “targeted” resection of only clinically/radiologically evident disease) whenever possible and safe to maximize locoregional control and extend PDFS.4 Further systematic investigation is needed to validate these findings externally.

Disclosures:

This work was supported by NIH/NCATS, project # K12TR004908. Submission of the accepted manuscript to the PubMed Central (PMC) repository to make the work freely accessible online is required by NIH policy. The Scholar supported by the project and senior author, Dr. White, requests that the publisher make the deposit to PMC. The authors would additionally like the acknowledge the Dwyer Endowment and the Sun and Do Lee GI Fund.

References:

  • 1.Marincola Smith P, Lie J, Seldomridge A, et al. Repeat cytoreductive surgery for colorectal cancer metastatic to the peritoneal cavity. Annals of Surg Onc. 2025;In Press. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Sarofim M, Wijayawardana R, Ahmadi N, Morris DL. Repeat cytoreductive surgery with HIPEC for colorectal peritoneal metastases: a systematic review. World J Surg Oncol. Apr 17 2024;22(1):99. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Valenzuela CD, Levine EA, Mangieri CW, et al. Repeat Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Cancers with Peritoneal Metastasis: A 30-year Institutional Experience. Annals of surgical oncology. Jun 2022;29(6):3436–3445. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.White MG, Smith PM, Bhutiani N, et al. Long-Term Cytoreduction Outcomes With or Without Heated Intraperitoneal Chemotherapy For Colorectal Peritoneal Metastases. J Am Coll Surg. Jul 1 2025;241(1):28–37. [DOI] [PMC free article] [PubMed] [Google Scholar]

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