Review of: Resectable Pancreatic Cancer With Peritoneal Metastases: Is Cytoreduction Combined With Hipec Effective and When?

I thank the authors for the work done, but I believe that the HIPEC treatment + CRS in peritoneal carcinosis deserves special attention in order to better guide the work of researchers and physicians dealing with this matter. I think that in this work, the subject has been treated with a lot of superficiality."

First of all HIPEC is a well-established treatment for peritoneal pathologies like pseudomyxoma peritonei, peritoneal mesothelioma and for ovarian carcinosis that even though aggressive conditions are still less aggressive when compared with the pancreatic cancer.

Moreover for gastric cancer with peritoneal carcinosis the HIPEC+CRS is not currently recommended by the National Comprehensive Cancer Network (NCCN) guidelines but only in patients with low PCI value and for particular isotypes (1,2) and for the colon-rectal cancer with peritoneal carcinosis, in the latest guidelines, HIPEC is no longer recommended unless particular clinical trials and in very selected patients.

Therefore, I believe that HIPEC+CRS for pancreatic cancer with peritoneal carcinosis deserves comparative and preferably randomized studies in order to understand his utility

In the “patients and method” part you say that the ethical committee approved the “Protocol”.

 I have not understood what the specificity of the protocol is and there is no a control group in order to evaluate your treatment modality. You have analyzed a very heterogeneous group of patients (patients with liver mts, peritoneum mts) and no cut-off for the PCI index. This lack of patient selection criteria does not allow us to understand if there are specific indications or cut off limits in the patient selection (a patient with 1 liver metastasis is not the same as 1 patients with 2 or more liver metastasis and is not the same with 1 patient with low PCI or high PCI index).

Furthermore

- in your, already small group, there are two patients who have undergone HIPEC+CRS treatment for ovarian carcinosis with doubts about the primary origin of the carcinosis;

- three patients underwent treatment for the recurrence of carcinosis, considering the primary tumor and the recurrence at the same level of prognosis (with the same treatment protocol)

- there is no lymph nodes staging or number of affected lymph nodes for each patients in order to understand the lymph node involvement of the pathology.

- there is not a control group even though a storical one in order to confront or validate what was done is right or wrong.

None of the results of this study indicate us in which cases HIPEC+CRS can bring benefits to the patients and in which cases it is an useless procedure  

In my opinion, this study does not add anything specific to the existing literature and can be a source of incorrect indications for the treatment of patients with this kind of pathology.

So I think that the paper must be rejected.