Comparative oncological efficacy of chemotherapy, cytoreductive surgery with or without HIPEC in recurrent ovarian cancer: A network meta-analysis.

BACKGROUND: The role of secondary cytoreductive surgery (SCS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in platinum-sensitive recurrent ovarian cancer remains challenging. While chemotherapy (CHT) remains the standard approach, interest has grown in SCS, either with or without HIPEC. Despite promising results, the comparative effectiveness of SCS, SCS + HIPEC, and chemotherapy alone remains controversial, with no trials directly comparing SCS + HIPEC with CHT alone. METHODS: This systematic review and network meta-analysis included five randomized controlled trials (GOG-0213, DESKTOP III, SOC-1, CHIPOR, and HORSE) identified through PubMed, Embase, Scopus, and Cochrane. The analysis encompassed 1831 patients. A frequentist random-effects network meta-analysis was performed, with CHT as the reference. Heterogeneity was quantified using I2. RESULTS: Neither SCS (HR 0.97, 95% CI 0.80-1.19) nor SCS + HIPEC (HR 0.76, 95% CI 0.54-1.08) significantly improved 5-year OS compared to CHT alone (I2 = 68.4%). Both interventions significantly prolonged 5-year PFS (SCS HR 0.75, 95% CI 0.63-0.88; SCS + HIPEC HR 0.71, 95% CI 0.53-0.94, I2 = 13.8%). When excluding GOG-0213, SCS + HIPEC significantly improved OS (HR 0.65, 95% CI 0.44-0.94, p = 0.023, I2 = 0%). For CC-0 patients, SCS + HIPEC and SCS improved both OS and PFS compared to CHT. For CC-1 patients, SCS + HIPEC may be associated with improved OS and PFS, whereas SCS alone may be associated with worse OS. CONCLUSIONS: SCS with or without HIPEC is associated with increased PFS and may also increase OS in certain scenarios. The comparison of SCS + HIPEC versus CHT rests on indirect evidence and possible bias given that CHIPOR trial used neoadjuvant chemotherapy. The apparent benefit of SCS + HIPEC in CC-1 patients remain exploratory.