Surgical management of carcinomatosis from colorectal cancer

Abstract

Until recently, peritoneal carcinomatosis from colorectal cancer was a universally fatal manifestation of this cancer. However, two innovations in treatment have improved outcome for these patients. The new surgical interventions are collectively referred to as peritonectomy procedures. During these procedures, all visible cancer is removed in an attempt to leave the patient with only microscopic residual disease. Perioperative intraperitoneal chemotherapy, the second innovation, is employed to eradicate small-volume residual disease. The intraperitoneal chemotherapy is administered in the operating room with moderate hyperthermia and is referred to as heated intraoperative intraperitoneal chemotherapy. If tolerated, additional intraperitoneal chemotherapy can be administered during the first 5 postoperative days. The use of these combined treatments, cytoreductive surgery and intraperitoneal chemotherapy, improves survival, optimizes quality of life, and maximally preserves function. This article describes the natural history of colorectal cancer with carcinomatosis, the patterns of dissemination within the peritoneal cavity, and the benefits and limitations of intraperitoneal chemotherapy. Peritonectomy procedures are defined and described. Also presented are the mechanics of delivering perioperative intraperitoneal chemotherapy and the clinical assessments used to select patients who will benefit from combined treatment. The results of combined treatment for colorectal carcinomatosis are presented.

Keywords: 5-fluorouracil; Peritonectomy; colorectal cancer; hyperthermia; intraperitoneal chemotherapy; mitomycin C; peritoneal surface malignancy.

Figure 1

Selection of patients for a complete cytoreduction based on implant size and invasive nature. Noninvasive peritoneal surface malignancy can be adequately cytoreduced even though tumor volume is extensive. Invasive cancer implants need to be removed before they invade the small bowel surface. The earlier the combined treatment, the more favorable the expected result. (From Sugarbaker PH. Review of a personal experience in the management of carcinomatosis and sarcomatosis. 2001;31:573–583, with permission.)

Figure 2

Tubes and drains used for heated intraoperative intraperitoneal chemotherapy. There are four drainage tubes and a single inflow catheter.

Figure 3

Perfusion circuit for heated intraoperative intraperitoneal chemotherapy. Four closed suction drains are positioned, one beneath each hemidiaphragm and within the pelvis. A Tenckhoff catheter is placed at the site that the surgeon thinks is at greatest risk for recurrent disease, which is the area within the abdomen to receive the greatest heat. Some dose intensification occurs with this approach, from both heat and chemotherapy exposure. Roller pumps, a heat exchanger, and thermometry allow the perfusion to proceed. A smoke evacuator tube pulls air from beneath the plastic sheet, keeping the airflow moving from operating theater to peritoneal cavity to smoke evacuator and through a charcoal filter.

Figure 4

Peritoneal cancer index. This composite score is determined after complete exploration of the abdomen and pelvis. The lesion size score (0–3) and the involvement of abdominopelvic regions (0–12) are combined.

Figure 5

Completeness of cytoreduction score. A CC score of zero (CC-0) indicates that no peritoneal seeding occurred during the complete exploration. A CC-1 score indicates that tumor nodules persisting after cytoreduction are smaller than 2.5 mm. A CC-2 score indicates residual tumor nodules between 2.5 mm and 2.5 cm. A CC-3 score indicates residual tumor nodules greater than 2.5 cm or a confluence of unresectable tumor nodules at any site within the abdomen or pelvis.

Figure 6

Comparison of the survival of a group of patients with colorectal metastases to the liver and a second group with carcinomatosis. In all liver metastases patients, the liver resection was scored R0; in all the carcinomatosis patients, the cytoreduction was scored as complete. (From Sugarbaker. Reprinted with permission.)