A new standard of care for the management of peritoneal surface malignancy

Abstract

Cancer dissemination to peritoneal surfaces was, in the past, a lethal condition with a limited survival. Clinical and pharmacologic research have shown that options for both treatment and prevention are now reality. The diseases most commonly treated include peritoneal dissemination from appendiceal malignancy, colorectal malignancy, and peritoneal mesothelioma. Selection factors are important to minimize the number of treated patients who will experience short-term benefit. Treatments involve cytoreductive surgery and perioperative chemotherapy. The intraperitoneal chemotherapy in the operating room is used with heat. Although this combined approach has been criticized, the informed oncologist will seek to identify those patients that may benefit from this more optimistic concept of peritoneal dissemination of cancer.

Keywords: Cytoreductive surgery; appendiceal cancer; carcinomatosis; colorectal cancer; hipec; hyperthermic intraperitoneal chemotherapy; mitomycin C; peritoneal mesothelioma; pseudomyxoma peritonei.

FIGURE 1

Survival of all patients with epithelial appendiceal neoplasms treated by cytoreductive surgery and intraperitoneal chemotherapy. The red line represents patients with disseminated peritoneal adenomucinosis, and the blue line, patients with peritoneal mucinous carcinoma. Reproduced, with permission, from Sugarbaker, 2009 .

FIGURE 2

Peritoneal carcinomatosis index (pci). Two transverse planes and two sagittal planes divide the abdomen into 9 regions. The upper transverse plane is located at the lowest aspect of the costal margin, and the lower transverse plane is placed at the anterior superior iliac spine. The sagittal planes divide the abdomen into 3 equal sectors. The lines define the 9 regions, which are numbered clockwise starting with 0 at the umbilicus and with 1 defining the space beneath the right hemidiaphragm. Regions 9–12 divide the small bowel into upper and lower jejunum and upper and lower ileum. “Lesion size score” is determined after complete lysis of all adhesions and complete inspection of all parietal and visceral peritoneal surfaces. It refers to the greatest diameter of tumour implants distributed on the peritoneal surfaces. Primary tumours or localized recurrences at the primary site that can be definitively removed are excluded from the lesion size assessment. If a confluence of disease is matting abdominal or pelvic structures together, lesion size is automatically scored 3, even if the confluence of cancerous implants is thin. The pci is determined during the complete abdominal and pelvic exploration that is conducted before the cytoreductive surgery.

FIGURE 3

Survival by peritoneal carcinomatosis index (pci) for mucinous appendiceal neoplasms. (A) Adenomucinosis patients with pci 1–20 (blue line, n = 165) or 21–39 (red line, n = 144). (B) Mucinous carcinoma patients with pci 1–20 (blue line, n = 82) or 21–39 (red line, n = 225). Reproduced, with permission, from Sugarbaker, 2009 .

FIGURE 4

The predictive value of computed tomography scan findings by tree-structured diagram. ac = adequate cytoreduction; sc = suboptimal cytoreduction; sb/sbm = small bowel and small-bowel mesentery. Reproduced, with permission, from Yan et al., 2005 .

FIGURE 5

Treatment of appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome at 4 well-known centres. The only institution to use cytoreductive surgery simultaneously with chemotherapy was the Washington Cancer Institute. The other 3 institutions used serial debulking combined with systemic chemotherapy or delayed intraperitoneal chemotherapy. Reproduced, with permission, from Sugarbaker, 2006 .

FIGURE 6

Survival of patients with metastatic colorectal cancer treated with cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy or systemic chemotherapy alone. Modified from Elias et al., 2010 , Sanoff et al., 2008 , and Verwaal, 2009 .