Well structured PPT

1. Moderator: Prof Vishal Gupta
PRESENTER: DR NITIN M.ch SGE,
KGMU
Peritoneal Surface Malignancy

2.  INTRODUCTION
 PRINCIPLES OF TREATMENT: HIPEC
 CURRENT INDICATIONS
 LOCOREGIONAL STAGING
 PERITONECTOMY PROCEDURES
 COMPICATIONS
 RESPONSE TO CRS AND HIPEC
 INDIAN EXPERIENCE

3. INTRODUCTION
 Primary peritoneal malignancy :originated from
the peritoneum itself.
 Secondary peritoneal malignancy
:metastatically spread to the peritoneum from a
different primary site .

4. PATTERNS OF SPREAD
 Random Proximal Distribution :early peritoneal
implantation, presence of adherence molecules on
cancer cell surface. Adenocarcinoma appendix, non-
mucinous colorectal cancer, gastric cancer and serous
ovarian cancer.(Mod to high grade) :selective parietal
peritonectomy
 Complete redistribution : no adhesion to the
peritoneal surface close to primary; pseudomyxoma
peritonei and diffuse malignant mesothelioma(low
Grade):complete peritonectomy
 Widespread cancer distribution : presence of
adherence molecules on the surface of cancer cells that
produce a great amount of mucus ,interfering with cell

5. WHY STUDY AND TREAT PSM
 LOCO REGIONAL DISEASE associated with poor
prognosis and a median survival of less than 1 year in
absence of systemic metastasis

6. PRINCIPLES OF TREATMENT
 COMPLETE
CYTOREDUCTION:
Peritonectomy and
Visceral Resections with
removal of all visible
disease
 PERIOPERATIVE
INTRAPERITONEAL
HYPERTHERMIC
CHEMOTHERAPY
 NO ROLE OF CRS OR
HIPEC ALONE

7. Peritonectomy procedures
The initially described six peritonectomy procedures have recently been
modified.
SUGARBAKER 1995,1999, 2013

8. INTRAPERIONEAL
CHEMOTHERAPY
 PERITONEAL
PLASMA BARRIER
 Concentration
difference
(peritonealexposurisu
pto 27 times of bone
marrowexposure)
 HIPEC/EPIC/BIDIRE
CTIONAL
 HIPEC:
OPEN/CLOSED

9. PERIOPERATIVE CHEMOTHERAPY
 HIPEC
 HYPERTHERMIA
 SHORT DURATION(90MIN)
 DRUGS DO NOT REQUIRE
CELL REPLICATION
 EPIC
 FOR 5 DAYS POST
OP
 DRUGS REQUIRE
CELL REPLICATION
 23 HOURS
DWELLING TIME

11. CREDITS AND DEBITS OF TWO DIFFERENT TECHNOLOGIES FOR
HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY

12. Paul H Sugarbaker, Kurt Van der Speeten

14. CURRENT INDICATIONS

15. INVESTIGATIONS
 GOLD STANDARD: Direct visualisation with
Laparoscopy or Laparotomy
 USG/ CT/ MRI/ FDG PET
 Standard is CT abdomen.
 low sensitivity in assessing small-bowel lesions (8%–
17%), which further drop down in less than 5mm lesion
 both CT and 18F-FDG PET/CT were unable to give a
correct staging of carcinomatosis
 18F-FDGPET/CT and MRI: No advantage
Pfannemberg et al 2009 .
Passot G et al 2010

16.  Diagnostic imaging (CT and CT/PET)
 When imaging-based PCI is in favor of enrolling the
patient for treatment, VLS staging allows
assessment of the true PCI, granting a correct
selection of patients.
 104/351 (29%) patients were excluded from surgical
exploration because of massive infiltration of the small
bowel or its mesentery basis detected by VLS. Valle et al 2009
ROLE OF STAGING
LAPAROSCOPY

17. LOCOREGIONAL STAGING
 SUGARBAKER’S PERITONEAL CANCER INDEX

18. LOCOREGIONAL STAGING
PRIOR SURGICAL SCORE
 PSS uses abdominopelvic
regions 0-8 to create an
important quantitative
prognostic indicator.
 No prior abdominopelvic
surgery or biopsy : PSS of 0
 Up to 1 abdominopelvic region
dissected : PSS of 1,
 2 – 5 abdominopelvic regions :
PSS of 2
 6 or more regions dissected :
PSS of 3
GILLY’S CLASSIFICATION
 Stage 0: no macroscopic
signs of disease
 Stage I: nodules smaller
than 5 mm,
 confined to one abdominal
region
 Stage II: nodules smaller
than 5 mm, disseminated
through the abdomen
 Stage III: size of nodules
between 5 mm and 2 cm
 Stage IV: lesions larger
than 2 cm

19. LOCOREGIONAL STAGING
JAPANESE CLASSIFICATION
 P1 (FEW NODULES ABOVE
THE MESOCOLON) 21% 2 YR
OS
 P2 (MODERATE AMOUNT OF
NODULES EVEN BELOW
TRANSVERSE MESOCOLON)
 P3 (MANY SPREAD
NODULES) 4% 2 YR OS
DUTCH SIMPLIFIED CANCER
INDEX
 Tumor is recorded as
Large >5cm
Moderate 1–5cm
Small <1cm
None
I Pelvis
II Right lower abdomen
III Greater omentum,
transverse colon and spleen
IV Right subdiaphragmatic area
V Left subdiaphragmatic area
VI Subhepatic and lesser
omental area
VII Small bowel and small
bowel mesentery

20. PROGNOSTIC INDICATORS
 BIOLOGICAL NATURE OF MALIGNANCY
 COMPLETENESS OF CYTOREDUCTIONSCORE
 Major prognostic factor for survival in PC patients.
 Absolute R0 resection is not necessary.
 According to this residual tumor classification,
 CC-0 no visible peritoneal seeding after CRS.
 CC-1 Persisting nodules less than 0.25 cm after CRS
indicates,
 CC-2 nodules between 0.25 and 2.5 cm indicates and
 CC-3 nodules greater than 2.5 cm indicates
AIM OF CRS: CC-0/CC-1

21. CRITERIA FOR PATIENT
SELECTION
CANADIAN HIPEC GROUP
GUIDELINES. Curr Oncol, Vol. 22 ,
2015

22. CONTRAINDICATIONS
 Mesenteric Root Infiltration
 Massive Involvement Of Retroperitoneum
 Massively Infiltrated Pancreatic Capsule
 Expected Small Bowel Resection For More Than One-third
Of The Whole Length
 BIOPSY PROVEN EXTRA-ABDOMINAL DISEASE LIKE
LUNG METS, SCLN.
 EXTRAPERITONEAL DISEASE, SUCH AS
MORE THAN 3 LIVER METASTASES
UNKNOWN PRIMARY TUMOUR.

23. RELATIVE CONTRAINDICATIONS :
 Bowel Obstruction at time of HIPEC
 Non responders to NACT (If Used To Downstage The Disease),
 Grade 3 Adeno- Carcinoma (Including Signet-ring Cells And Pmca)
 Frozen pelvis secondary to rectal cancer recurrence
SHORT INTERVAL B/W PRIMARY ADENOCARCINOMA & PC
(SYNCHRONOUS OR <6 MONTHS)
 Careful selection of patients
 NACT Is Strongly Recommended Before Crs Plus
HIPEC
 Patients with up to 3 liver metastases responding to NACT could be
eligible if all other patient and disease criteria are favourableCANADIAN HIPEC GROUP
GUIDELINES. Curr Oncol, Vol. 22 , 2015

24. CYTO-REDUCTION IN 2 STEPS
 In selected cases of a high PCI score and DPAM OR
PMCA-I, performing the cytoreduction as two
separate procedures is an option if
 Complete Cytoreduction Is Expected To Last More
Than 10–15 Hours,
 If Blood Loss Is Too High, Or
 If Surgical Complications Make Proceeding With
HIPEC a Contraindication.
 In such a situation,
First Surgery : Infra-mesocolic area is addressed
Second surgery : Supra- mesocolic + HIPEC

25. Locations of peritoneal surface
malignancy
 3 IMPORTANT anatomic sites .
1. THE RECTOSIGMOID COLON : non-mobile,
dependent site and frequently layered by peritoneal
metastases.
2. THE ILEOCECAL VALVE
3. ANTRUM OF THE STOMACH which is fixed to the
retroperitoneum at the pylorus.
 Tumor coming into the foramen of Winslow
accumulates in the subpyloric space and may cause
GOO.
 Large volumes of tumor in the lesser omentum
combined with disease in the subpyloric space may
require total gastrectomy for complete cytoreduction
Carmignani CP, Sugarbaker TA, ET AL Cancer
Metastasis Rev 2003;22:465-72.
Sugarbaker PH. Eur J Surg Oncol 2002;28:443-6.

26.  Isolated tumor nodules are removed using electro-
evaporation using ball tip cautery (viable tumor cells
at margin)
 Electroevaporation/ electrosurgery
 Less blood loss,
 less dissemination
of tumor cells.
 High energy likely to
kill tumor cells at
resection margin

27. ABDOMINAL EXPOSURE
Elevation of the edges of the abdominal incision. Skin traction on
a self-retaining retractor facilitates dissection of abdominal wall
structures and minimizes the likelihood of damage to bowel loops
adherent to the abdominal wall.

28. Xiphoidectomy
Xiphoidectomy is used to gain maximal exposure
beneath the right and left hemidiaphragms

29. Total anterior parietal
peritonectomy
Peritoneal window is necessary to assess the
need for total anterior parietal peritonectomy

30. Lateral dissection of the parietal peritoneum away
from the posterior rectus sheath and the
abdominal wall musculature completes the
anterior parietal peritonectomy.

31. Self-retaining retractor provides
continuous exposure of all quadrants of
the abdomen including the pelvis.

32. Left subphrenic peritonectomy

33. LEFT SUBPHRENIC
PERITONECTOMY COMPLETED

34. Stripping of tumor from glisson’s
capsule
Electroevaporation of tumor from the liver surface with
resection of Glisson’s capsule

35. Completed right subphrenic
peritonectomy

36. Lesser omentectomy and
cholecystectomy with stripping of the
hepatoduodenal ligament

37. Circumferential resection of the
hepatogastric ligament and lesser
omental fat by digital dissection

38. Stripping of the omental bursa after
dividing the peritoneal reflection
between left caudate lobe and
superior vena cava

39. Stripping of peritoneum from the
floor of the omental bursa and body
of the pancreas has been completed.

40. A. Division of the pont hepatique (hepatic bridge) for
cytoreduction along the umbilical ligament AND
B. Pont hepatique (hepatic bridge) divided showing
tumor nodules on the umbilical ligament beneath the
divided liver parenchyma. The umbilical ligament will
be resected at its entrance into the liver parenchyma.

41. The complete pelvic peritonectomy
includes uterus and ovaries,
rectosigmoid colon and pelvic
peritoneum.

42. Resection of rectosigmoid colon and
cul-de-sac of Douglas.

43. Vaginal closure and low colorectal
anastomosis

44. Optimization of cytoreduction of
small bowel and its mesentery
ELECTROSURGICAL DESTRUCTION
(ELECTROEVAPORATION) OF TUMOR
NODULES ON SMALL BOWEL
MESENTERY DURING HYPERTHERMIC
INTRAPERITONEAL CHEMOTHERAPY
USING THE OPEN TECHNIQUE.

45. CYTOREDUCTION OF SMALL
BOWEL AND ITS MESENTERY
Type 1 - non-invasive tumor nodules are usually
resectable using a curved Mayo scissor.

48. Complications
 Over all complication rates : 30-45%
 Chemotherapy toxicity to kidneys, bone
marrow, liver, lungs- 2-5%
 Organ damage secondary to hyperthermia
(Careful intra-operative monitoring avoids
them)
 Surgical complications – 25-30%
 MC small bowel fistula
 Mortality during procedure- 0-5%
EJSO 2008

49. RESPONSE TO CRS AND HIPEC
 PMP(APPENDICEAL ORIGIN)
 2298 patients in 16 centres having all subtypes of PMP
and being treated with CRS followed by HIPEC with
mitomycin C or oxaliplatin, a median progression-free
survival of 98MONTHS, a median os of 196 months, and
10- and 15-year survival rates of 63% and 59% Chua TC, Moran
BJ, Sugarbaker PH, et al JClin Oncol 2012
 MALIGNANT PERITONEAL MESOTHELIOMA
1047 patients), complete CRS was achieved in 67% of
cases (range: 46%–93%), yielded 3- and 5-year os rates
of 59% and 42% Helm JH, Miura JT, Glenn JA, et al Ann Surg Oncol 2015

50. RESPONSE TO CRS AND HIPEC
 GASTRIC CANCER
RCT 68 Chinese patients were allocated to crs with or
without hipec57. Morbidity did not vary, but hipec with
mitomycin C and cisplatin improved the os duration
(11.2 months vs. 5.6 months,p = 0.046). Yang XJ, Huang CQ,
Suo T, et alAnn Surg Oncol 2011
 COLORECTAL CANCER
Survival was better with crs and hipec (1884 patients)
than with palliative surgery and systemic
chemotherapy (1408 patients): median os was 33.0
months compared with 12.5 months, and 5-year
survival was 40% compared with 13%. Chua TC, Esquivel J,
Pelz JO, Morris DLJ Surg Oncol 2013

51. RESPONSE TO CRS AND HIPEC
 OVARIAN CANCER
 566 patients with advanced ovarian cancer treated
with crs and hipec, mortality wasvery low and
morbidity was acceptable, with the medianos being 35
months and 46 months for primary and recurrent
disease respectively Bakrin N, Bereder JM, Decullier E, et alEur J Surg
Oncol2013

52. LAPAROSCOPIC CRS AND HIPEC

54. Characteristics of patients undergoing
CRS and HIPEC

55. Morbidity and Mortality in patients
undergoing CRS and HIPEC