Peritoneal Surgery and
Intraperitoneal Chemotherapy, presented by Garrett Nash, MD of Memorial Sloan-Kettering at the Mesothelioma Applied Research Foundation's conference in New York, NY on September 28, 2012. www.curemeso.org
Peritoneal Surgery and Intraperitoneal Chemotherapy | Mesothelioma Applied Research Foundation
1. Peritoneal Mesothelioma
Cytoreductive Surgery and
Intraperitoneal Chemotherapy
Garrett Nash MD, MPH
Assistant Attending Surgeon
Memorial Sloan-Kettering Cancer Center
September 28th, 2012
2. Peritoneal Mesothelioma
About me
• Training in Colorectal Surgery and
Surgical Oncology
• Peritoneal based diseases
– Appendix Cancer
– Metastatic Colorectal Cancer
– Peritoneal Mesothelioma
3. Peritoneal Mesothelioma
Peritoneal Mesothelioma
• What is the disease?
• What are the surgical options?
• What are the outcomes after surgery?
4. Peritoneal Mesothelioma
Peritoneal Mesothelioma
• 2nd most common site of mesothelioma is the
peritoneum
– 10-30% of cases of mesothelioma
– 300-400/cases in U.S. year
5. Peritoneal Mesothelioma
Background
• Causes
– Asbestos exposure
– Simian virus-40
– Radiation
– Chronic inflammation of the peritoneum
• Presentation
– Increased abdominal girth
– Ascites (fluid in the abdomen)
– Abdominal pain
– Weight loss
6. Peritoneal Mesothelioma
Treatment Options
• “Traditional”
– Chemotherapy (doxorubicin and cisplatin)
– Radiation
– Drainage of abdominal fluid to alleviate pressure
(palliative paracentesis)
– Surgical excision of some of the tumor to alleviate
intestinal blockage (palliative debulking)
8. Peritoneal Mesothelioma
Surgical Options
• Cytoreductive surgery (CRS) and perioperative
intraperitoneal chemotherapy (IPC)
– Surgical cytoreduction to eliminate visible disease
by destroying tumor (burning/peeling/wiping) or
removing organs
– Delivery of chemotherapy directly to the
peritoneal surfaces to eliminate microscopic
disease
10. Peritoneal Mesothelioma
Management of Ovarian Cancer
415 patients with peritoneal metastasis were randomized
1. Intraperitoneal chemotherapy (post operative)
2. Intravenous chemotherapy after cytoreductive surgery
Gynecologic Oncology Group. N Engl J Med. 2006.5;354:34-43.
11. Peritoneal Mesothelioma
Management of Colorectal Cancer
105 patients with peritoneal metastasis were randomized
1. Intravenous chemotherapy
2. Cytoreductive surgery + intraperitoneal chemo + intravenous
chemo
CRS + IPC + IVC
IVC
Verwaal. J Clin Oncol. 2003;21(20):3737-43.
12. Peritoneal Mesothelioma
• Review of cytoreductive surgery and IPC
• 7 non randomized studies
• 240 patients
13. Peritoneal Mesothelioma
Inclusion Criteria Exclusion Criteria
• Histological diagnosis of • Surgical debulking without IPC
diffuse malignant peritoneal • Studies that mix in other
mesothelioma (DMPM) cancer types
• Patients undergoing
cytoreductive surgery (CRS) +
intraperitoneal chemo (IPC)
Annals of Oncology 18:827-834, 2007
15. Peritoneal Mesothelioma
Survival after CRS with IPC
• Range of average survival by study: 3-7 years
Annals of Oncology 18:827-834, 2007
16. Peritoneal Mesothelioma
Complications and Mortality after
Cytoreductive Surgery and IPC
• Average length of operation 6-10 hours
• Average hospital length of stay 16 days
• Surgical complication rate 25-40%
• Hematological toxicity 8-26%
• Perioperative mortality 0-8%
Annals of Oncology 18:827-834, 2007
17. Peritoneal Mesothelioma
How can we predict prognosis?
• No widely accepted staging system for
peritoneal mesothelioma
• No information on National Cancer Institute
website (cancer.gov)
18. Peritoneal Mesothelioma
• 8 institutions prospective collected data
• 294 patients treated with cytoreductive
surgery and intraperitoneal chemotherapy
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
19. Peritoneal Mesothelioma
• Primary objective: Formulate a staging
system through identification of prognostic
factors.
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
20. Peritoneal Mesothelioma
Patient Factors
Associated with Survival
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
21. Peritoneal Mesothelioma
Pathology/Surgery Factors
Associated with Survival
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
23. Peritoneal Mesothelioma
Pathology/Surgery Factors
Associated with Survival
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
24. Peritoneal Mesothelioma
Peritoneal cancer index (PCI)
• During surgery
• Tumor distribution (13 abdominal pelvic regions)
•Tumor nodule size (0-3 points)
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
25. Peritoneal Mesothelioma
Pathology/Surgery Factors
Associated with Survival
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
30. Peritoneal Mesothelioma
TNM staging system
• Most common system used for staging cancer
• T stage – size or depth of tumor (1-4)
• N stage – presence of lymph nodes with cancer (0-2)
• M stage – presence of metastasis to organs (0- 1)
31. Peritoneal Mesothelioma
TNM staging system
• Most common system used for staging cancer
• T stage – size or depth of tumor (1-4)
• N stage – presence of lymph nodes with cancer (0-2)
• M stage – presence of metastasis to organs (0- 1)
• For colon cancer
• Stage I = T1/2, N0, M0
• Stage II = T3/4, N0, M0
• Stage III = N1/2, M0
• Stage IV = M1
32. Peritoneal Mesothelioma
Survival Stratified by T Stage
Based on PCI
• T1 = PCI 1-10
• T2 = PCI 11-20
• T3 = PCI 21-30
• T4 = PCI 30-39
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
33. Peritoneal Mesothelioma
Survival Stratified by Nodal Stage
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
34. Peritoneal Mesothelioma
Survival Stratified by M stage
• M1 = extraabdominal
disease (e.g. chest/skin)
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
35. Peritoneal Mesothelioma
Overall survival stratified by
TNM staging system
52 patients
T1 N0 M0
166 patients
T2-3 N0 M0
76 patients
T4 or N1 or M1
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
36. Peritoneal Mesothelioma
Combining TNM Stage
with Histology and Optimal Surgery
HR CI
Sarcomatoid vs. epitheloid 5.5 2.9-10.5
Incomplete vs. complete CRS 2.0 1.2-3.2
Stage II vs. I 3.3 1.2-9.4
Stage III vs. I 5.9 2.1-17.2
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
37. Peritoneal Mesothelioma
Summary
• Appears to stratify patients for prognosis
– Patients who do poorly
• High volume disease
• Extra-abdominal disease
• Non-epitheloid histology
– Patients who do ‘well’
• Low volume disease
• Node negative
– Selected patients undergoing CRS
Yan TD, et al. Cancer. 2011 May 1;117(9):1855-63
38. Peritoneal Mesothelioma
Conclusions
• Surgery offers good long term outcomes
for selected patients with favorable
tumors
• Surgery is high risk
• We need comparative studies that
demonstrate how much surgery and
intraperitoneal chemotherapy may
benefit patients
39. Peritoneal Mesothelioma
Thank You
• Mesothelioma Applied Research
Foundation and Lee Krug, MD
40. Peritoneal Mesothelioma
Thank You
• Mesothelioma Applied Research
Foundation and Lee Krug, MD
• My medical oncology collaborator,
Andrea Cercek, MD
41. Peritoneal Mesothelioma
Thank You
• Mesothelioma Applied Research
Foundation and Lee Krug, MD
• My medical oncology collaborator,
Andrea Cercek, MD
• The patients who allow us to study their
tumors