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By 
Ihab Samy Fayek 
Lecturer of Surgical Oncology 
National Cancer Institute – Cairo University 
2014
Peritoneal carcinomatosis. 
Mesothelioma. 
Sarcomatosis.
Two essential components: 
First, cytoreductive surgery (CRS) to resect 
visible implants within the abdomen and pelvis 
(Peritonectomy along with visceral resections was 
developed to surgically deal with cancer on 
peritoneal surfaces). 
Second, local-regional chemotherapy 
(intraperitoneal chemotherapy or hyperthermic 
intraperitoneal chemotherapy HIPEC).
Lack of Clinical Evidence for Alternative 
Management Strategies. 
Natural History Studies Document the 
Importance of Local-Regional Progression. 
Validated Quantitative Prognostic Indicators.
A near total lack of scientific data to support an 
alternative treatment plan. 
Level 1 data regarding the effectiveness of systemic 
chemotherapy for peritoneal carcinomatosis has not 
been published. 
The response to systemic chemotherapy is not the 
same for all anatomic sites of metastatic disease. 
Over the past decade, multiple phase 2 and 3 studies 
with CRS and POC report a median survival benefit 
two to four times greater than survival using systemic 
chemotherapy.
Recurrence of the primary cancer isolated to the 
surfaces of the abdomen and pelvis is a reality. 
Isolated peritoneal surface progression of 
abdominal or pelvic malignancy is not unusual. 
Cancer cells at low density result in peritoneal 
carcinomatosis at a distance from the primary 
cancer resection. 
Cancer cells at higher density become trapped 
within raw surfaces at the resection site.
The same group of quantitative prognostic 
indicators operates for all patients with peritoneal 
surface malignancy. 
Prognostic indicators are used to refine the 
selection of patients to those most likely to benefit 
and to exclude those who are unlikely to benefit. 
Histopathology assessments, the peritoneal cancer 
index (PCI), the completeness of cytoreduction 
score (CC), and radiologic imaging by computed 
tomography (CT) play a central role in refining 
patient selection.
Mucinous appendiceal neoplasms Patients with 
adenomucinosis: maximal survival benefit, while those 
with mucinous carcinoma show survivals similar to that 
for peritoneal carcinomatosis of colorectal origin. 
Peritoneal Mesothelioma Seven different histologic 
patterns of peritoneal mesothelioma contribute to three 
distinct histologic groups that have a very different 
prognosis following CRS with POC. 
Poor prognosis for sarcomatoid, deciduoid, or biphasic 
type; intermediate prognosis for papillary and epithelial 
type; and excellent prognosis for low-grade or 
multicystic type.
The PCI is an assessment combining lesion 
size (0 to 3) with tumor distribution 
(abdominopelvic regions 0 to 12) to quantify 
the extent of disease within the abdomen and 
pelvis as a numerical score. 
It is calculated at the time of surgical 
exploration of the abdomen and pelvis. 
The higher the PCI, the less likely CRS and 
POC will result in long-term survival.
The new definition of complete cytoreduction is 
no visible evidence of cancer or only minute 
nodules reliably penetrated by POC, a 
completeness of cytoreduction score of 0 (CC- 
0) or CC-1, respectively. 
With few exceptions an optimal CC-0 or CC-1 
score is necessary for long-term benefit with 
CRS and POC.
CT of the chest, abdomen, and pelvis is an essential 
tool in the selection of patients for CRS with POC. 
Systemic metastases and spread to pleural surfaces 
can be identified. 
The location and quantity of mucinous carcinoma within 
the peritoneal cavity can be accurately determined, 
small bowel compartmentalization versus diffuse 
involvement of the small bowel. 
If the small bowel and its mesentery are coated by 
tumor or a large mass of cancer occupies the epigastric 
region, the likelihood of achieving complete 
cytoreduction is small.
As determined by physical properties, some 
chemotherapy agents are especially appropriate 
for hyperthermic use in the peritoneal cavity after a 
cytoreductive surgery has been completed. 
Other chemotherapy agents are more appropriate 
for early postoperative intraperitoneal 
chemotherapy. 
As experience with POC has accumulated, the use 
of multiple-agent chemotherapy has evolved and 
promises to be increasingly effective. 
Heat targeting is the goal of treatment.
The cytoreductive surgical procedure involves 
visceral resections and peritonectomy procedures 
in an attempt to leave the abdomen visibly free of 
cancer. 
After the CRS is complete, tubes and drains are 
positioned to facilitate inflow and outflow of the 
chemotherapy solution. 
The chemotherapy solution circulates through 
roller pumps and a heat exchanger to maintain 
moderate hyperthermia (42°C/109°F) within the 
abdomen and pelvis.
The skin edges are elevated on a self-retaining 
retractor (open method) or the skin closed 
(closed method) in order to create a reservoir 
for the hyperthermic chemotherapy solution. 
Following the HIPEC treatment, access to the 
abdomen and pelvis is re-established to 
perform the intestinal reconstruction. 
Mechanical and chemical washing of the 
complete parietal and visceral surfaces by the 
warm chemotherapy solution will prevent a 
reimplantation of cancer cells following CRS.
The complexity originates from the treatment as 
well as from the management of the complications. 
The peak of the learning curve in the study of is 
reached after approximately 130 procedures. 
Surgical skill is undoubtedly the main component 
of this learning process, but experience in handling 
complications contributed to a decreased morbidity 
and mortality.
Intra-abdominal seeding of tumor cells early in 
the natural history of the disease with 
neoplastic cells throughout the peritoneal 
cavity. 
Simple mucinous adenoma: A tumor with more 
than 90% mucus, flat epithelial cells, no atypia, 
and no mitoses had a good prognosis despite 
extensive intra-abdominal spreading  DPAM, 
disseminated peritoneal adenomucinosis
Peritoneal carcinoma (PCA): a primary tumor 
with much atypia, abundant mitoses, and less 
than 50% mucus has a prognosis similar to 
colorectal carcinomatosis, even with much less 
intra-abdominal spreading. 
Peritoneal mucinous carcinoma (PMCA): 
Intermediate prognosis.
Stage IV colorectal cancer is a very morbid 
disease, with a 5-year survival rate of 10% and 
a median survival of 14.4 months. 
The prognosis is significantly worse when 
peritoneal carcinomatosis (PC) is present, with 
a median survival of 6.7 months versus 18.1 
months without PC (P <.01).
At the initial diagnosis of colon cancer, the 
peritoneal surface is involved with tumor in 
10% to 15% of patients. 
Besides the liver, the peritoneal surfaces are 
the most common sites of cancer recurrence 
after “curative” colorectal cancer resections. 
Cancer progression occurs in as many as 50% 
of patients who had an R0 resection.
The key issue is to determine whether palliative 
(systemic chemotherapy) or curative (complete 
cytoreductive surgery [CCRS] with HIPEC) 
treatment is indicated. 
Contraindications 
1. The presence of metastases at another site. 
2. A poor general status. 
3. Extensive PC is likely to be unresectable in its 
entirety (PCI >20).
Five years after surgery, no patient was alive if 
the size of the residual tumor nodules 
exceeded 2 mm after surgery, whereas 30% of 
the patients were alive if CCRS was possible 
(P <.0001). 
Median survival was 63 months in the CCRS 
with HIPEC group versus 24 months in the 
systemic chemotherapy group.
Peritoneal dissemination is the most frequent 
pattern of metastasis and recurrence with 
gastric cancers. 
PC occurs in 5% to 20% of patients being 
explored for potentially curative resection. 
Regarding the efficiency of this combined 
procedure (CRS and HIPEC) remains 
controversial for carcinomatosis (incurable?).
A median follow-up of 20.4 months, the overall 
median survival was only 9.2 months but the 5- 
year survival rate was 13%, with some long-term 
survivors. 
The combination of cytoreductive surgery with 
HIPEC was the only therapeutic strategy that 
reported survivors at 5 years. 
Recently, a 5-year survival of 23% and a median 
survival of 15 months, was obtained in patients 
treated with complete macroscopic resection 
(PCI<12).
The median overall survival was 30.3 months. 
The factors significant for increased survival were 
sensitivity to platinum response (P = .048), 
completeness of cytoreduction score of 1 or 0 (P = 
.025), carboplatin alone or combination (P = .011), 
and duration of hospital stays of 10 days or less (P 
= .021). 
A 75% 5-year survival in those 55 years or less, 
with the best survival in those with no visible 
disease at the end of CRS.
Peritoneal surface malignancies

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Peritoneal surface malignancies

  • 1. By Ihab Samy Fayek Lecturer of Surgical Oncology National Cancer Institute – Cairo University 2014
  • 3. Two essential components: First, cytoreductive surgery (CRS) to resect visible implants within the abdomen and pelvis (Peritonectomy along with visceral resections was developed to surgically deal with cancer on peritoneal surfaces). Second, local-regional chemotherapy (intraperitoneal chemotherapy or hyperthermic intraperitoneal chemotherapy HIPEC).
  • 4. Lack of Clinical Evidence for Alternative Management Strategies. Natural History Studies Document the Importance of Local-Regional Progression. Validated Quantitative Prognostic Indicators.
  • 5. A near total lack of scientific data to support an alternative treatment plan. Level 1 data regarding the effectiveness of systemic chemotherapy for peritoneal carcinomatosis has not been published. The response to systemic chemotherapy is not the same for all anatomic sites of metastatic disease. Over the past decade, multiple phase 2 and 3 studies with CRS and POC report a median survival benefit two to four times greater than survival using systemic chemotherapy.
  • 6. Recurrence of the primary cancer isolated to the surfaces of the abdomen and pelvis is a reality. Isolated peritoneal surface progression of abdominal or pelvic malignancy is not unusual. Cancer cells at low density result in peritoneal carcinomatosis at a distance from the primary cancer resection. Cancer cells at higher density become trapped within raw surfaces at the resection site.
  • 7. The same group of quantitative prognostic indicators operates for all patients with peritoneal surface malignancy. Prognostic indicators are used to refine the selection of patients to those most likely to benefit and to exclude those who are unlikely to benefit. Histopathology assessments, the peritoneal cancer index (PCI), the completeness of cytoreduction score (CC), and radiologic imaging by computed tomography (CT) play a central role in refining patient selection.
  • 8. Mucinous appendiceal neoplasms Patients with adenomucinosis: maximal survival benefit, while those with mucinous carcinoma show survivals similar to that for peritoneal carcinomatosis of colorectal origin. Peritoneal Mesothelioma Seven different histologic patterns of peritoneal mesothelioma contribute to three distinct histologic groups that have a very different prognosis following CRS with POC. Poor prognosis for sarcomatoid, deciduoid, or biphasic type; intermediate prognosis for papillary and epithelial type; and excellent prognosis for low-grade or multicystic type.
  • 9. The PCI is an assessment combining lesion size (0 to 3) with tumor distribution (abdominopelvic regions 0 to 12) to quantify the extent of disease within the abdomen and pelvis as a numerical score. It is calculated at the time of surgical exploration of the abdomen and pelvis. The higher the PCI, the less likely CRS and POC will result in long-term survival.
  • 10. The new definition of complete cytoreduction is no visible evidence of cancer or only minute nodules reliably penetrated by POC, a completeness of cytoreduction score of 0 (CC- 0) or CC-1, respectively. With few exceptions an optimal CC-0 or CC-1 score is necessary for long-term benefit with CRS and POC.
  • 11. CT of the chest, abdomen, and pelvis is an essential tool in the selection of patients for CRS with POC. Systemic metastases and spread to pleural surfaces can be identified. The location and quantity of mucinous carcinoma within the peritoneal cavity can be accurately determined, small bowel compartmentalization versus diffuse involvement of the small bowel. If the small bowel and its mesentery are coated by tumor or a large mass of cancer occupies the epigastric region, the likelihood of achieving complete cytoreduction is small.
  • 12. As determined by physical properties, some chemotherapy agents are especially appropriate for hyperthermic use in the peritoneal cavity after a cytoreductive surgery has been completed. Other chemotherapy agents are more appropriate for early postoperative intraperitoneal chemotherapy. As experience with POC has accumulated, the use of multiple-agent chemotherapy has evolved and promises to be increasingly effective. Heat targeting is the goal of treatment.
  • 13. The cytoreductive surgical procedure involves visceral resections and peritonectomy procedures in an attempt to leave the abdomen visibly free of cancer. After the CRS is complete, tubes and drains are positioned to facilitate inflow and outflow of the chemotherapy solution. The chemotherapy solution circulates through roller pumps and a heat exchanger to maintain moderate hyperthermia (42°C/109°F) within the abdomen and pelvis.
  • 14. The skin edges are elevated on a self-retaining retractor (open method) or the skin closed (closed method) in order to create a reservoir for the hyperthermic chemotherapy solution. Following the HIPEC treatment, access to the abdomen and pelvis is re-established to perform the intestinal reconstruction. Mechanical and chemical washing of the complete parietal and visceral surfaces by the warm chemotherapy solution will prevent a reimplantation of cancer cells following CRS.
  • 15. The complexity originates from the treatment as well as from the management of the complications. The peak of the learning curve in the study of is reached after approximately 130 procedures. Surgical skill is undoubtedly the main component of this learning process, but experience in handling complications contributed to a decreased morbidity and mortality.
  • 16. Intra-abdominal seeding of tumor cells early in the natural history of the disease with neoplastic cells throughout the peritoneal cavity. Simple mucinous adenoma: A tumor with more than 90% mucus, flat epithelial cells, no atypia, and no mitoses had a good prognosis despite extensive intra-abdominal spreading  DPAM, disseminated peritoneal adenomucinosis
  • 17. Peritoneal carcinoma (PCA): a primary tumor with much atypia, abundant mitoses, and less than 50% mucus has a prognosis similar to colorectal carcinomatosis, even with much less intra-abdominal spreading. Peritoneal mucinous carcinoma (PMCA): Intermediate prognosis.
  • 18. Stage IV colorectal cancer is a very morbid disease, with a 5-year survival rate of 10% and a median survival of 14.4 months. The prognosis is significantly worse when peritoneal carcinomatosis (PC) is present, with a median survival of 6.7 months versus 18.1 months without PC (P <.01).
  • 19. At the initial diagnosis of colon cancer, the peritoneal surface is involved with tumor in 10% to 15% of patients. Besides the liver, the peritoneal surfaces are the most common sites of cancer recurrence after “curative” colorectal cancer resections. Cancer progression occurs in as many as 50% of patients who had an R0 resection.
  • 20. The key issue is to determine whether palliative (systemic chemotherapy) or curative (complete cytoreductive surgery [CCRS] with HIPEC) treatment is indicated. Contraindications 1. The presence of metastases at another site. 2. A poor general status. 3. Extensive PC is likely to be unresectable in its entirety (PCI >20).
  • 21. Five years after surgery, no patient was alive if the size of the residual tumor nodules exceeded 2 mm after surgery, whereas 30% of the patients were alive if CCRS was possible (P <.0001). Median survival was 63 months in the CCRS with HIPEC group versus 24 months in the systemic chemotherapy group.
  • 22. Peritoneal dissemination is the most frequent pattern of metastasis and recurrence with gastric cancers. PC occurs in 5% to 20% of patients being explored for potentially curative resection. Regarding the efficiency of this combined procedure (CRS and HIPEC) remains controversial for carcinomatosis (incurable?).
  • 23. A median follow-up of 20.4 months, the overall median survival was only 9.2 months but the 5- year survival rate was 13%, with some long-term survivors. The combination of cytoreductive surgery with HIPEC was the only therapeutic strategy that reported survivors at 5 years. Recently, a 5-year survival of 23% and a median survival of 15 months, was obtained in patients treated with complete macroscopic resection (PCI<12).
  • 24. The median overall survival was 30.3 months. The factors significant for increased survival were sensitivity to platinum response (P = .048), completeness of cytoreduction score of 1 or 0 (P = .025), carboplatin alone or combination (P = .011), and duration of hospital stays of 10 days or less (P = .021). A 75% 5-year survival in those 55 years or less, with the best survival in those with no visible disease at the end of CRS.