Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden How to handle peritoneal carcinomatosis found at laparotomy
Swedish Gastrointestinal Tumour Adjuvant Therapy Group Adjuvant Chemotherapy Intraperitoneal chemotherapy (5-FU 500 mg/m 2 /day i.p.) (Leucovorin 60 mg/m 2 /day i.v.) vs Surgery alone (Double - blinded)
Swedish Gastrointestinal Tumour Adjuvant Therapy Group Intraperitoneal chemotherapy 100 patients included (All Dukes´ stages) Postop. recovery not affected ! Graf et. al. Int J Colorect Dis 1994; 9:35-39
Cytoreductive surgery + i.p chemo Objectives Local effect on the surgical bed Early treatment start I.v. chemo does not reach the target
Cytoreductive surgery + i.p chemo Isolated peritoneal carcinomatosis Colorectal cancer Ovarian cancer Mesothelioma Peritoneal pseudomyxoma Other GI malignancies
Cytoreductive surgery + i.p chemo Uppsala series Type of malignancy Pseudomyxoma 197 Colorectal cancer259 Mesothelioma 41 Miscellaneous 46 Total543
Cytoreductive surgery + i.p chemo Uppsala series Many patients have had second - look operations Approx. two procedure per week in total 650 operations
Cytoreductive surgery + i.p chemo What survival figures do you expect ? A: As good as for liver met ! B: Not as good as for liver met !
Cytoreductive surgery + i.p chemo If not as good as for liver metastasis, how good is it ? A: % 5-years survival B: % 5-years survival C: % 5-years survival D: % 5-years survival
Mahteme et al Br J Cancer 2004 Cytoreductive surgery + i.p chemo Uppsala series Colon cancer
Mahteme et al Br J Cancer 2004 Cytoreductive surgery + i.p chemo Uppsala series Colon cancer
Cytoreductive surgery + i.p chemo Uppsala experience colon cancer Randomized trial Classic chemotherapy vs Cytoreductive surgery + i.p chemo
Randomized trial in Uppsala 50 patients included 46 evaluated Significant survival benefit in the cytoreduction + chemo group 30 % DSF 3-years survival
Cashin et al E J S O 2013 Cytoreductive surgery + i.p chemo
Patient stage with a good CT Sigmoid cancer. You find 3 small nodules on the surface of the liver easy to remove: A: Leave them and do a better staging B: Take them out C: Use intraoperative ultra sound.
Patient stage with a good CT No good evidence but B is correct: A: Leave them and do a better staging B: Take them out C: Use intraoperative ultra sound.
Patient stage with a good CT Right-sided cancer. Massive peritoneal carcinosis around the primary: A: Leave the primary for better staging B: Resect the tumour and give adjuvant chemotherapy C: Leave the primary and refer the patient to a HIPEC-unit
Patient stage with a good CT This is a classic case for C: A: Leave the primary for better staging B: Resect the tumour and give adjuvant chemotherapy C: Leave the primary and refer the patient to a HIPEC-unit
Patient stage with a good CT Right-sided cancer. Just a few deposits around the primary tumour: A: Leave the primary for better staging B: Resect the tumour and give adjuvant chemotherapy C: Leave the primary and refer the patient to a HIPEC-unit
Patient stage with a good CT Still C is correct: A: Leave the primary for better staging B: Resect the tumour and give adjuvant chemotherapy C: Leave the primary and refer the patient to a HIPEC-unit
Patient stage with a good CT Why always send all peritoneal carcinosis to a HIPEC-unit: A: Cytoreductive surgery is difficult if retroperitoneum is opened B: An increase for distant spread C: HIPEC does not work if retroperitoneum is opened
Patient stage with a good CT A correct ! It is very difficult to take peritoneum out at the next operation: A: Cytoreductive surgery is difficult if retroperitoneum is opened B: An increase for distant spread C: HIPEC does not work if retroperitoneum is opened
Cytoreductive surgery + HIPEC Special issues Laparoscopy Drainage Distant metastases Morbidity
Cytoreductive surgery + HIPEC Take home message Always send the patients to a HIPEC-unit
Cytoreductive surgery + HIPEC Conclusion Pseudomyxoma; Standard of care CRC; Standard of care Ovarian cancer; experimental ? Mesotelioma; Standard of care ? Gastric cancer; No