1. Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden How to handle peritoneal carcinomatosis found at laparotomy

2. 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)

3. 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

4. Cytoreductive surgery + i.p chemo Objectives  Local effect on the surgical bed  Early treatment start  I.v. chemo does not reach the target

5. Cytoreductive surgery + i.p chemo Isolated peritoneal carcinomatosis  Colorectal cancer  Ovarian cancer  Mesothelioma  Peritoneal pseudomyxoma  Other GI malignancies

6. Cytoreductive surgery + i.p chemo Uppsala series 1991 - 2010 Type of malignancy Pseudomyxoma 197 Colorectal cancer259 Mesothelioma 41 Miscellaneous 46 Total543

7. Cytoreductive surgery + i.p chemo Uppsala series 1991 - 2010 Many patients have had second - look operations Approx. two procedure per week in total  650 operations

8. 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 !

9. Cytoreductive surgery + i.p chemo  If not as good as for liver metastasis, how good is it ? A: 30 - 40 % 5-years survival B: 20 - 30 % 5-years survival C: 15 - 20 % 5-years survival D: 10 - 15 % 5-years survival

10. Mahteme et al Br J Cancer 2004 Cytoreductive surgery + i.p chemo Uppsala series Colon cancer

11. Mahteme et al Br J Cancer 2004 Cytoreductive surgery + i.p chemo Uppsala series Colon cancer

12. Cytoreductive surgery + i.p chemo Uppsala experience colon cancer Randomized trial Classic chemotherapy vs Cytoreductive surgery + i.p chemo

13. Randomized trial in Uppsala 50 patients included 46 evaluated Significant survival benefit in the cytoreduction + chemo group 30 % DSF 3-years survival

14. Cashin et al E J S O 2013 Cytoreductive surgery + i.p chemo

15. 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.

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Cytoreductive surgery + HIPEC Special issues  Laparoscopy  Drainage  Distant metastases  Morbidity

24. Cytoreductive surgery + HIPEC Take home message Always send the patients to a HIPEC-unit

25. Cytoreductive surgery + HIPEC Conclusion  Pseudomyxoma; Standard of care  CRC; Standard of care  Ovarian cancer; experimental ?  Mesotelioma; Standard of care ?  Gastric cancer; No