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/m2/day i.p.)

(Leucovorin 60 mg/m2/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 1991 - 2010

Type of malignancy

Pseudomyxoma 197

Colorectal cancer 259

Mesothelioma 41

Miscellaneous 46

Total 543

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

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: 30 - 40 % 5-years survival

B: 20 - 30 % 5-years survival

C: 15 - 20 % 5-years survival

D: 10 - 15 % 5-years survival

Mahteme et al Br J Cancer 2004

Cytoreductive surgery + i.p chemo

ip group

Control group

Cumulative Proportion Surviving (Kaplan-Meier)

Complete Censored

Months

Cu

mu

lativ

e P

rop

ort

ion

Su

rviv

ing

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

0 12 24 36 48 60 72 84 96 108 120 132 144

Figure 1

Uppsala seriesColon cancer

Mahteme et al Br J Cancer 2004

Cytoreductive surgery + i.p chemo

Uppsala series

Radically operated

Non-radical operated

Cumulative Proportion Surviving (Kaplan-Meier)

Complete Censored

Months

Cum

ulat

ive

Pro

port

ion

Sur

vivi

ng

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

0 12 24 36 48 60 72 84 96 108 120 132 144

Figure 2

Uppsala seriesColon cancer

Cytoreductive surgery + i.p chemo

Uppsala experience colon cancer

Randomized trial

Classic chemotherapy

vs

Cytoreductive surgery + i.p chemo

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