Complete peritonectomy and intraperitoneal chemotherapy for recurrent rectal cancer with peritoneal metastasis

A 68-year-old man underwent laparoscopic low anterior resection for rectal carcinoma in December 2006.Nearly 19 mo after the operation,he developed recurrent rectal cancer with peritoneal metastasis. In September 2008,he subsequently underwent a laparotomy with a peritonectomy,omentectomy, splenectomy,and a Hartmann procedure.Hyperthermic intraperitoneal oxaliplatin 750 mg was administered. The patient was discharged with no postoperative complications and has been well with postoperative FOLFOX chemotherapy.

Peritonectomy HIPEC-contemporary results,indications

Paul Sugarbaker＇s procedural description in this paper （1）comes from the pioneer and master of this area. His original description of peritoneal cancer index （PCI） and cytoreduction score （CC） is also fundamental to selection of patients and intraoperative assessment. PCI is calculated by dividing

Encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis(EPS) is a debilitating condition characterized by a fibrocollagenous membrane encasing the small intestine, resulting in recurrent small bowel obstructions. EPS is most commonly associated with long-term peritoneal dialysis, though medications, peritoneal infection, and systemic inflammatory disorders have been implicated. Many cases remain idiopathic. Diagnosis is often delayed given the rarity of the disorder combined with non-specific symptoms and laboratory findings. Although cross-sectional imaging with computed tomography of the abdomen can be suggestive of the disorder, many patients undergo exploratory laparotomy for diagnosis. Mortality approaches 50% one year after diagnosis. Treatment for EPS involves treating the underlying condition or eliminating possible inciting agents(i.e. peritoneal dialysis, medications, infections) and nutritional support, frequently with total parenteral nutrition. EPSspecific treatment depends on the disease stage. In the inflammatory stage, corticosteroids are the treatment of choice, while in the fibrotic stage, tamoxifen may be beneficial. In practice, distinguishing between stages may be difficult and both may be used. Surgical intervention, consisting of peritonectomy and enterolysis, is timeconsuming and high-risk and is reserved for situations in which conservative medical therapy fails in institutions with surgical expertise in this area. Herein we review the available literature of the etiology, pathogenesis, diagnosis, and treatment of this rare, but potentially devastating disease.

Malignant peritoneal mesothelioma

Malignant mesothelioma is a highly aggressive neoplasm.The incidence of malignant mesothelioma is increasing worldwide.Diffuse malignant peritoneal mesothelioma(DMPM) represents one-fourth of all mesotheliomas.Association of asbestos exposure with DMPM has been observed,especially in males.The great majority of patients present with abdominal pain and distension,caused by accumulation of tumors and ascitic ? uid.In the past,DMPM was considered a pre-terminal condition;therefore attracted little attention.Patients invariably died from their disease within a year.Recently,several prospective trials have demonstrated a median survival of 40 to 90 mo and 5-year survival of 30% to 60% after combined treatment using cytoreductive surgery and perioperative intraperitoneal chemotherapy.This remarkable improvement in survival has prompted new search into the medical science related to DMPM,a disease previously ignored as uninteresting.This review article focuses on the key advances in the epidemiology,diagnosis,staging,treatments and prognosis of DMPM that have occurred in the past decade.

Cytoreduction and hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis from pseudomixoma peritonei

AIM： To investigate the most important aspects of hyperthermic intraperitoneal chemotherapy （HIPEC） that has been accepted as the standard treatment for pseudomyxoma peritonei （PMP）, with special regard to morbidity, overall survival （OS） and disease free survival （DFS） over 10 years. METHODS： Fifty-three patients affected by PMP underwent cytoreduction （CCR） and HIPEC with a ＂semi-closed＂ abdomen technique in our institution. The peritonectomy procedure and completeness of CCR were classified according to Sugarbaker criteria. Preoperative evaluation always included thoracic and abdominal CT scan to stage peritoneal disease and exclude distant metastases. Fifty-one patients in our series were treated with a protocol based on administration of cisplatinum 100 mg/m^2 plus mitomycin C 16 mg/m^2, at a temperature of 41.5℃ for 60 min. Anastomoses were always performed at the end of HIPEC. The mean duration of surgery was 12 h including HIPEC. Continuous monitoring of hepatic and renal functions and hydroelectrolytic balance was performed in the postoperative period. RESULTS： Twenty-four patients presented with postoperative complications： surgical morbidity was observed in 16 patients and 6 patients were reoperated. All complications were successfully treated and no postoperative deaths were observed. Risk factors for postoperative morbidity were considered to be gender, age, body surface, duration of surgery,Peritoneal Cancer Index （PCI） and tumor residual value （CC score）. No statistically significant correlation was found during the multivariate analysis： only the CC score was statistically significant. The OS in our experience was 81.8%, with a DFS of 80% at 5 years and of 70% at 10 years. CONCLUSION： In our experience, even if HIPEC combined with cytoreductive surgery involves a high risk of morbidity, postoperative complications can be resolved favorably in most cases with correct patient selection and adequate postoperative care, thus minimizing mortality. The association of CCR and HIPEC can be considered as the standard treatment for PNP. The OS and DFS results confirm the validity of this combined approach for the treatment of this rare neoplasm. The impact of preoperative chemotherapy on OS, in our opinion, is due to a major aggressiveness of tumors in treated patients.

Management of pseudomyxoma peritonei

Pseudomyxoma peritonei (PMP) is a rare disease. It refers to a progressive disease process within the peritoneum which originates from the appendix or ovaries and is characterised by the production of copious amounts of mucinous fluid resulting in a “jelly belly”. If untreated the condition is fatal. The traditional approach to PMP is based on repeated surgical debulking procedures, often associated with intraperitoneal or systemic chemotherapy. The natural history of this disease has been drastically modified since the introduction of a new surgical approach defined as a peritonectomy procedure. This paper is to review the literature on this treatment strategy.

Multimodality treatment strategies have changed prognosis of peritoneal metastases

For a long time, treatment of peritoneal metastases(PM) was mostly palliative and thus, this status was link with "terminal status/despair". The current multimodal treatment strategy, consisting of cytoreductive surgery(CRS) and hyperthermic intraperitoneal chemotherapy(HIPEC), has been strenuously achieved over time, but seems to be the best treatment option for PM patients. As we reviewed the literature data, we could emphasize some milestones and also, controversies in the history of proposed multimodal treatment and thus, outline the philosophy of this approach, which seems to be an unusual one indeed. Initially marked by nihilism and fear, but benefiting from a remarkable joint effort of human and material resources(multi-center and-institutional research), over a period of 30 years, CRS and HIPEC found their place in the treatment of PM. The next 4 years were dedicated to the refinement of the multimodal treatment, by launching research pathways. In selected patients, with requires training, it demonstrated a significant survival results(similar to the Hepatic Metastases treatment), with acceptable risks and costs. The main debates regarding CRS and HIPEC treatment were based on the oncologists' perspective and the small number of randomized clinical trials. It is important to statement the PM patient has the right to be informed of the existence of CRS and HIPEC, as a real treatment resource, the decision being made by multidisciplinary teams.

Comprehensive treatment for the peritoneal metastasis from gastric cancer

Recently, a novel comprehensive treatment consisting of cytoreductive surgery(CRS) and perioperative chemotherapy(POC) was developed for the treatment of peritoneal metastasis(PM) with a curative intent. In the treatment, the macroscopic disease is completely removed by the peritonectomy techniques in combination with POC. This article reviews the results of the comprehensive treatment for PM from gastric cancer, and verifies the effects of CRS and POC, including neoadjuvant chemotherapy(NAC) and hyperthermic intraoperative intraperitoneal chemotherapy(HIPEC). Completeness of cytoreduction, peritoneal carcinomatosis index(PCI) less than the threshold levels after NAC,absence of ascites, cytologic status, pathologic response after NAC are the independent prognostic factors. Among these prognostic factors, PCI threshold level is the most valuable independent prognostic factor. After staging laparoscopy, patients with PM from gastric cancer are recommended to treat with NAC before CRS. After NAC, indication for CRS is determined by laparoscopy. The indications of the comprehensive treatment are patients with PCI less than the threshold levels, negative cytology, and responders after NAC. Patients satisfy these factors are the candidates for the CRS and HIPEC.

Total Peritoneal Gutter Removal versus Random Peritoneal Biopsy in Cases of Ovarian Cancer

Introduction: Ovarian cancer is the fourth most prevalent cancer among women and the seventh most common cancer overall. Every year, an estimated 200,000 cases and 125,000 deaths related to ovarian cancer are reported around the world. It is most common in high-resource countries, with an incidence rate of 9.3 per 100,000 women. Ovarian cancer is detected at an advanced stage in about 70% of instances, and only 30% of women with such cancers live for more than 5 years. Although only around 20% of ovarian cancers are limited to the ovaries at diagnosis, patients with localized disease have a 5-year survival rate of more than 90%. Peritonectomy is a crucial part of the surgical treatment for ovarian cancer. Visual inspection and palpation are not reliable methods for determining the extent of tumour involvement. The majority of gynecologic oncologists are suspicious about the benefits of a full peritonectomy, concerned about the benefits and hazards. They believe that the tumor’s fundamental biology, not surgical aggressiveness, dictates the tumor’s resectability. The aim of this work was primarily to compare the differences between total peritoneal gutter removal and random peritoneal biopsy in cases of early ovarian cancer. A secondary aim of this work is to show ability of total peritoneal gutter removal in relation to that of random peritoneal biopsy to detect positivity of metastasis in the histopathological specimens. Patients and Methods: This prospective cohort study was conducted on 130 patients with early ovarian cancer in El-Shatby hospital, Faculty of Medicine, Alexandria University. For each patient, we took random and total peritoneal biopsy and compared between them regarding technique, timing, post-operative complications, and histopathological results. Inclusion criteria: all age group, suspected ovarian cancer using IOTA score, absence of nodules in the peritoneal gutter using CT and any case that needs staging laparotomy for ovarian cancer. Exclusion criteria: presence of gross peritoneal disease in the gutter and CT features of advanced ovarian cancer (peritoneal deposits, omental cakes, pelvic and para-aortic lymphadenopathy). All cases will be subjected to the followings: history taking, clinical examination, suspicious ovarian mass using IOTA score, tumor markers, CT staging, staging laparotomy and random and total peritoneal biopsies will be collected from the same case and sent to the lab of pathology for histopathological examination and the results will be compred regarding positivity of metastasis. Results: Random peritoneal biopsy showed positive metastasis in 6 (4.6%) cases and free in 124 (95.4%) cases while total peritoneal gutter removal showed positive metastasis in 19 (14.6%) cases and free in 111 (85.4%) with Chi-square test was 7.479 and P value was 0.004 which is statistically significant. 108 (97.3%) cases had negative random peritoneal biopsy and negative total peritoneal gutter removal, 3 (2.7%) cases had positive random peritoneal biopsy and negative total peritoneal gutter removal, 16 (84.2%) cases had positive total peritoneal gutter removal and negative random peritoneal biopsy & 3 (15.8%) cases had positive total peritoneal gutter removal and positive random peritoneal biopsy with Chi-square test 6.311, FEp 0.04 and Kappa test 0.183 (0.012) which is statistically significant with poor strength of agreement. Conclusions: Modified total peritoneal gutter removal is a safe, fast and easy technique compared to random peritoneal biopsy and even to traditional peritonectomy procedure with high detection rates of peritoneal involvement with sensitivity of 50% and specificity of 87.5% and it is recommended to be done as a routine alternative to random peritoneal biopsy and even to traditional total gutter removal in all cases of ovarian malignancies for diagnostic and therapeutic values.

Peritoneal mesothelioma

This review provides an overview of articles about peritoneal mesothelioma(PM)to analyze the effect of treatment modalities on response rates,post-treatment side effects,morbidity and mortality,and survival.Median survival in months following systemic chemotherapy(SC)ranged from 8.7 to 26.8 months.However,no patient was reported to have survived for more than five years with SC alone.In contrast,comprehensive treatment that included cytoreductive surgery(CRS)+perioperative chemotherapy(POC)showed a significantly longer median survival time than SC alone.Additionally,CRS+POC demonstrated 10-year survival rates of 12%-35%.Accordingly,CRS+POC is an innovative treatment that provides long-term survival in selected patients with PM.Selection criteria are performance status(ECOG PS≤1),the absence of extraperitoneal metastasis,PCI less than cutoff levels(from<10 to<28),MIB-1 index(<10),and histologic type(epithelioid type).Postoperative morbidity and mortality rates after CRS+POC were significantly higher than with more conventional operations.Accordingly,CRS and POC should be done at the specialized peritoneal surface malignancy centers.