Post on 25-Jan-2016
description
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