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1
How to handle peritoneal carcinomatosis
found at laparotomy
Lars Påhlman Dept. Surgery, Colorectal unit,
University Hospital, Uppsala, Sweden
2
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)

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 935-39

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 cancer 259
• Mesothelioma 41
• Miscellaneous 46
• Total 543

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
Cytoreductive surgery i.p chemo
Uppsala series Colon cancer
Mahteme et al Br J Cancer 2004
11
Cytoreductive surgery i.p chemo
Uppsala series
Uppsala series Colon cancer
Mahteme et al Br J Cancer 2004
12
Cytoreductive surgery i.p chemo

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

13
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

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