Cytoreductive Surgery In Combination Research Articles

Improved survival of patients with pseudomyxoma peritonei receiving intraperitoneal chemotherapy with cytoreductive surgery: a systematic review and meta-analysis

BackgroundPseudomyxoma peritonei (PMP) is an uncommon but lethal variant of adenocarcinoma. Many recent case series have reported improved survival with the combination of cytoreductive surgery and intraperitoneal chemotherapy (IPEC) in treating PMP. The aim of this study was to analyze the published studies for improved survival with this treatment strategy. MethodsData from all studies using IPEC in treating PMP were analyzed. We searched PubMed, MEDLINE, and the Cochrane Library (through September 2011). Studies were limited to English and PMP with appendiceal origin. Twenty-nine studies were identified, with 15 studies from different treatment centers that were specifically analyzed for differences in 5-y mortality and morbidity. Observed to expected (OE) ratios were calculated for both mortality and morbidity. ResultsMean and median 3-y, 5-y, and 10-y survival rates were 77.18%/77.85%, 76.63%/79.5%, and 57.3%/55.9%, respectively. Of the 10 studies that had sufficient data to calculate OE ratios from the 5-year mortality data, two had OE ratios lower than 1. Of the 11 studies that had data sufficient to calculate OE ratios from the morbidity data, four had OE ratios that were less than 1. ConclusionsCombining cytoreductive surgery and IPEC improves the survival of patients with PMP, regardless of treatment modality. Although this treatment strategy is associated with an increased risk of morbidity, the increase in survival may be acceptable in proposing an alternative to debulking procedures alone.

Aggressive Pseudomyxoma Peritonei: A Case Report with an Unusual Clinical Presentation

Introduction. Pseudomyxoma peritonei (PMP) is an uncommon surgical entity. We report a case of aggressive disease with an unusual clinical presentation and we analyze current data on diagnosis and management of PMP. Case Presentation. A 71-year-old male patient presented with intermittent diarrhea and loss of appetite during the last two months, without any other classic symptoms of PMP. The clinical examination was misleading due to patient's obesity. The radiological evaluation revealed ascites of the abdomen and possible mucocele of the appendix, whereas the laboratory exams showed high values of specific tumour markers. The patient underwent an exploratory laparotomy for definite diagnosis. Biopsies and immunohistochemical examination confirmed the diagnosis of an aggressive and extended peritoneal mucinous carcinomatosis (PMCA). The patient was programmed for adjuvant systematic chemotherapy, which was not completed due to progression of the disease. Conclusions. Progressed PMP can present with unspecific symptoms that mislead diagnosis. Cytoreductive surgery in combination with systematic chemotherapy could be appropriate for aggressive PMCA, even with an unfavourable prognosis.

Pulmonary influences on early post-operative recovery in patients after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy treatment: a retrospective study.

BackgroundThe combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment option for peritoneal carcinomatosis (PC). There have been few studies on the pulmonary adverse events (AEs) affecting patient recovery after this treatment, thus this study investigated these factors.MethodsBetween January 2005 and December 2006, clinical data on all pulmonary AEs and the recovery progress were reviewed for 76 patients with after CRS and HIPEC. Patients with pulmonary interventions (thoracocenthesis and chest tubes) were compared with the non-intervention patients. Two senior radiologists, blinded to the post-operative clinical course, separately graded the occurrence of pulmonary AEs.ResultsOf the 76 patients, 6 had needed thoracocentesis and another 6 needed chest tubes. There were no differences in post-operative recovery between the intervention and non-intervention groups. The total number of days on mechanical ventilation, the length of stay in the intensive care unit, total length of hospital stay, tumor burden, and an American Society of Anesthesiologists (ASA) grade of greater than 2 were correlated with the occurrence of atelectasis and pleural effusion. Extensive atelectasis (grade 3 or higher) was seen in six patients, major pleural effusion (grade 3) in seven patients, and signs of heart failure (grade 1–2) in nine patients.ConclusionsClinical and radiological post-operative pulmonary AEs are common after CRS and HIPEC. However, most of the pulmonary AEs did not affect post-operative recovery.

Pseudomyxoma Peritonei Treated with Cytoreductive Surgery and Hyperthermic Chemotherapy: A 7-Year Single-Center Experience

Pseudomyxoma peritonei (PMP) is a rare clinical entity characterized by diffuse intraabdominal gelatinous collections with mucinous implants on the peritoneal surfaces and omentum. This condition should be considered a borderline malignancy with disease progression over time. Encouraging treatment results have been recently reported with the combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). . From December 2003 to December 2010, 18 patients with PMP were referred to our institution. All patients underwent peritonectomy and CRS combined with HIPEC in accordance with Sugarbaker's procedure. The mean Peritoneal Cancer Index score was 27.6 (range, 5-39). Twelve (67%) patients had disseminated peritoneal adenomucinosis and 6 (33%) peritoneal mucinous carcinomatosis. Optimal cytoreduction with no visible residual disease or residual disease ≤2.5 mm in diameter was achieved in all patients. The mean duration of the surgical procedure including HIPEC was 9 hours and 30 minutes (range, 5-13 hours); major morbidity occurred in 30% of patients and the mortality was 11%. The mean follow-up was 27 months (range, 1-72) and the 5-year overall survival 66%. In line with the existing literature, our experience suggests that patients with PMP could benefit from CRS + HIPEC in terms of survival and locoregional disease control.

Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion for malignant pleural tumours: perioperative management and clinical experience

A combination of cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion (HITHOC) was performed for the treatment of primary and secondary pleural malignancies. We describe the perioperative management and our clinical experience. Between September 2008 and August 2011, eight patients with pleural manifestation of thymoma (Masaoka stage IVa) and eight patients with malignant pleural mesothelioma (MPM) were prospectively enrolled. Postoperative morbidity, recurrence and survival rates were analysed. All the patients received multimodality therapy, including chemotherapy, radiation and surgical resection (pleurectomy/decortication) followed by the HITHOC procedure. Chemotherapy perfusion was performed with cisplatin (100-150 mg/m(2)) at 42°C for 1 h. Severe chemotherapy-related complications were not observed. Reoperation was necessary in two patients. There was no 30-day mortality. The median stay on the intensive care unit was 1 day, and the median duration of hospitalization was 15 days. Pleural recurrence of thymoma was evident in one thymoma patient 6 months after HITHOC. At mean follow-up of 22 months, seven thymoma patients (7/8; 88%) are alive without recurrence. Tumour progression was present in six mesothelioma patients (6/8; 75%). Four patients (50%) with MPM are alive, including two with no evidence of mesothelioma, and the median survival is 18 months. Cytoreductive surgery in combination with HITHOC can be performed with acceptable morbidity and mortality rates in selected patients. Patients should be evaluated by an interdisciplinary team to determine their eligibility for this therapeutic alternative. Early clinical results may encourage the use of this surgical option to provide better local tumour control in a multimodality treatment setting.

Intraperitoneal bevacizumab combined with cytoreductive surgery: a pre-clinical study of tolerance and pharmacokinetics in an animal model

Cytoreductive Surgery (CRS) combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is currently the only potentially curative treatment for peritoneal carcinomatosis (PC). Systemic administration of bevacizumab improves survival in patients with metastatic colorectal or ovarian cancer. Intraperitoneal administration of bevacizumab has been shown to be safe and effective in treating malignant ascites. The combination of CRS with intraperitoneal (IP) bevacizumab could maximize local control and survival from PC, but the associated morbidity from this is unknown. The aim of this study was to evaluate the safety of the combination of CRS with IP bevacizumab and to determine the pharmacokinetics of the drug in a rabbit model. Twenty healthy rabbits underwent a standardized procedure of debulking surgery, including peritonectomy and gastrointestinal anastomosis and were randomized to receive IP bevacizumab (25mg/kg) or placebo. Another group of three rabbits underwent an instillation of IP bevacizumab (25mg/kg) without surgery. One rabbit that received IP bevacizumab died with no complication associated with the use of bevacizumab at autopsy. There was no significant difference between IP bevacizumab and placebo in weight loss, length of surgery or morbidity. The plasma concentration of bevacizumab increased to a peak at 24h post IP administration. Bevacizumab was not detected in the plasma of animals without surgery. This study suggests that IP bevacizumab does not increase morbidity and mortality of debulking surgery in an animal model. When surgery is performed, the pharmacokinetics of IP bevacizumab are modified in plasma.

P-0183 Outcomes of Patients With Colorectal Cancer With Peritoneal Carcinomatosis Who Underwent Cytoreductive Surgery and Intraperitoneal Chemotherpy Versus Palliative Chemotherapy

ABSTRACT Introduction Patients with advanced colorectal cancer and peritoneal carcinomatosis (PC) have a poor prognosis with median survival ranging from 6 to 8 months. Novel treatment strategies have emerged combining cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) with improved outcomes. The aim of this retrospective analysis is to evaluate the outcomes in patients with advanced colorectal cancer with PC who had undergone CRS with peritonectomy and HIPEC versus those who underwent resection of primary and palliative chemotherapy. Methods From our institutional database, we identified 43 patients with colorectal cancer with metastasis isolated to the peritoneum. 21 patients received local resection of the primary colonic tumour and chemotherapy. 22 patients received CRS with peritonectomy and HIPEC. Demographic data, treatment and survival data were collated and analysed. Results All patients had good performance status with ECOG less than or equal to 1. The median follow up of all patients still alive was 20.7 months. The median time from detection of peritoneal metastasis to peritonectomy was 4.6 months. The progression free survival for patients who underwent peritonectomy and HIPEC was 9.6 months (95% CI 6.6-12.6). From time of detection of peritoneal metastasis, overall survival for patients who underwent peritonectomy versus those who did not was 47 months and 18 months respectively (HR 0.18; 95% CI: 0.05-0.67, p =0.01). However there is substantial selection bias with the peritonectomy group comprising younger patients with mean age of 49 years old versus 59 years old in the non - peritonectomy group (P=0.02). All the patients who did not undergo peritonectomy were stage IV at diagnosis whereas in the group who underwent peritonectomy, only 45.4% were stage IV at diagnosis. Conclusion In well selected group of patients with advanced colorectal cancer and peritoneal carcinomatosis, good long term survival outcomes with cytoreductive surgery with peritonectomy and HIPEC can be achieved.

Current Status of Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy in Patients With Peritoneal Carcinomatosis From Colorectal Cancer

Peritoneal carcinomatosis (PC) arising from colorectal cancer (CRC) is generally considered a terminal condition with no treatment options. However novel treatment strategies have emerged combining cytoreductive surgery (CRS), including peritonectomy procedures, with intraperitoneal chemotherapy. The intraoperative application of cytotoxic drugs combined with hyperthermia (hyperthermic intraperitoneal chemotherapy [HIPEC]) has been considered to deliver cytotoxicity most effectively to peritoneal tumor implants. In selected groups of patients with no remaining macroscopic tumor manifestations on peritoneal surfaces after CRS and HIPEC, median survival times may reach 5 years, with a 5 year overall survival rate of 50%. HIPEC has been performed with different cytotoxic drugs, in combination with early postoperative intraperitoneal chemotherapy (EPIC), and embedded into various systemic perioperative and/or postoperative chemotherapeutic regimens. Prognosis largely depends on the intraabdominal tumor burden, which can be assessed by the peritoneal cancer index (PCI), and the completeness of cytoreduction. In this review we discuss the most relevant prognostic parameters, the outcome of patients with PC from CRC treated with CRS and HIPEC, and the impact of different chemotherapeutic variations used during HIPEC. From this analysis it can be concluded that CRS and HIPEC offers a chance for long-term survival in selected patients with PC of colorectal origin.

Therapeutic strategies in epithelial ovarian cancer

Ovarian cancer is the most lethal gynecologic malignancy. It appears that the vast majority of what seem to be primary epithelial ovarian and primary peritoneal carcinomas is, in fact, secondary from the fimbria, the most distal part of the fallopian tube.Treatment of epithelial ovarian cancer is based on the combination of cytoreductive surgery and combination chemotherapy using taxane and platinum. Although clear cell type is categorized in indolent type, it is known to show relatively strong resistance to carboplatin and paclitaxel regimen and thus poor prognosis compared to serous adenocarcinoma, especially in advanced stages. Irinotecan plus cisplatin therapy may effective for the clear cell adenocarcinoma.The larger expectation for improved prognosis in ovarian carcinoma is related to the use of the new biological agents. One of the most investigated and promising molecular targeted drugs in ovarian cancer is bevacizumab, a monoclonal antibody directed against VEGF. PARP inhibitor is another one. A few recent studies demonstrated positive results of bevacizumab on progression-free survival in ovarian cancer patients, however, investigation of molecular targeting drugs in patients with ovarian cancer are still underway.

Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion for malignant pleural tumors: perioperative management and early clinical experience

Objectives: Since a few years the combination of cytoreductive surgery (pleurectomy/decortication) and hyperthermic intrathoracic chemotherapy perfusion (HITHOC) is performed for treatment of primary and secondary pleural malignancies. We describe the perioperative management and our early clinical experience with this innovative treatment option.

MULTICYSTIC PERITONEAL MESOTHELIOMA: report of a case

SummaryBackground:Multicystic peritoneal mesothelioma is a rare disease. It is not certain if it is a benign or a borderline tumor. Although many therapeutic approaches have been used, complete cytoreductive surgery in combination with hyperthermic intraoperative intraperitoneal chemotherapy has gained acceptance.Case Report:A case of multicystic peritoneal mesothelioma in a 16-year old patient is reported. The patient underwent complete cytoreduction and received intraoperative hyperthermic intraperitoneal chemotherapy. The patient is disease-free one year after surgery.Conclusions:Complete cytoreductive surgery in combination with hyperthermic intraoperative intraperitoneal chemotherapy appears to be a rational therapeutic approach in multicystic peritoneal mesothelioma.

Peritoneal carcinomatosis from colorectal cancer

Peritoneal carcinomatosis is the most frequent cause of death in patients treated for colorectal cancer. It presents with a rate of 25–35% and is traditionally followed by median survival of less than 6 months. In 1982, Paul Sugarbaker proposed combined cytoreductive surgery with intraperitoneal hyperthermic chemotherapy in the treatment of peritoneal carcinomatosis as a local relapse of the disease; he achieved a five-year survival rate of >30%. The spectrum of peritoneal carcinomatosis ranges from the presence of some tiny surface nodules, usually near the primary site of the tumour, to the full coverage of the peritoneal surface with invasive neoplastic massive tumours, with or without clinical evidence of systemic metastatic disease. In 10–15% of patients it appears synchronous with the primary tumour and in 20–50% as a late recurrence. The intrabdominal relapse of colorectal cancer can be successfully treated with radical oncologic cytoreductive peritonectomy and intraoperative intraperitoneal hyperthermic chemotherapy. The aim is the complete excision of the macroscopically visible neoplastic disease (peritonectomy and excision of all infected organs) as well as treatment of the remnant microscopic disease with intraoperative intraperitoneal hyperthermic chemotherapy. This combined approach can be performed with acceptable rates of surgical morbidity and mortality in high volume reference centres. A multivariate oncologic approach in combination with a meticulous patient selection, significantly improves the survival rate compared to the conventional palliative chemotherapy.

Treatment of gastric cancer with peritoneal carcinomatosis by cytoreductive surgery and HIPEC: A systematic review of survival, mortality and morbidity

Introduction Gastric cancer with peritoneal carcinomatosis (PC) has an extremely poor prognosis with median survival estimated at four-months with best supportive care, and 7-10 months with aggressive chemotherapy. Cytoreductive surgery combined with heated intra-peritoneal chemotherapy (HIPEC) has been shown to improve survival in colorectal cancer with PC compared to systemic chemotherapy. The efficacy of cytoreductive surgery combined with HIPEC in gastric cancer remains unproven. Our objective is to systematically review the literature regarding the effectiveness of cytoreductive surgery combined with HIPEC in patients with gastric cancer who also have PC. Methods A comprehensive search of electronic databases was completed from 2000-2010. Unpublished and non-English-language results were excluded. All studies involving cytoreductive surgery combined with HIPEC in adults with gastric cancer with PC were included. Two authors identified potentially relevant articles and assessed the studies for inclusion, and extracted data. Results An initial screen identified 144 titles of which 36 studies met the inclusion criteria. Following full manuscript assessment, 10 articles were included. 441 patients with gastric cancer and PC were extracted with a median follow-up of 48 months. Overall median survival was 7.9 months (range: 6.1-9.2 months) and improved to 15 months (range: 9.5-43.4 months) for patients with completeness of cytoreduction scores of 0/1. The median 30-day mortality rate was 4.8% (range: 0-14.3%) with combined morbidity of 21.5%. Conclusions This systematic review demonstrates that combined cytoreductive surgery and HIPEC may improve survival in selected patients with gastric cancer with PC when a complete cytoreduction is achieved, albeit with significant risk of mortality and morbidity.

Phagocytosis of dying tumor cells by human peritoneal mesothelial cells

Peritoneal carcinomatosis is an advanced form of metastatic disease characterized by cancer cell dissemination onto the peritoneum. It is commonly observed in ovarian and colorectal cancers and is associated with poor patient survival. Novel therapies consist of cytoreductive surgery in combination with intraperitoneal chemotherapy, aiming at tumor cell death induction. The resulting dying tumor cells are considered to be eliminated by professional as well as semi-professional phagocytes. In the present study, we have identified a hitherto unknown type of 'amateur' phagocyte in this environment: human peritoneal mesothelial cells (HMCs). We demonstrate that HMCs engulf corpses of dying ovarian and colorectal cancer cells, as well as other types of apoptotic cells. Flow cytometric, confocal and electron microscopical analyses revealed that HMCs ingest dying cell fragments in a dose- and time-dependent manner and the internalized material subsequently traffics into late phagolysosomes. Regarding the mechanisms of prey cell recognition, our results show that HMCs engulf apoptotic corpses in a serum-dependent and -independent fashion and quantitative real-time PCR (qRT-PCR) analyses revealed that diverse opsonin receptor systems orchestrating dying cell clearance are expressed in HMCs at high levels. Our data strongly suggest that HMCs contribute to dying cell removal in the peritoneum, and future studies will elucidate in what manner this influences tumor cell dissemination and the antitumor immune response.

Hyperthermic Intraperitoneal Chemotherapy in Advanced Gastric Cancer: The End of Skepticism?

Over the past two decades, novel therapeutic approaches to peritoneal carcinomatosis (PC) have emerged, combining cytoreductive surgery and peritonectomy procedures with perioperative intraperitoneal chemotherapy (PIC), including hyperthermic intraperitoneal chemotherapy (HIPEC) and/or early postoperative intraperitoneal chemotherapy (EPIC). Theoretically, cytoreductive surgery is performed to treat macroscopic disease and PIC to treat microscopic residual disease aiming to remove disease completely with a single procedure. Many consider it a standard of care for disease such as pseudomyxoma peritonei, peritoneal mesothelioma, or localized and resectable colorectal carcinomatosis. Because of its negative prognosis, the question regarding the efficiency of this combined procedure still remains controversial for carcinomatosis from gastric origin. Peritoneal dissemination is the most frequent pattern of metastasis and recurrence with gastric cancers. Traditionally, there was a mutual agreement in the oncologic community that those patients with gastric peritoneal dissemination were incurable. For the past 10 years, despite improvements in systemic chemotherapy with the development of new targeted therapy and encouraging tumor response rates, there have been no large phase III studies that demonstrated the real benefit of one regimen and really changed the negative prognosis of this disease evolution. With this phase III study including 68 patients with PC from gastric cancer, Yang et al. demonstrated that the use of HIPEC with the association cisplatinum-mitomycin C significantly improved survival. With HIPEC, the overall survival was extended by nearly 70% (6.5 vs 11.0 months) when compared with cytoreductive surgery alone. The authors compared their results and the design of their study to those reported by the Netherlands phase III study, conducted for the treatment of PC from colorectal origin and that compared the combination of CRS with HIPEC compared with systemic chemotherapy. This important study strongly influenced the oncologic community and precipitated the evolution to a new management of colorectal carcinomatosis with a curative intent. However, it demonstrated the potential benefit of CRS combined with HIPEC and not of HIPEC only. To our knowledge, Yang et al. is the first study that demonstrated the benefit of HIPEC in one phase III study for the treatment of PC, whatever the origin is. The experience of few single institutions, combined with phase II studies, reported encouraging survival results following treatment of PC with this therapeutic strategy. Recently, a collaborative effort of French institutions collected data from 159 patients and represents the largest experience of the treatment of PC from gastric origin. With a median follow-up of 20.4 months, the overall median survival was 9.2 months, which is close to that reported by Yang et al. in the experimental group (11 months). This median survival rate remains low, but the 5-year survival rate was 13% with some long-term survivors. These survival results are less encouraging than those obtained for other peritoneal surface malignancies, reflecting either a more aggressive disease process less responsive to this combined treatment modality or the need for better patient selection. However, the combination of cytoreductive surgery with HIPEC was the only therapeutic strategy that reported long-term survivors at 5 years. Prognostic factors are essential for a better patient selection for the combined procedure, and some have been identified in the phase III study. For intraperitoneal chemotherapy to be effective, residual disease following attempted cytoreductive surgery must be of low volume. In the recent French study, long-term survival, with a 5-year Society of Surgical Oncology 2011

Two bi-institutional prospective studies using intraperitoneal oxaliplatin with or without irinotecan during HIPEC following complete cytoreductive surgery for colorectal carcinomatosis.

486 Background: In treatment of peritoneal carcinomatosis (PC) of colorectal origin, studies combining cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) have shown encouraging survival results. Intraperitoneal drugs usually used are mitomycin C or oxaliplatin in monotherapy. The aim of this study was to assess long-term survival in patients treated with a new combination of oxaliplatin and irinotecan (ox-irino) and to compare it with that obtained with oxaliplatin alone (ox-alone). Methods: Two bi-institutional prospective studies were carried out. All patients with PC who had undergone CRS with HIPEC using either ox-alone 460 mg/m2 or ox-irino (ox: 300 mg/m2 and irino: 200 mg/m2) from January 1998 to December 2007 were included. Results: 146 patient underwent CRS + HIPEC for PC from colorectal carcinoma. 103 patients received ox-irino and 43 patients received ox-alone HIPEC. The overall mortality rate was 4.1%. The overall morbidity rate was 47.2%. It was significantly lower in the ox-alone group compared to the ox-irino group (34.9% vs. 52.4%, p =0.05). After a median follow-up of 48.5 months, (95%CI 41.0-56.3), the median OS was 41 months (95%CI 32-60) and the median RFS was 15.7 months (95%CI 12-18). The median RFS of the ox-alone group was 16.8 months (95%CI 11-25) and was not significantly different from that of ox-irino group (15.7 months, 95%CI 11-18, p = 0.93). There was no significant difference between the median OS of the ox-alone group (40.83 months, 95%CI 29–61) and the ox-irino group (47 months, 95%CI 32-61, p = 0.94). At 5 years, the OS and the RFS rates were respectively 41.8% (95% CI 25.20-57.58) and 13.8% (95% CI 4.66-27.84) in the ox-alone group and 42.4% (95% CI 28.52-56.09) and 14.2% (95% CI 6.27-25.20) in the ox-irino group. Conclusions: This study confirms the interesting survival results of CRS + HIPEC to treat colorectal PC. 460 mg/m2 of oxaliplatin alone HIPEC is as efficient as 300 mg/m2 of oxaliplatin associated with 200 mg/m2 of irinotecan, but with lower morbidity. Ox-alone HIPEC, should remain the current gold standard. No significant financial relationships to disclose.

Pure choriocarcinoma of the ovary: a case report

Pure ovarian choriocarcinomas are extremely rare and aggressive tumors which are gestational or non-gestational in origin. Due to the rarity of the tumor, there is a lack of information on the clinicopathologic features, diagnosis, and treatment. We report a case of a pure ovarian choriocarcinoma, likely of non-gestational origin, treated by cytoreductive surgery in combination with post-operative chemotherapy. The patient was free of disease after a 12-month follow-up.

Risk of exposure to mitomycin C during hyperthermic intraperitoneal chemotherapy (HIPEC) with an open abdomen technique. Guidelines for safety in the operating room

Background: Several studies have shown that the treatment of peritoneal carcinosis with curative intent is feasible, with a 25% long-term survival. Such results can be achieved by the combination of cytoreductive surgery (CS) and HIPEC. The use of antiblastic drugs in the operating room (OR) implies a risk of exposure for the OR personnel. For this reason a standardisation of the procedure is required. The purpose of this study was to assess the risk of environmental exposure (EE) to mitomycin C in the OR during HIPEC with an open abdomen technique in order to validate our safety procedure.

Selection of patients and staging of peritoneal surface malignancies

Peritoneal carcinomatosis (PC) is a common evolution of cancer of the gastrointestinal tract, and has been traditionally regarded as a terminal disease with short median survival. During the last 20 years, thanks to its favourable oncologic results, a new loco-regional therapeutic approach, combining cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), has an important development. Due to its significant, but acceptable, morbidity and mortality, and high cost, this comprehensive management plan requires knowledgeable patient selection. Quantitative prognostic indicators are required to assess a patient's eligibility. Large multicenter studies have identified several prognostic factors, which can be used for a better selection of patients who would benefit from the combination of cytoreductive surgery with HIPEC. Indications for treatment of PC with cytoreduction and HIPEC are now validated for several diseases: peritoneal mesothelioma, pseudomyxoma peritonei, PC from the appendix, and colorectal cancer. Indications are still under discussion for gastric and ovarian carcinomatosis. Computed tomography is the best radiological for staging the disease. The extent of peritoneal carcinomatosis is, however, difficult to evaluate preoperatively, and precise evaluation is most often performed during surgical exploration. Cytoreductive surgery associated with HIPEC for the treatment of peritoneal carcinomatosis should be performed for young patients with limited and resectable carcinomatosis, in specialized institutions involved in the management of peritoneal surface malignancies.

Peritoneal carcinomatosis of colorectal origin

Peritoneal carcinomatosis is, after liver metastases, the second most frequent cause of death in colorectal cancer patients and at the present time, is commonly inserted and treated as a stage IV tumour. Because there is no published data that outlines the impact of new therapeutic regimens on survival of patients with peritoneal surface diffusion, the story of carcinomatosis can be rewritten in light of a new aggressive approach based on the combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Also if these treatment perhaps allow to obtain better results than standard therapies, we suggest, that a large prospective randomised control trial is needed to compare long-term and progression-free survival under the best available systemic therapy with or without cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.