Evidence Of Peritoneal Disease Research Articles

Outcomes After Adjuvant Hyperthermic Intraperitoneal Chemotherapy for High-Risk Primary Appendiceal Neoplasms After Complete Resection.

Appendiceal neoplasms are uncommon tumors. Optimal treatment for patients with perforation or high-grade pathology after initial resection is unknown. This study evaluated patients with increased risk for peritoneal dissemination after primary resection, but no evidence of peritoneal disease, who underwent adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC). This multi-institutional cohort study evaluated 56 patients with high-risk (HR) appendiceal neoplasms with a peritoneal carcinomatosis index of 0 who underwent HIPEC. The patients were divided into two groups: perforated low-grade appendiceal (LGA) carcinoma and HR neoplasms, which included perforated high-grade appendiceal carcinoma, positive margins after initial resection, minimal macroscopic peritoneal disease that was previously resected or completely responded to systemic chemotherapy prior to HIPEC, goblet cell carcinoma, and adenocarcinoma with signet ring cell features. Overall survival (OS) and recurrence-free survival (RFS) were estimated by Kaplan-Meier analysis. Thirty-eight percent of patients had perforated LGA and 68% had HR features. Five-year OS probability was 82.1% for the entire cohort, and 100% and 70.1% for patients with perforated LGA and HR features, respectively (p = 0.024). Five-year RFS probability was 79.3% for the entire cohort, and 90.0% and 72.4% for patients with perforated LGA and HR features, respectively (p = 0.025). Eight patients recurred after HIPEC and their OS was significantly worse (p < 0.001). While adjuvant HIPEC is both safe and feasible, there appears to be little benefit over close surveillance when outcomes are compared with historical and prospective studies, especially for perforated LGA carcinoma.

A Single Case of Two Synchronous Metastatic Tumours

The incidence of multiple primary tumours increases with age and due to multiple other factors as environmental and genetic predisposition. The authors describe a case of a 77-year-old female patient with diagnosis in September 2009 of colon mucinous adenocarcinoma. She was submitted to surgery, considered R1 and adjuvant chemotherapy. Six months after treatment she had abdominal recurrence on a nodular lesion in peritoneal fat. The patient was submitted to surgery and did multiple courses of systemic treatment. She underwent cytoreductive surgery with hyperthermic chemotherapy, too. In December 2014 she presented a nodular lesion on the bladder and after excision, the histology confirmed a high-grade transitional cell carcinoma and she maintains treatment with endovesical BCG instillations. After that, she had no evidence of peritoneal disease progression. Besides the bad prognosis associated to peritoneal disease, our case report describes a long survival (5 years with no disease progression) in a patient with high risk at diagnosis to peritoneal recurrence. This case shows the importance of multimodal approach and the impact of locoregional treatment in localized metastatic disease.

Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls

Many women who experience endometriosis and endometriomas also encounter problems with fertility. The purpose of this study was to determine the impact of surgical excision of endometriosis and endometriomas compared with control subjects on ovarian reserve. This was a prospective cohort study of 116 women aged 18-43 years with pelvic pain and/or infertility who underwent surgical treatment of suspected endometriosis (n=58) or endometriomas (n=58). Based on surgical findings, the suspected endometriosis group was further separated into those with evidence of peritoneal disease (n=29) and those with no evidence of endometriosis (n=29). Ovarian reserve was measured by anti-Müllerian hormone and compared before surgery and at 1 month and 6 months after surgery. Baseline anti-Müllerian hormone values were significantly lower in the endometrioma vs negative laparoscopy group (1.8 ng/mL [95% confidence interval, 1.2-2.4 ng/mL] vs 3.2 ng/mL [95% confidence interval, 2.0-4.4 ng/mL]; P<.02), but the peritoneal endometriosis group was not significantly different than either of these groups. Only patients with endometriomas had a significant decline in ovarian reserve at 1 month (-48%; 95% confidence interval, -54 to -18%; P<.01; mean anti-Müllerian hormone baseline value, 1.77-1.12 ng/mL at 1 month). Six months after surgery, anti-Müllerian hormone values continued to be depressed from baseline but were no longer significantly different. The rate of anti-Müllerian hormone decline was correlated positively with baseline preoperative anti-Müllerian hormone values and the size of endometrioma that was removed. Those with bilateral endometriomas (n=19) had a significantly greater rate of decline (53.0% [95% confidence interval, 35.4-70.5%] vs 17.5% [95% confidence interval, 3.2-31.8%]; P=.002). At baseline, patients with endometriomas had significantly lower anti-Müllerian hormone values compared with women without endometriosis. Surgical excision of endometriomas appears to have temporary detrimental effects on ovarian reserve.

Prognostic Impact of RT-PCR-Based Detection of Peritoneal Micrometastases in Patients with Pancreatic Cancer Undergoing Curative Resection

Positive peritoneal fluid cytology predicts poor outcome in patients with resected pancreatic cancer. Reverse transcription-polymerase chain reaction (RT-PCR) has been proposed as a more sensitive means of detection of peritoneal micrometastases than conventional cytology. The clinical significance of RT-PCR positivity in the absence of other evidence of peritoneal disease is unknown. The purpose of the current study was to determine the outcome RT-PCR positive/cytology-negative patients who underwent potentially curative resection. Peritoneal washings were collected prospectively from 115 patients with pancreatic cancer undergoing diagnostic laparoscopy at a single institution. Specimens were analyzed by a cytopathologist and by RT-PCR for carcinoembryonic antigen (CEA). Of the 115 patients, 62 (54%) underwent R0 resection. Eleven of the 62 patients (18%) had peritoneal washings that were negative by conventional cytology but positive for CEA by RT-PCR. Those 11 patients experienced early peritoneal and overall disease recurrence versus those who were RT-PCR negative (P = 0.001, P = 0.003, respectively) independent of nodal status. RT-PCR for CEA is a sensitive and specific method for the detection of clinically significant peritoneal micrometastases from pancreatic cancer and it might identify a subgroup of patients with otherwise negative findings at staging laparoscopy who might respond better to treatment other than primary surgical resection.

Three‐dimensional ultrasonographic characteristics of endometriomata

Endometriosis is a common condition, affecting somewhere between 5% and 60% of women of reproductive age and approximately 2 million women in the UK. The exact prevalence is difficult to ascertain and varies according to diagnostic criteria used and the populations studied, varying from 2 to 50% in women without symptoms, 40 to 60% in women with dysmenorrhea, and 20 to 30% in women with subfertility1,2. The etiology is unknown, but the disease is characterized by the objective demonstration of endometrial-like tissue outside the uterus. The condition is seen predominantly in women of reproductive age, and it occurs in all ethnic and social groups. Whilst extrapelvic disease can occur, endometriosis typically affects the pelvic organs and peritoneum. Disease severity is assessed semi-quantitatively at laparoscopy or laparotomy and is scored according to the American Society for Reproductive Medicine3, but is a poor predictor of the patient’s symptoms in many cases. The extent of the disease varies considerably; it may involve small areas of the peritoneum alone, or be associated with significant fibrosis, adhesions and nodular infiltration, in different individuals with the same symptoms1. The ovary may be involved only superficially or can contain a cyst lined with endometrial-like tissue known as an ‘endometrioma’. Endometriotic cysts have always been a controversial entity. There is no consensus as to the pathological processes which define their development or to their management in terms of the timing, type and effects of surgery. Opinion is divided as to whether these cysts arise from progressive invagination of endometriotic deposits on the ovarian cortex4,5, from metaplasia of epithelial inclusions in the ovary5,6 or because of secondary involvement of functional ovarian cysts in the endometriotic process7. The invagination theory is accepted by most, but there is no agreement as to whether the endometrial cells are superficial ovarian implants of endometriosis or they are derived through metaplastic transformation of normal ovarian cortical tissue. The invagination theory is supported by histological studies, which consistently show that these cysts are pseudocysts, with no real plane of cleavage between the endometrialtype stroma and the ovarian cortex, containing an obliterated, mostly endometrial-gland, lining8. The walls of an endometrioma are initially thin, but subsequently become fibrotic and thickened, and can give the cyst an irregular external border. Endometriomata are typically small, with 81% measuring between 30 and 59 mm in diameter9, although they can reach 15–20 cm in diameter. Is an isolated endometrioma a different disease from peritoneal endometriosis? Many women are found to have an endometrioma without evidence of peritoneal disease, and the pathophysiological mechanisms that determine how the disease is expressed remain unclear. Women with peritoneal endometriosis are thought to have reduced fertility, and surgical treatment may improve fecundity in those with minimal to mild disease10. Just how endometriosis affects fertility is unknown, but any effect probably relates to anatomical distortion and immobilization of the pelvic organs through adhesion formation and organ infiltration and/or a change in the peritoneal environment to one that is less favorable for fertilization and embryo implantation. The effect of an isolated endometrioma on fertility is less clear, and there is no definitive evidence that fertility is impaired. However, surgical intervention is often recommended when an endometrioma measures more than 3–4 cm in diameter11 and so, unsurprisingly, endometriomata represent the most frequently reported histological subtype following operative laparoscopy for the excision of ovarian cysts12. Preoperative detection of endometriomata is therefore important, and ultrasound is the investigative tool of choice in most cases. Conventional two-dimensional ultrasound has an established role in the detection of adnexal masses and in their differentiation through pattern recognition of characteristic morphological patterns13. Most studies use transvaginal rather than transabdominal ultrasound, as this approach allows a closer approximation of the probe to the ovary and the use of higher frequencies, which provide better resolution. However, transvaginal

Staging Laparotomy for Endometrial Carcinoma: Assessment of Peritoneal Spread

To evaluate surgical staging procedures in women with endometrial carcinoma, we examined the techniques used to assess the peritoneal cavity in 295 clinical stage I patients treated between 1985 and 1993. These patients were felt to be at increased risk for extrauterine disease because of significant myometrial invasion, high-grade (2 or 3), or variant histology (papillary serous, clear cell, or mixed). Patients had a mean of two intraperitoneal samples taken: 224 patients (76%) had at least an omental biopsy and peritoneal cytology. Additional peritoneal biopsy sites included pericolic gutters (50), pelvic peritoneum (45), bowel serosa/mesentery (24), diaphragm (22), appendix (11), and adhesions (7). At the time of staging laparotomy, 22 patients (7.5%) had gross evidence of peritoneal spread, which was readily confirmed by directed biopsy. In the 273 women without gross peritoneal disease, 3 (1%) had occult metastases detected by routine biopsy, 3 (1%) had microscopic metastases in palpably abnormal biopsies, and 22 bad positive cytology as the only evidence of peritoneal disease. Only three operative complications were potentially attributable to peritoneal assessment: cystotomy (1), partial small bowel obstruction (1), and ileus (1). Peritoneal failures have been noted in 12 patients over a mean follow-up interval of 39 months. Seven of these patients had obvious peritoneal disease at laparotomy. Two of the remaining 5 had optimal peritoneal sampling and represent false-negative cases. A staging laparotomy that included total abdominal hysterectomy with adnexal resection, cytology, omental biopsy, and biopsy of grossly abnormal sites would have potentially identified all patients with known peritoneal disease. Routine biopsy of other grossly normal peritoneal sites is associated with extremely low yield and is not recommended.

The role of postoperative local or regional irradiation in the treatment of stage I ovarian cancer.

Histological grade and cell type were major prognostic factors in a retrospective study of 63 patients with Stage I epithelial carcinoma of the ovary. Grading by architectural pattern seemed to predict relapse better than cytological grading. With serous, mucinous, and endometrioid cystadenocarcinomas, relapses increased with higher grades. Relapse occurred in none of 18 tumors of borderline malignancy, 2 of 27 (7%) with Grade I or II tumor, and 4 of 6 (67%) with Grade III. The upper abdomen and pelvis were both at risk. Because most recurrences were limited to the peritoneal surface in Grade III serous, mucinous, and endometrioid carcinoma, local and regional radiation therapy are justified; postoperative therapy is not recommended for borderline or Grade I tumors unless ascites or cytological evidence of peritoneal disease is present. Clear-cell carcinoma was uncommon and unfavorable; of 12 cases, 5 involved relapse, with 3 recurrences developing outside the abdomen.