Peritoneal Surface Malignancies Research Articles

Second Annual Workshop of the Mid-Atlantic Chapter of the American Society of Peritoneal Surface Malignancy

Second Annual Workshop of the Mid-Atlantic Chapter of the American Society of Peritoneal Surface Malignancy, Mercy Medical Center, Baltimore, MD, USA, 20–21 June 2013 The annual workshop is dedicated to the regional advancement and coordination of efforts to control the peritoneal surface component of gastrointestinal and gynecologic malignancy. It was attended by surgeons, medical oncologists, radiologists, gastroenterologists and nurses involved in clinical and laboratory research efforts to optimally manage peritoneal metastases and peritoneal mesothelioma. During the first day of the 2-day meeting, presentations were coordinated with live video transmission from the operating room at Mercy Medical Center (MD, USA). The live surgery, didactic speeches and patient presentations were displayed for open discussion in real-time. Twenty regional and global opinion leaders spoke and interacted regarding clinical and research information relevant to the rapidly developing multidisciplinary subspecialty of peritoneal surface oncology.

Morbidity and mortality outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with primary and recurrent advanced ovarian cancer

BackgroundThe aim of this study is to report the perioperative outcomes of CRS and HIPEC from a single institution and review those factors that are associated with a poor perioperative outcome in patients with peritoneal dissemination from primary or recurrent ovarian cancer. Patients and methodA retrospective cohort study setting was conducted in a third level hospital peritoneal surface malignancy program. Ninety one patients diagnosed with ovarian peritoneal carcinomatosis, primary and recurrent without extraperitoneal metastasis were included for cytoreductive surgery and HIPEC with paclitaxel. We analyzed the postoperative morbidity rates and a univariate and multivariate analysis of factors associated with overall (grade I–IV) and major (grade III–IV) postoperative morbidity were performed. ResultsPeritoneal Cancer Index (PCI) upper than 12 (OR = 2.942 95%: 1.892–9.594 p = 0.044) was an independent factor associated with the occurrence of I–IV postoperative morbidity. Regarding major complications (grade III–IV), on multivariate analysis, in addition to PCI >12 (OR = 6.692, 95% CI: 1974–45, 674, p = 0.032), the need to carry out intestinal resection (OR = 4.987, 95% CI: 1350–27, 620, p = 0.046) was an independent factor related with major morbidity (grade III–IV). ConclusionsThe use of HIPEC after aggressive cytoreductive surgery in patients with ovarian cancer with peritoneal dissemination can be performed with acceptable postoperative morbidity rates. Knowledge of the factors associated with the onset of these postoperative adverse events allows better management of the same and offers the patient a safe procedure.

Randomized trial on peritoneal carcinosis diagnosis in mucinous colorectal cancer by laparoscopic second look at six months from a radical resection

Peritoneal tumour dissemination arising from colorectal cancer (CRC) is a sign of advanced tumour stage or disease recurrence and mostly associated with poor prognosis. Mucinous colorectal cancer is characterized by an early peritoneal spread and a worse prognosis. Radiologic diagnosis is difficult. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment option for isolated peritoneal surface malignancy (PC) from CRC. A recent consensus statement describes videolaparoscopy (VLS) as a staging step prior to cytoreduction.

Single incision laparoscopy to select patients with peritoneal carcinomatosis from colorectal carcinoma before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment option for peritoneal surface malignancy (PC) from colorectal cancer (CRC). Videolaparoscopy (VLS) is a staging step prior to CRS, in patients with a Peritoneal Cancer Index (PCI) ≤ 20 at CT scan, but it is mandatory to use median line only. Single port laparoscopy device offers the advantage of single access on the midline for staging.

Risk factors for morbidity and postoperative outcome of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. A single – center experience

Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) represents a treatment option for peritoneal surface malignancies. Even if it has been reported that this new approach improved survival of selected patients, it may be associated with high morbidity and mortality rates. Purpose of the study is to analyze postoperative morbidity and mortality in order to identify possible risk factors.

Morbidity and Mortality of Cytoreduction with Intraperitoneal Chemotherapy: Outcomes from the ACS NSQIP Database

Cytoreduction with intraperitoneal chemotherapy (IPC) for treatment of peritoneal surface malignancies is increasingly utilized. However, the described morbidity and mortality rates are based predominantly on the experience at high-volume centers. We analyzed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for a nationwide perspective on morbidity and mortality associated with IPC. The NSQIP database was queried for all patients undergoing IPC and cytoreduction from 2005 to 2011. Univariate and forward stepwise multivariate regression identified factors associated with 30-day death and morbidity. A total of 795 patients underwent IPC. Patients underwent a median of seven operative procedures (range 2-13). Median hospital stay was 9 days (range 2-79 days). A total of 521 complications occurred in 249 (31 %) patients, and there were 19 (2.3 %) mortalities. The most common complications were bleeding (15.1 %) and sepsis (14.6 %). Univariate analysis identified age ≥60 years, ascites, weight loss, recent prior operation, albumin <3 g/dl, bilirubin ≥2 mg/dl, hematocrit ≤30 %, colon, spleen, small bowel, liver, kidney, diaphragm, and gastric resections, wound classification, operative time, and intraoperative transfusion requirement as significantly associated with death and morbidity. By multivariate analysis, age ≥60 years, preoperative albumin <3 g/dl, gastrectomy, operative time, and intraoperative transfusion requirement remained significantly associated with death and morbidity. Particularly high death and morbidity rates were associated with preoperative albumin <3 g/dl (58 %), gastrectomy (62 %), and operative time of >500 min (46 %). In this nationwide cohort, the death and morbidity rate associated with cytoreduction and IPC is consistent with other large series. Age ≥60 years, albumin <3 g/dl, gastrectomy, operative time, and intraoperative transfusion requirement were associated with 30-day death and morbidity. These factors may help guide patient selection, counseling, and preoperative optimization before IPC.

Surgical Approach Including Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Patients with Peritoneal Metastasis

Background: Peritoneal metastasis arising from colorectal cancer, appendiceal cancer, gastric cancer and gynecologic malignancies, or primary peritoneal surface malignancies such as peritoneal mesothelioma and primary peritoneal adenocarcinoma may be efficiently treated by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in selected patients. Method: CRS is based on the technique of parietal and visceral peritonectomy and consists of multiple surgical procedures. HIPEC combines high local doses of cytostatics with the additional cytotoxic effects of hyperthermia. Results: The goal of CRS is to achieve a complete macroscopic cytoreduction (CC-0/1) as a precondition for consecutive HIPEC that should destroy residual tumor cells within the abdominal cavity. Conclusion: CRS and HIPEC can be performed with acceptable morbidity and low mortality in specialized centers. However, due to long learning curves, consistent surgical training is strongly recommended.

Diffuse malignant peritoneal mesothelioma: Long-term survival with complete cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC)

BackgroundPrognosis of diffuse malignant peritoneal mesothelioma (DMPM) has been recently improved by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). As with other peritoneal surface malignancies, the survival benefit is maximal when a complete surgical cytoreduction is achieved, but additional factors predicting long-term outcome are still poorly understood. We sought to investigate outcome and prognostic factors in patients with DMPM treated by complete cytoreduction and HIPEC. MethodsFrom a prospective database, we selected 108 patients with DMPM undergoing complete cytoreduction (residual tumour nodules ⩽2.5mm) and closed-abdomen HIPEC with cisplatin and doxorubicin or mitomycin-C. Twenty-seven patient-, tumour- and treatment-related variables were assessed by multivariate analysis with respect to overall (OS) and progression-free (PFS) survival. A panel of immunohistochemical markers was tested. ResultsOperative mortality was 1.9% and major morbidity 38.9%. Median follow-up was 48.8months (95% confidence interval (CI) 37.1–60.6). Median OS and PFS were 63.2months (95%CI 29.6–96.7) and 25.1months (95%CI 5.1–45.1). The survival curve reached a plateau after 7years, representing 19 actual survivors of 39 patients (43.6%) with potential follow-up ⩾7years. Cytokeratin 5/6, calretinin, Wilms tumour-1 (WT-1), podoplanin and epithelial growth factor receptor (EGFR) were mostly positive. At multivariate analysis, epithelial histological subtype, negative lymph-nodes, ⩽10% Ki67-positive cells correlated with both increased OS and PFS. Positive podoplanin correlated to increased PFS. ConclusionsAfter complete cytoreduction and HIPEC, prognosis of DMPM is primarily dependent on pathologic and biologic features. Patients with DMPM surviving ⩾7years appeared to be cured. Cure rate was 43.6%. Proliferative index and podoplanin may be used for prognostic stratification.

Consensus Guidelines from The American Society of Peritoneal Surface Malignancies on Standardizing the Delivery of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Colorectal Cancer Patients in the United States

The American Society of Peritoneal Surface Malignancies (ASPSM) is a consortium of cancer centers performing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). This is a position paper from the ASPSM on the standardization of the delivery of HIPEC. A survey was conducted of all cancer centers performing HIPEC in the United States. We attempted to obtain consensus by the modified method of Delphi on seven key HIPEC parameters: (1) method, (2) inflow temperature, (3) perfusate volume, (4) drug, (5) dosage, (6) timing of drug delivery, and (7) total perfusion time. Statistical analysis was performed using nonparametric tests. Response rates for ASPSM members (n = 45) and non-ASPSM members (n = 24) were 89 and 33 %, respectively. Of the responders from ASPSM members, 95 % agreed with implementing the proposal. Majority of the surgical oncologists favored the closed method of delivery with a standardized dual dose of mitomycin for a 90-min chemoperfusion for patients undergoing cytoreductive surgery for peritoneal carcinomatosis of colorectal origin. This recommendation on a standardized delivery of HIPEC in patients with colorectal cancer represents an important first step in enhancing research in this field. Studies directed at maximizing the efficacy of each of the seven key elements will need to follow.

New frontiers in peritoneal malignancies.

I was honored to be asked to write an editorial on ‘cytoreductive surgery using peritonectomy and visceral resections for peritoneal surface malignancy’ (1) written by Paul H. Sugarbaker. A strategic approach using peritonectomy and cytoreductive surgery to treat peritoneal cancers has gradually evolved over the past 30 years that has emanated by our impressive leader Paul H. Sugarbaker. He has brought many surgeons together from all over the world for these procedures. His skill made so many of us enthused by peritonectomy procedures and cytoreductive surgery with long operation time, a major postoperative morbidity and high mortality risk. However, we are all persisted with these procedures because of sometimes moribund patients with peritoneal cancers may cure with peritonectomy procedures and cytoreductive surgery.

Immunotoxin targeting EpCAM effectively inhibits peritoneal tumor growth in experimental models of mucinous peritoneal surface malignancies

Cytoreductive surgery and intraperitoneal (i.p.) chemotherapy constitute a curative treatment option in mucinous peritoneal surface malignancies of intestinal origin, but treatment outcome is highly variable and the search for novel therapies is warranted. Immunotoxins are attractive candidates for targeted therapy in the peritoneal cavity because of direct cytotoxicity, distinct mechanisms of action and tumor cell selectivity. The MOC31PE immunotoxin targets the tumor-associated adhesion protein EpCAM (Epithelial Cell Adhesion Molecule), and has been administered safely in early clinical trials. In our work, the efficacy of i.p. administration of MOC31PE alone and together with mitomycin C (MMC) was investigated in unique animal models of human mucinous peritoneal surface malignancies. In initial model validation experiments, clear differences in efficacy were demonstrated between MMC and oxaliplatin, favoring MMC in five investigated tumor models. Subsequently, MOC31PE and MMC were given as single i.p. injections alone and in combination. In the PMCA-2 model, moderate growth inhibition was obtained with both drugs, while the combination resulted in at least additive effects; whereas the PMP-2 model was highly sensitive to both drugs separately and in combination and intermediate sensitivity was found for the PMCA-3 model. Furthermore, results from ex vivo experiments on freshly obtained mucinous tumor tissue from animals and patients suggested that classic mechanisms of immunotoxin activity were involved, i.e., inhibition of protein synthesis and induction of apoptosis. The present results suggest that adding MOC31PE to MMC-based i.p. chemotherapy should be further explored for EpCAM-expressing peritoneal surface malignancies, and a phase I trial is in preparation.

Intraperitoneal Cytokine Level in Patients with Peritoneal Surface Malignancies. A Study of the RENAPE (French Network for Rare Peritoneal Malignancies)

Prognosis of peritoneal surface malignancies is influenced by the adequacy of surgical and chemotherapeutic treatment and by tumor spread at the time of diagnosis. By promoting morphological changes in the mesothelium, inflammatory cytokines reflect tumor biology and could be evaluated as biomarkers. Our objective was to evaluate intraperitoneal levels of IL-6, IL-8, IL-10, TNF-alpha, and sICAM in patients with pseudomyxoma peritonei and peritoneal mesothelioma. Serum and peritoneal fluid samples were prospectively collected in patients managed for peritoneal surface malignancies including pseudomyxoma peritonei (PMP), mesotheliomas, and other rare primitive peritoneal cancers (cancer group) and patients who underwent intraperitoneal laparoscopic surgical procedures for benign diseases (noncancer group). Samples were analyzed for IL-6, IL-8, IL-10, TNF-alpha, and sICAM concentrations. Correlations were assessed with tumor spread related clinical scores. In both patient groups, intraperitoneal cytokine levels were higher than serum levels. Cancer patients had significantly higher intraperitoneal cytokine levels than noncancer patients. Peritoneal levels tended to increase in cancer patients with free tumor cells in peritoneal fluid. They were significantly higher in patients with tumor implants ≥2cm and/or patients with peritoneal carcinomatosis index (PCI) >19. Furthermore, patients with malignant pseudomyxoma peritonei (grades II and III) had higher levels than patients with nonmalignant disease (grade I). Assessment of intraperitoneal IL-6, IL-8, IL-10, TNF-alpha, and sICAM levels can be performed in patients with peritoneal surface malignancies. They can be considered as both diagnostic and prognostic biomarkers that could be used as useful adjuncts for therapeutic decision making.

Regional treatment with liquid barrier agents: A novel therapeutic option for intraperitoneal endometriosis?

Endometriosis is a frequent gynecological disease, which is characterized by the presence of endometriotic lesions, i.e. ectopic endometrial glands and stroma, outside the uterine cavity. Most of these lesions are located in the peritoneal cavity, where they induce a chronic inflammatory and angiogenic tissue response. This is often associated with the formation of peritoneal adhesions. Accordingly, endometriosis is crucially dependent on the close interaction of the ectopic endometrial tissue with the peritoneum and the peritoneal fluid. Therefore, we hypothesize in the present paper that regional treatment of endometriosis, selectively targeting the peritoneal microenvironment without inducing severe systemic side effects, may represent a promising novel treatment strategy. This may be achieved by the application of liquid barrier agents, which are already well established in clinical practice for peritoneal dialysis, treatment of peritoneal surface malignancies and prevention of postoperative adhesions. Of interest, some of these agents have been shown to exhibit anti-inflammatory, anti-oxidant and anti-tumoral properties. Thus, they may act as pleiotropic compounds, affecting multiple mechanisms, which are involved in the pathogenesis of endometriosis.

Complications and Toxicities After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

The purpose of our study was to evaluate the perioperative complications, toxicity, mortality rates after cytoreductive surgery (CRS), and effects of hyperthermic intraperitoneal chemotherapy (HIPEC) used in the treatment of peritoneal surface malignancies. Between September 2007 and March 2012, we performed 118 CRS and HIPEC with the closed abdominal technique on 115 patients with peritoneal carcinomatosis (PC). Systemic toxicities were graded according to the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 3.0 criteria and were analyzed from a prospectively collected database. The mean age of patients was 53.4 (range, 20-82) years; 76.3% were female. PC was synchronous to primary cancer in 53.4% of patients, metachronous in 41.5%, and recurrent in 5.1% of the patients. PCI was ≥15 in 53.4% of the patients, and CC-0 cytoreduction was achieved in 68.5% of the patients. Perioperative mortality was observed in 9 (7.6%) patients. A total of 98 complications were observed in 46 (39.0%) patients, and 4 patients underwent 6 reoperations for perioperative surgical complications. We observed toxicity in 25.4% of the patients, nephrotoxicity in 18.6%, and hematological toxicity in 13.6% of patients. No significant difference was observed among age, gender, PCI and CC scores, origin of the primary tumor, and occurrence of toxicity and surgical complications. Prolonged operation times resulted in higher complication and/or toxicity rates (P<0.01). Cytoreductive surgery and HIPEC is a combined treatment strategy for peritoneal surface malignancies with acceptable complication and toxicity rates.

Risk factors for recurrence following complete cytoreductive surgery and HIPEC in colorectal cancer-derived peritoneal surface malignancies

Recurrent disease following complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a relevant clinical scenario. We aimed to determine risk factors for recurrence. Prospectively collected data of patients enrolled in the Peritoneal Surface Malignancy Program at the University of Tübingen between 2005 and 2011 were retrospectively analyzed. All patients were treated by standardized CRS and HIPEC. Recurrence was defined either radiographically by CT, PET-CT scan, or reoperation. Fifty-two patients received complete CRS (CC-0/CC-1) and HIPEC. Median time to recurrence was 229 days (103-1,028). Overall recurrence rate within follow-up was 48 %. Of patients with recurrent disease, 44 % experienced extraperitoneal systemic tumor spread. In multivariate analysis, grading of ≥ 3 was shown as an independent risk factor for recurrent disease, while a trend was observed for maximal tumor load in the upper abdominal region. Clinical parameters did not show an impact on recurrence. Primary tumor grading seems to be an independent risk factor for recurrence following complete CRS and HIPEC in colorectal cancer-derived peritoneal surface malignancies.

558 Urologic complications of cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy; incidence, risk factors, and management in 934 consecutive procedures

558 Urologic complications of cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy; incidence, risk factors, and management in 934 consecutive procedures

Photodynamic detection and management of intraperitoneal spreading of primary peritoneal papillary serous carcinoma in a man: report of a case

As a peritoneal surface malignancy, primary peritoneal papillary serous carcinoma (PPPSC) almost always occurs in women. Our search of the literature found only two previous case reports of men with PPPSC, both with very short survival. We report the case of a 63-year-old man with PPPSC, treated effectively with cytoreductive surgery and docetaxel-based hyperthermic intraperitoneal chemotherapy following six cycles of docetaxel-based laparoscopic neoadjuvant intraperitoneal and cisplatin-based systemic chemotherapy. Furthermore, we detected intraoperative intraperitoneal spreading of the tumor after the oral administration of 5-amino levulinic acid (5-ALA). The patient remains in good health without ascites 18 months after his diagnosis. Thus, primary peritoneal papillary serous carcinoma should be managed by intraperitoneal chemotherapy combined with peritonectomy procedures. Moreover, the intraoperative detection of the intraperitoneal spreading of the tumor after administering oral 5-ALA shows that this is an exciting and promising diagnostic technique, which needs to be confirmed by further studies.

Prevention of surgical site infections in high-risk patients with laparotomy incisions using negative-pressure therapy

BackgroundThis study evaluates the efficacy of negative-pressure therapy (NPT) in preventing surgical site infections (SSIs) in high-risk surgical oncology patients. MethodsA retrospective analysis of 191 operations for colorectal, pancreatic, or peritoneal surface malignancies was performed. Incisional NPT was used in patients with multiple SSI risk factors. Rates of SSIs were compared with patients treated with a standard sterile dressing (SSD). ResultsNPT was used in 104 patients, whereas SSDs were used in 87 patients. Despite being at an increased risk of SSI, patients treated with NPT developed fewer superficial incisional SSIs compared with SSD patients (6.7% vs 19.5%, P = .015). In a subgroup analysis of clean-contaminated cases, NPT was associated with fewer superficial incisional SSIs (6.0% vs 27.4%, P = .001), fewer total SSIs (16.0% vs 35.5%, P = .011), and fewer wound openings for any reason (16.0% vs 35.5%, P = .011). ConclusionsOur findings suggest that NPT decreases SSIs in high-risk surgical oncology patients.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for rare sarcomatosis in pediatric patients – perfusion, anaesthetic and toxicity management

Aims: Peritoneal surface malignancies arising from cancer of gastrointestinal or gynaecological origin in adults are treated with the established combination of cytoreductive surgery and intraperitoneal hyperthermic application of cytotoxic drugs (HIPEC). In contrast to adults malignancies in pediatric patients are very rare, reporting of treatment is restricted to small series.

Assessment of clinical benefit and quality of life in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for management of peritoneal carcinomatosis.

Peritoneal carcinomatosis (PC) is a challenging problem with poor prognosis. Survival even with the current standard chemotherapy is dismal. Cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC) in appropriately selected patients may offer significant survival benefit. In the review article entitled “Assessment of Clinical benefit and quality of life in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for management of peritoneal carcinomatosis” authors provide a comprehensive review of the available data related to the morbidity, mortality, survival and quality of life with CRS and HIPEC for the management of peritoneal carcinomatosis (1). Several retrospective studies have shown the feasibility and benefit of CRS and HIPEC in the management of various peritoneal surface malignancies (2,3). Although clinical utility of CRS and HIPEC in the management of mesothelioma and peritoneal dissemination of appendiceal malignancies is widely accepted, its role in colorectal cancer peritoneal carcinomatosis has been heavily debated. Randomized controlled trial by Veerwal et al. demonstrated a survival benefit of 9 months for patients with colorectal peritoneal carcinomatosis treated with CRS and HIPEC followed by 5-FU chemotherapy compared to palliative surgery and 5-FU chemotherapy (4). Furthermore, patients who underwent complete cytoreduction had a 5-year survival rate of 45%, which favorably compares to the reported survival for colorectal hepatic metastasectomy. Despite these promising results skepticism still exists, as the patients in the control arm of the trial did not receive current standard chemotherapy. However, recent studies utilizing current standard chemotherapy with or without biologic agents have reported a median overall survival of 10-15 months in patients with colorectal peritoneal carcinomatosis (5,6). These results underscore the decreased efficacy of systemic treatment in the setting of PC, when feasible CRS and HIPEC should be considered as the standard treatment for patients with colorectal cancer peritoneal carcinomatosis. As described in the review article cytoreductive surgery is a major surgical procedure with significant morbidity. However, in appropriately selected patients the risk-benefit ratio favors an aggressive treatment approach. Extent of peritoneal dissemination, measured as peritoneal cancer index (PCI) and the completeness of cytoreduction have been indisputably shown to be major predictors of outcome (7). Patient selection is a challenging task, as the risk-benefit ratio is influenced by multiple factors. In addition, the ability to accurately estimate the extent of peritoneal dissemination and predicting the chances of complete cytoreduction is far from perfect. Esquivel and Pelz have proposed a peritoneal surface disease severity (PSDS) scoring system based on symptoms, extent of disease and histology to stratify patients with colon cancer peritoneal carcinomatosis into different prognostic groups that may aid in patient selection for different treatment (8). The risk-benefit ratio for CRS and HIPEC not only depends on the ability to achieve complete cytoreduction but on the biologic aggressiveness of the tumor, which is heavily weighed into the PSDS score. Multi-institutional prospective validation studies are required to assess the clinical utility of the PSDS scoring system. Finally, the importance of measurement of health related quality of life (HRQoL) cannot be overemphasized in patients undergoing CRS and HIPEC. The authors have provided a comprehensive review of the available scoring systems and the data for QoL. Most studies report a decrease in the quality of life up to six months after CRS and HIPEC, with improvement in majority of patients at one year. This should be taken into consideration while counseling patients about the outcomes of CRS and HIPEC. In summary, management of patients with peritoneal carcinomatosis is complex and requires a multidisciplinary approach. Proper patient selection for CRS and HIPEC based on favorable risk-benefit ratio is of utmost importance. Management should focus on both cancer-specific outcomes and quality of life.