Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

World Journal of Surgical Oncology BioMed Central Open Access Review Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy Gabriel Glockzin, Hans J Schlitt and Pompiliu Piso* Address: Department of Surgery, University of Regensburg Medical Center, Regensburg, Germany Email: Gabriel Glockzin - ; Hans J Schlitt - ; Pompiliu Piso* - * Corresponding author Published: 8 January 2009 World Journal of Surgical Oncology 2009, 7:5 doi:10.1186/1477-7819-7-5 Received: 9 October 2008 Accepted: 8 January 2009 This article is available from: http://www.wjso.com/content/7/1/5 © 2009 Glockzin et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: Peritoneal tumor dissemination arising from colorectal cancer, appendiceal cancer, gastric cancer, gynecologic malignancies or peritoneal mesothelioma is a common sign of advanced tumor stage or disease recurrence and mostly associated with poor prognosis. Methods and results: In the present review article preoperative workup, surgical technique, postoperative morbidity and mortality rates, oncological outcome and quality of life after CRS and HIPEC are reported regarding the different tumor entities. Conclusion: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provide a promising combined treatment strategy for selected patients with peritoneal carcinomatosis that can improve patient survival and quality of life. The extent of intraperitoneal tumor dissemination and the completeness of cytoreduction are the leading predictors of postoperative patient outcome. Thus, consistent preoperative diagnostics and patient selection are crucial to obtain a complete macroscopic cytoreduction (CCR-0/1). Background Peritoneal carcinomatosis is a common sign of advanced tumor stage, disease progression or recurrence in numerous tumor entities of gastrointestinal or gynecological origin. Moreover, there are primary peritoneal malignancies such as malignant peritoneal mesothelioma or primary peritoneal carcinoma. In general, the diagnosis of peritoneal tumor manifestation is associated with poor prognosis. In the European multicenter EVOCAPE I study the median survival rates were 5.2 months for advanced colorectal cancer (CRC, n = 118) and 3.1 months for advanced gastric cancer (GC, n = 125), respectively[1]. The median survival rate in patients with stage IV ovarian cancer (OC) range from 12 to 23 months [2-4]. For diffuse malignant peritoneal mesothelioma (DMPM) median survival rates of less than one year are reported in most existing studies [5-7]. However, in a Phase II trial with systemic application of permetrexed and gemcitabine the median survival rate was 26.8 months in patients with malignant peritoneal mesothelioma [8]. The treatment of choice for patients with peritoneal surface malignancies is palliative systemic chemotherapy. In the past, surgery was performed in palliative intention for prevention or therapy of tumor-related complications such as gastrointestinal obstruction, bleeding or tumor perforation [9]. Solely, in ovarian cancer cytoreductive surgery was already estab- Page 1 of 8 (page number not for citation purposes) World Journal of Surgical Oncology 2009, 7:5 http://www.wjso.com/content/7/1/5 lished as an inherent part of the standard treatment regimen [10]. In the early 1990's Sugarbaker et al. introduced cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) as a new innovative therapeutic option for selected patients with peritoneal carcinomatosis [11,12]. Over the years peritoneal carcinomatosis treatment centers were established in the United States, Europe and Japan. Feasibility, efficacy and safety of CRS and HIPEC have been proved in numerous clinical trials. In the present review article patient selection, treatment strategy, mortality and morbidity rates and oncological outcome is reported regarding the different tumor entities. Cytoreductive surgery CRS consists of numerous surgical procedures depending on the extent of peritoneal tumor manifestation. In appendiceal malignancies, the omental cake, a disseminated tumor infiltration of the greater omentum, represents the most affected abdominal area (Fig. 1). Surgery may include parietal and visceral peritonectomy, greater omentectomy, splenectomy, cholecystectomy, resection of liver capsule, small bowel resection, colonic and rectal resection, (subtotal) gastrectomy, lesser omentectomy, pancreatic resection, hysterectomy, ovariectomy and urine bladder resection. In patients with mucinous tumors and infiltration of the umbilicus, an omphalectomy is necessary. Extraperitoneal dissection may enable the anterior parietal peritonectomy and avoid a tumor contamination of the abdominal wall (Fig. 2). The extent of intraperitoneal tumor manifestation is determined using the peritoneal cancer index (PCI), a combined numerical score of lesion size (LS-0 to LS-3) and tumor localization (region 0–12) [13,14]. The aim of CRS is to Figurefrom 'Omental arising 1 cake' appendiceal in a patient cancer with peritoneal carcinomatosis 'Omental cake' in a patient with peritoneal carcinomatosis arising from appendiceal cancer. Figure 2 Omphalectomy in a patient with umbilical tumor infiltration Omphalectomy in a patient with umbilical tumor infiltration. obtain complete macroscopic cytoreduction (CCR-0/1) as a precondition for the application of HIPEC. The residual disease is classified intraoperatively using the completeness of cytoreduction (CCR) score. CCR-0 indicates no visible residual tumor and CCR-1 residual tumor nodules ≤ 2.5 mm. CCR-2 and CCR-3 indicate residual tumor nodules between 2.5 mm and 2.5 cm and > 2.5 cm, respectively [14]. Hyperthermic intraperitoneal chemotherapy In case of complete macroscopic cytoreduction (CCR-0/1) CRS is followed by hyperthermic intraperitoneal chemotherapy (HIPEC). The theoretical advantage of the intraperitoneal distribution of cytostatics is a high local concentration of the used agents and reduced systemic toxicity. In vitro studies could show that hyperthermia may potentiate the cytostatic effects. For example an improved tissue penetration could be shown for cisplatin. Moreover, hyperthermia leads to direct cytotoxic effects such as protein denaturation, induction of apoptosis and inhibition of angiogenesis [15]. For the performance of HIPEC one inflow and three outflow drainages are placed subphrenically and in the small pelvis. The cytostatic agent is applied via the inflow drainage using a roller pump and heat exchanger in a closed system that allows perfusate circulation (Fi (...truncated)