Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden How to handle peritoneal carcinomatosis found at laparotomy
Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden
Jan 25, 2016
How to handle peritoneal carcinomatosis found at laparotomy. Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden. Adjuvant Chemotherapy Intraperitoneal chemotherapy (5-FU 500 mg/m 2 /day i.p.) (Leucovorin 60 mg/m 2 /day i.v.) vs - PowerPoint PPT Presentation
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Lars Påhlman
Dept. Surgery, Colorectal unit,
University Hospital, Uppsala, Sweden
How to handle peritoneal carcinomatosis found at
laparotomy
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)
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; 9:35-39
Cytoreductive surgery + i.p chemo
Objectives
Local effect on the surgical bed
Early treatment start
I.v. chemo does not reach the target
Cytoreductive surgery + i.p chemo
Isolated peritoneal carcinomatosis
Colorectal cancer Ovarian cancer Mesothelioma Peritoneal pseudomyxoma Other GI malignancies
Cytoreductive surgery + i.p chemo
Uppsala series 1991 - 2010
Type of malignancy
Pseudomyxoma 197
Colorectal cancer 259
Mesothelioma 41
Miscellaneous 46
Total 543
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
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 !
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
Mahteme et al Br J Cancer 2004
Cytoreductive surgery + i.p chemo
ip group
Control group
Cumulative Proportion Surviving (Kaplan-Meier)
Complete Censored
Months
Cu
mu
lativ
e P
rop
ort
ion
Su
rviv
ing
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
0 12 24 36 48 60 72 84 96 108 120 132 144
Figure 1
Uppsala seriesColon cancer
Mahteme et al Br J Cancer 2004
Cytoreductive surgery + i.p chemo
Uppsala series
Radically operated
Non-radical operated
Cumulative Proportion Surviving (Kaplan-Meier)
Complete Censored
Months
Cum
ulat
ive
Pro
port
ion
Sur
vivi
ng
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
0 12 24 36 48 60 72 84 96 108 120 132 144
Figure 2
Uppsala seriesColon cancer
Cytoreductive surgery + i.p chemo
Uppsala experience colon cancer
Randomized trial
Classic chemotherapy
vs
Cytoreductive surgery + i.p chemo
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
Cashin et al E J S O 2013
Cytoreductive surgery + i.p chemo
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.
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.
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
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
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
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
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
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
Cytoreductive surgery + HIPEC
Special issues
Laparoscopy
Drainage
Distant metastases
Morbidity
Cytoreductive surgery + HIPEC
Take home message
Always send the
patients to a
HIPEC-unit
Cytoreductive surgery + HIPEC
Conclusion
Pseudomyxoma; Standard of care
CRC; Standard of care
Ovarian cancer; experimental ?
Mesotelioma; Standard of care ?
Gastric cancer; No
Related Documents
