Innovations in Surgical OncologyInnovations in Surgical Oncology
Sricharan Chalikonda, M.D.Surgical Oncology
Director Gen.Surg Robotics ProgramCleveland Clinic
Sricharan Chalikonda, M.D.Surgical Oncology
Director Gen.Surg Robotics ProgramCleveland Clinic
DisclosuresDisclosures
CovidienSpeaker
BardSpeaker
Intuitive SurgicalProctorSpeaker
CovidienSpeaker
BardSpeaker
Intuitive SurgicalProctorSpeaker
Surgical Oncology ProgramsSurgical Oncology Programs
CarcinomatosisHIPEC
SarcomaResection with HAM catheters
Minimally Invasive/Robotic Approaches
CarcinomatosisHIPEC
SarcomaResection with HAM catheters
Minimally Invasive/Robotic Approaches
Peritoneal CarcinomatosisPeritoneal Carcinomatosis
Progressive involvement of peritoneal surfaces by tumor seeded within peritoneal cavity
Rupture primary tumorSpillage tumor cells by surgical manipulation
Traditionally considered Stage IV diseaseTreated with systemic chemotherapySurgical treatment palliative for sympotomatic disease
Progressive involvement of peritoneal surfaces by tumor seeded within peritoneal cavity
Rupture primary tumorSpillage tumor cells by surgical manipulation
Traditionally considered Stage IV diseaseTreated with systemic chemotherapySurgical treatment palliative for sympotomatic disease
Gastric~11,000
Colon~17,000
Appendiceal~1100
Ovarian~20,000
Mesothelioma~500
Pseudomyxoma
Aggressiveness
Patient PopulationPatient Population
Peritoneal Carcinomatosis-Natural History-
Peritoneal Carcinomatosis-Natural History-
Crampy abdominal painAnorexia/Weight lossBowel ObstructionAscitesInanitionInfectionDeath
Crampy abdominal painAnorexia/Weight lossBowel ObstructionAscitesInanitionInfectionDeath
Major problem in cancer management
Hard to detect by imagingDifficult to manageMarked deterioration in quality of life Short survival
Major problem in cancer management
Hard to detect by imagingDifficult to manageMarked deterioration in quality of life Short survival
Peritoneal CarcinomatosisPeritoneal Carcinomatosis
Treatment OptionsTreatment OptionsSurgical Treatment
Surgery with or without systemic chemotherapy has shown to be inadequate for the treatment of patients with PC.
Systemic ChemotherapyPoor penetration to peritoneum
Peritoneal Chemo Dwell
Surgical TreatmentSurgery with or without systemic chemotherapy has shown to be inadequate for the treatment of patients with PC.
Systemic ChemotherapyPoor penetration to peritoneum
Peritoneal Chemo Dwell
Rationale: Cyto-Surgery + HIPEC Rationale: Cyto-Surgery + HIPEC
Cancer is confined to peritoneal cavitySurgeon can take down adhesions, cytoreduce tumorsHeat has effect on cancer cells“Targeting” and localizing the principal effect of a multi-modality treatment
Cancer is confined to peritoneal cavitySurgeon can take down adhesions, cytoreduce tumorsHeat has effect on cancer cells“Targeting” and localizing the principal effect of a multi-modality treatment
Multi-Modality TreatmentMulti-Modality Treatment
CYTOREDUCTIVESURGERY
INTRAPERITONEAL HYPERTHERMIA
CHEMOTHERAPY
Improve SurvivalImprove SurvivalPeritonealCancer
Average Life expectancy with standard therapy
With “HIPEC”
Colon 6 mos. 18 – 36 mos.
AppendixPMP
10 mos.5 -10 yrs.
30 mos.10 – 20 yrs.
Mesothelioma 12 – 21 mos. 34 – 92 mos.
Ovarian 6 mos. 25 – 28 mos.
Gastric 1 mos. 14 – 24 mos.
Cytoreductive SurgeryCytoreductive Surgery
The first and most important stepThe goal is to remove all visible disease.This would leave microscopic and small surface tumors.
The first and most important stepThe goal is to remove all visible disease.This would leave microscopic and small surface tumors.
Approach to Patients with Peritoneal CarcinomatosisApproach to Patients with Peritoneal Carcinomatosis
Recommend Biopsy of nodules and peritoneal washingsNo need to resect primary unless perforatedNeoadjuvant chemo followed by cytoreductive surgery with HIPEC if possible
Recommend Biopsy of nodules and peritoneal washingsNo need to resect primary unless perforatedNeoadjuvant chemo followed by cytoreductive surgery with HIPEC if possible
Retroperitoneal SarcomaRetroperitoneal Sarcoma
Usually grow to a large size before presentationRequire multivisceral resection to remove completelyHigh recurrence rate
Usually grow to a large size before presentationRequire multivisceral resection to remove completelyHigh recurrence rate
Treatment OptionsTreatment Options
Neoadjuvant radiation followed by resection
Bowel and other structures protected by tumorDifficult to focus on margin
Resection followed by radiationBowel exposed to radiation which limits dose
Neoadjuvant radiation followed by resection
Bowel and other structures protected by tumorDifficult to focus on margin
Resection followed by radiationBowel exposed to radiation which limits dose
Resection with periop radiationResection with periop radiation
Tumor resectedBowel packed awayCatheters placed at margin and radiation administered over next 36hoursComplete treatment achieved during one hospitalization
Tumor resectedBowel packed awayCatheters placed at margin and radiation administered over next 36hoursComplete treatment achieved during one hospitalization
Case reportCase report
60 year old with abdominal fullness and vague pain
60 year old with abdominal fullness and vague pain
Surgical ResectionSurgical Resection
ColectomyNephrectomyCholecystectomyPlacement of Catheters
ColectomyNephrectomyCholecystectomyPlacement of Catheters
Biliary DissectionBiliary Dissection
55 Year old female with abdominal pain. Found to have choledochol cyst during routine IOC.
55 Year old female with abdominal pain. Found to have choledochol cyst during routine IOC.