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How to handle peritoneal
carcinomatosis found at
laparotomy
Lars Påhlman
Dept. Surgery, Colorectal unit,
University Hospital, Uppsala,
Sweden
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
Cytoreductive surgery + i.p chemo
Cumulative Proportion Surviving (Kaplan-Meier)
Figure 1
Complete
Censored
Cum ulative Proportion Surviving
1,0
Uppsala series
Colon cancer
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
ip group
0,0
0
12
24
36
48
60
72
84
96
108
120
132
144
Control group
Months
Mahteme et al Br J Cancer 2004
Cytoreductive surgery + i.p chemo
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Uppsala series
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Uppsala
Colon cancer
0
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,7
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CumulativeProportionSurviving
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Mahteme et al Br J Cancer 2004
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
Cytoreductive surgery + i.p chemo
Cashin et al E J S O 2013
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