Peritoneal Surface Malignancies

• Appendix: Tumors arising from the appendix can lead to DPAM (disseminated peritoneal adenomucinosis) or PMCA (peritoneal mucinous carcinomatosis), the malignant form of appendiceal cancer. These tumors if they burst or perforate will disseminate cells throughout the abdomen and subsequently result in adenomucinosis or carcinomatosis. These tumors are best treated with cytoreductive procedures and heated intraperitoneal chemotherapy (HIPEC)
  
  
• Colorectal: 30-50% of patients with cancer arising from the colon or rectum will have spread to the abdominal cavity alone. Patients with mucinous carcinoma may be good candidates for cytoreductive surgery and HIPEC as well as those patients who have had perforation of their colon carcinoma found at the initial surgery.
  
  
• Gastric carcinoma: Peritoneal spread and recurrence is commonly seen in gastric cancer.  60% of the patients with more advanced cancer of the stomach despite what is thought to be a curative resection will have peritoneal recurrence. 20-40% of all gastric cancer patients die as a direct result of peritoneal dissemination. Recent European studies have shown improved survival and decrease in peritoneal spread using HIPEC at the time of the initial surgery. Similar improvement in eradicating peritoneal disease has been reported in some patients who recur with limited peritoneal disease after their primary resection using cytoreductive surgery and HIPEC.
  
  
• Peritoneal mesothelioma: Is a rare disease that usually affects the lining of the chest, but also can involve the lining of the abdominal cavity. Peritoneal mesothelioma has several histologic types. Some have relatively benign behavior and may not result in death of the patient for many years. However, more aggressive mesotheliomas may show spread to lymph nodes and peritoneal and intestinal surfaces and can lead to death. Peritoneal mesothelioma is amenable in most cases to initial cytoreductive surgery and HIPEC and also postoperative intraperitoneal and systemic “intravenous” chemotherapy. Occasionally it is recommended that intravenous chemotherapy be delivered prior to surgery. This is done to decrease the size of the tumor in order to make the cytoreductive surgery easier. Some histologic types of peritoneal mesothelioma are not considered for cytoreductive surgery because of their poor prognosis.
  
  
• Ovarian carcinoma: Ovarian cancer is the sixth most common cancer of women worldwide and is responsible for the greatest number of deaths from all gynecological malignancies. Patients with Stage III/IV disease who undergo cytoreductive surgery followed by intravenous chemotherapy can achieve complete response rates of 70-80%.  However, only 20-40% of the patients who undergo second look surgery after completing this chemotherapy are found to be free of disease at the second look surgery. Of the 20-40% found to have no disease at the time of second look surgery, 50-70% of these patients will recur within five years.
  
  
• Most of the recurrences found in ovarian cancer are confined to the abdominal cavity. This means that there are microscopic cells remaining that are not seen at the time of the second look surgery. Therefore we strongly recommend at the time of the second look surgery or if one has been first treated with neoadjuvant chemotherapy to reduce tumor load prior to the initial surgery, that HIPEC be performed as well as EPIC (early postoperative intraperitoneal chemotherapy). We have found using HIPEC that more patients are being cured of the disease at five years and there is less chance of recurrence in those patients who present with advanced tumors (Stage III/IV).
  
  
• Uterine Carcinoma: Cancers that arise from the uterus are called endometrial carcinoma. Most of these tumors are best treated with radical hysterectomy, radiation, and chemotherapy. Although there are some types of endometrial cancers when they recur will recur primarily in the abdomen. Some of these patients are  candidates for cytoreductive surgery and HIPEC. Sarcoma: These are tumors that can originate from the gastrointestinal tract such at GIST (gastrointestinal stromal tumor), or from the uterus (leiomyosarcoma). These tumors when they have spread to the peritoneum can be treated with cytoreductive surgery and HIPEC.