Management of peritoneal surface malignancy with cytoreductive surgery and perioperative intraperitoneal chemotherapy

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Abstract

Aims

A new treatment strategy combining maximal cytoreductive surgery for treatment of macroscopic disease and maximal perioperative intraperitoneal chemotherapy for residual microscopic disease, suggests that in a selected group of patients benefit is possible. The purpose of this study was to report our experience with this combined treatment and to identify the principal prognostic factors.

Methods

The study included 266 patients from 9 institutions operated on between July 1990 and July 2004. The median age was 55 years.

Results

The mortality rate was 7.8% and the morbidity rate 37.5%. The overall median survival was 13.7 months. Positive independent prognostic factors by multivariate analysis were gender, perioperative intraperitoneal chemotherapy and treatment by the second-look procedure.

Conclusions

The therapeutic approach combining cytoreductive surgery with perioperative intraperitoneal chemotherapy achieved long-term survival in a selected group of patients with an acceptable morbidity and mortality.

Introduction

Peritoneal carcinomatosis has long been considered incurable. Despite the development of new, more effective chemotherapeutic agents and combinations, the results of systemic chemotherapy treatment remain disappointing, with a limited impact on survival. Patients with peritoneal carcinomatosis have long been considered as a terminal condition with no curative options. The natural history of untreated patients with this condition showed a median survival ranging between 3 and 9 months depending on the primary tumor involved.1, 2, 3, 4 There is a renewed interest in peritoneal surface malignancies with a new therapeutic strategy towards peritoneal carcinomatosis being developed over the past 20 years combining maximum radical cytoreductive surgery and perioperative intraperitoneal chemotherapy. Some interesting results have been reported although a majority of oncologists remains skeptical regarding this combined therapeutic approach.5, 6 To provide further data, a collaborative effort of the Spanish institutions involved in the treatment of peritoneal surface malignancies gathered information on a large number of patients to evaluate the efficacy of this treatment, and to identify principal prognostic indicators. The aim of this study is to present the preliminary results of the Spanish national experience of the main groups involved in this new treatment alternative.

Section snippets

Patients and methods

A retrospective multicenter study was performed to evaluate the national experience with this combined treatment strategy and to identify the principal prognostic indicators.

During the months of April and June 2004, a questionnaire was sent out nationally to all the General Surgery and Digestive Tract departments of the hospital centers in Spain interested in this problem.

A data sheet was enclosed, with the date of July 31, 2004 as the limit for including patients and September 30 as the limit

Data forms

A standard data form was created to retrieve information on the primary tumor including its location, the presence or absence of hepatic or lymphatic metastases, and the differentiation of the primary tumor. The form also recorded information on the status of the patient before undergoing the combined procedure, including the sex, the age, the extent of peritoneal carcinomatosis, and the previous treatment with systemic chemotherapy. The extent of peritoneal carcinomatosis was assessed by

Statistical analysis

Analysis was performed up to July 2004. Data were recorded and analyzed with a commercially available computer program (SPSS 12.0 for Windows. The Apache Software Foundation, USA). To study relationships between variables, standard tests have been used: Chi-square with 2 variables, Pearson's correlation (or Spearman's ranks correlation) if quantitative, and analysis of variance, Student's t-test, otherwise Kruskall–Wallis H-test, depending on the number of distributions, normality, and

Clinico-pathological data

The study includes 266 patients from 9 National Institutions operated on between July 1990 and July 2004. The study population comprised 185 females and 81 males, with a median age of 55 years (range, 20–90 years). Of the total, 223 patients were treated in institutions that include more than 30 patients. The primary tumor origins of the carcinomatosis were ovarian cancer 93, pseudomyxoma of appendiceal origin 65, colon cancer 51, primary abdominal mesothelioma 27, gastric cancer 20, uterus 6

Conclusions

From the study of the database which draws on the cases reported by the 9 Spanish centers interested in the implementation and development of this treatment program for peritoneal carcinomatosis, it can be concluded that considering cancer management as a national problem few centers are at present offering this type of treatment, with experiences that are limited in time and number of cases. There is a progressive increase in interest that can be detected and there are already more than 6

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