Title | Introduction | Histopathology | Computed Tomography | Clinical Assessment Criteria | Pharmacokinetics of IP Chemotherapy
Appendix Cancer Morphology | Cytoreductive Surgery | Perioperative Intraperitoneal Chemotherapy | Results of Treatment


Results of Treatment



 

No.

No. treatment

     

Relative

   
Variables

patients

failures

(%)

p Value

 

risk (OR)

95% CI

 
                   
Tumor site                
  Appendix

108

38

35

         
  Colon

8

6

75

         
  Ovary

2

0

           
  Unknown

2

2

100

0.014

(b)      
  Appendix vs.

108

38

35

         
  colon

8

6

75

0.05

(a)

6

   
                   
Preoperative volume                
  Volume 1+2

16

             
  Volume 3

104

46

44

0.00004

(b)

--

0.4, 11.3

 
                   
Histopathology                
  Grade I

94

30

32

         
  Grade II

26

16

62

0.006

(b)

3.4

1.4, 8.4

(a)
                   
Cytoreduction                
  CC-1

90

19

21

         
  CC-2,3

30

27

90

0.00001

(b)

24.9

4.7, 79.8

(a)
                   
Grade + Resection                
  CC-1

74

13

18

         
  Grade I                
  CC-2,3

20

17

85

0.00001

(b)      
  CC-1

15

6

40

         
  Grade II                
  CC-2,3

11

10

91

0.014

(a) MH

22.4

8.4, 60.2

(a)
                   
Sex                  
  Female

40

10

25

         
  Male

80

36

45

0.047

(a)

2.4

1.04, 5.6

 
                   
Age                  
  <65

104

35

34

         
  >65

16

11

69

0.003

(b)

4.9

1.5, 14.9

(a)
                   
(a) p<0.05; RR #1                
(b) p<0.01                
MH = Mantel - Haenzel test                

Table 15

Clinical features of 46 treatment failures in 120 patients with mucinous tumors of peritoneal surfaces. From Sugarbaker PH, Fernandez-Trigo V, Shamsa F: Clinical determinants of treatment failure in patients with pseudomyxoma peritonei (In) Sugarbaker PH (Ed) Peritoneal Carcinomatosis: Principles of Management. Kluwer: Boston p 125, 1996.



Figure 43

Sites of treatment failure at second-look surgery in patients with pseudomyxoma peritonei. The most common sites of treatment failure were anterior surface of stomach, small bowel mesentery, surface of colon, especially the residual right colon, suture lines including gastrojejunostomy, colorectal stapled suture lines, and the abdominal incision. All of these anatomic sites would be suspect for recurrence as a result of the methylene blue dye studies performed when chemotherapy is instilled into the closed abdomen. From Zoetmulder FAN, Sugarbaker PH: Patterns of failures following treatment of pseudomyxoma peritonei of appendiceal origin. European Journal of Cancer 32:1727-1733, 1996



Figure 44

Pseudomyxoma spread to the pleural space. If there is full thickness damage to the hemidiaphragm during cytoreductive surgery, adenomatous epithelial cells will gain access to the pleural spaces. If this occurs without special treatments, all of these patients will develop pleural pseudomyxoma over time. If this occurs then the diaphragm should be widely opened so that the surgeon's hand can be thrust into the pleural space. Vigorous manipulation of the pleural surfaces during the heated intraoperative intraperitoneal chemotherapy should be used to eradicate disease from the pleural cavity. In this radiograph pseudomyxoma peritonei had penetrated the diaphragm to cause extensive mucin accumulations on the pleural surfaces.



Figure 45

Kaplan-Meier survival curve of 145 patients by type with pseudomyxoma peritonei treated with cytoreductive surgery and intraperitoneal chemotherapy. Thirty-three patients received four-six cycles of early postoperative intraperitoneal chemotherapy, thirty-three patients received a single cycle of early postoperative intraperitoneal chemotherapy, and thirty-seven patients received heated mitomycin C (HIIC) plus early postoperative intraperitoneal 5-fluorouracil. No significant differences were noted by type of intraperitoneal chemotherapy treatment.



Figure 46

Kaplan-Meier survival curve of 145 patients with pseudomyxoma peritonei. Complete (n=112) versus incomplete (n=33) resection are compared, p=0.0001.



Figure 47

Kaplan-Meier survival curve comparing patients with pseudomyxoma peritonei. Patients with one complete (n=87) versus incomplete cytoreductions (n=27) and patients with multiple surgeries (n=3 1) are shown. Patients required to have additional surgery are not statistically significantly different from those not requiring re-operation.



Figure 48

Kaplan-Meier survival curve showing distribution in pseudomyxoma peritonei patients by histology, p=0.0001. Mucinous tumor grade (MTG) 1 = adenomucinosis, MTG 1.5 = intermediate grade, and MTG 2 = mucinous adenocarcinoma. MTG1 = 113 patients, MTG 1.5 = 25 patients and MTG 2 = 10 patients.



Figure 49

Comparison of laser-mode electroevaporation of carcinomatosis nodules form adenomucinosis nodules. Even though all the cancer visible to the naked eye is resected, the invasive tumor may have persistent disease at the margins of the resection. In a non-invasive implant such as adenomucinosis, the electrosurgical dissection would leave a negative margin. Depth of invasion of the peritoneal surface nodule determines the duration of response to peritonectomy plus perioperative intraperitoneal chemotherapy.



Figure 50

Kaplan-Meier survival curve by prior surgical score. In patients with prior surgical score of 0-2, less than five abdominal regions have been previously explored. In the patients with a heavy prior surgery that are assigned a prior surgical score of three, greater than five abdominal regions had been previously dissected, p=0.0016. Extensive prior surgery before definitive cytoreduction with intraperitoneal chemotherapy jeopardizes the patient's likelihood of long-term survival. Prior surgical score 0-2 = 113 patients, prior surgical score of 3 = 64 patients, (p = 0.0016).



     

Projected Survival

 
   

Number

3-Year

5-Year

 
   

of Patients

(%)

(%)

p Value

Survival by the type of        
intraperitoneal chemotherapy        
(Complete Cytoreduction)        
  4-6 cycles

59

89

84

0.65

  1 cycle

42

87

65

 
  1 cycle with heat

30

100

100

 
           
Survival by complete vs.        
incomplete cytoreduction        
  Complete

138

89

82

0.0001

  Incomplete

32

45

36

 
           
Survival by Prior Surgical Score        
  0,1,2 (None to moderate)

105

84

84

 
  3 (Extensive prior surgery)

61

76

56

0.016

           
Survival by pathology        
  Pseudomyxoma

134

86

80

 
  Pseudomyxoma /        
  carcinoma hybrid

32

66

49

 
  Mucinous carcinoma

50

20

12

0.0001

  Pseudomyxoma, complete        
  cytoreduction

114

90

86

 
  Pseudomyxoma, incomplete        
  cytoreduction

20

56

45

 
  Pseudomyxoma /        
  carcinoma hybrid with        
  complete cytoreduction

24

75

56

 
  incomplete cytoreduction

8

33

33

 
  Mucinous carcinoma,        
  complete cytoreduction

14

44

33

 
  Mucinous carcinoma,        
  incomplete cytoreduction

36

6

0

0.0001

Table 16

Summary of prognostic features in patients with appendiceal malignancy showing pseudomyxoma peritonei, intermediate grade pseudomyxoma - adenocarcinoma hybrid or mucinous carcinoma. From Sugarbaker PH, Ronnett BM, Archer A, Averbach AM, Bland R, Chang D, Dalton RR, Ettinghausen SE, Jacquet P, Jelinek J, Koslowe P, Kurman U, Shmookler B, Stephens AD, Steves MA, Stuart OA, White SK, Zahn CM, Zoetmulder FAN. Pseudomyxoma peritonei syndrome. Advances in Surgery 30:233-280, 1997.



 

Treatment Group

 
         
 

Induction IPCT

EPIC

HIIC and

All

Morbidity / Mortality

and EPIC (%)

Only (%)

EPIC (%)

Patients (%)

         
Anastomotic leak

4.5

3.5

10

6

Small bowel or        
gastric fistula

13.6

4.2

8.3

8.7

Bile leak

4.5

1

5

3.5

Pancreatitis

4.5

0

5

3.9

Re-operation for bleeding

0

16.6

5

7.2

All intra-abdominal        
complications

27.3

20.8

31.7

26.6

Pulmonary complications

4.5

20.8

1.7

9

Wound dehiscence

0

0

1.7

0.6

Hematologic toxicity,        
grade III or IV

4.5

3

6.7

4.7

         
Overall morbidity

31.8

41.6

35

36.1

         
Mean duration of ileus

20

21

17

19.3

         
Mortality

1.6

1.5

5

2.7

Table 17

Morbidity and mortality of cytoreductive surgery with three variants of intraperitoneal chemotherapy. From Sugarbaker PH, Ronnett BM, Archer A, Averbach AM, Bland R, Chang D, Dalton RR, Ettinghausen SE, Jacquet P, Jelinek J, Koslowe P, Kurman RI, Shmookler B, Stephens AD, Steves MA, Stuart OA, White S, Zahn CM, Zoetmulder FAN. Pseudomyxoma peritonei syndrome. Advances in Surgery 30:233-280, 1997.



Figure 51

Clinical pathway for management of gastrointestinal fistulas in patients who have cytoreductive surgery and intraperitoneal chemotherapy. Fernandez-Trigo V, Sugarbaker PH: Diagnosis and management of postoperative gastrointestinal fistulas: A kinetic analysis. Journal of Experimental Clinical Cancer Research 13:233-241, 1994.






Title | Introduction | Histopathology | Computed Tomography | Clinical Assessment Criteria | Pharmacokinetics of IP Chemotherapy
Appendix Cancer Morphology | Cytoreductive Surgery | Perioperative Intraperitoneal Chemotherapy |
Results of Treatment