Management of Peritoneal Surface Malignancy:
Appendix Cancer and Pseudomyxoma Peritonei, Colon Cancer, Gastric Cancer, Abdominopelvic Sarcoma, and Primary Peritoneal Malignancy

Paul H. Sugarbaker, M.D.

The Washington Cancer Institute
Washington Hospital Center
106 Irving Street, NW, Suite 3900
Washington, DC 20010 USA

I. Introduction

II. Principles of Management

A. Peritonectomy Procedures

1. Rationale for Peritonectomy Procedures

a. Locations of Peritoneal Surface Malignancy

b. Lasermode Electrosurgery

c. Conversion of Peritoneal Surface to Invasive Malignancy by Surgery

2. Modified Lithotomy Position and Maximal Midline Incision for Cytoreductive Surgery

3. Abdominal Exposure Using a Self-retaining Retractor, Complete Greater Omentectomy and Splenectomy

4. Peritoneal Stripping from Beneath the Left Hemidiaphragm

5. Left Subphrenic Peritonectomy Completed

6. Peritoneal Stripping From Beneath the Right Hemidiaphragm

7. Stripping of Tumor from Beneath the Right Hemidiaphragm, from the Right Subhepatic Space, and from the Surface of the Liver

8. Completed Right Subphrenic Peritonectomy

9. Lesser Omentectomy and Cholecystectomy with Sripping of the Porta Hepatis

10. Stripping of the Omental Bursa

11. Complete Pelvic Peritonectomy

12. Resection of Rectosigmoid Colon and Cul-de-Sac of Douglas

13. Vaginal Closure and Low Colorectal Anastomosis

14. Left Colon Mobilization for a Tension Free Low Colorectal Anastomosis

15. Antrectomy and Gastric Reconstruction

16. Total Gastrectomy with Staged Reconstruction

17. Tubes and Drains Required for Intraoperative and Early Postoperative Intraperitoneal Chemotherapy

B. Intraperitoneal Chemotherapy

1. Conceptual Changes with Intraperitoneal Chemotherapy

2. Background

3. Peritoneal-Plasma Barrier

4. Tumor Cell Entrapment

5. Prior Limited Benefits with Intraperitoneal Chemotherapy

6. Clinical Evidence that Cytoreductive Surgery and Intraperitoneal Chemotherapy is of
Benefit to Patients with Peritoneal Surface Malignancy

C. Patient Selection for Treatment

1. Clinical Assessments of Peritoneal Surface Malignancy

2. Histopathology to Assess Invasive Character

3. Preoperative CT Scan

4. Peritoneal Cancer Index

5. Completeness of Cytoreduction Score

III. Current Methodology for Delivery of Intraperitoneal Chemotherapy

A. Heated Intraoperative Intraperitoneal Chemotherapy Administration

1. Mitomycin C

2. Cisplatin and Doxorubicin

B. Immediate Postoperative Lavage

C. Early Postoperative Intraperitoneal 5-fluorouracil

D. Adjuvant Intravenous Mitomycin C and Intraperitoneal 5-fluorouracil

E. Reoperative Surgery Plus Additional Intraperitoneal Chemotherapy

F. Oncologic Emergency

IV. Clinical Results of Treatment

A. Reliable Relief of Debilitating Ascites

1. Limited Goals of Treatment

2. Technique for Chemotherapy Instillation for Treatment of Ascites

3. Schedule and Dose of Intraperitoneal Chemotherapy for Treatment of Ascites

4. Treatment of Mucinous Ascites

B. Appendix Cancer and Pseudomyxoma Peritonei

1. Appendiceal Malignancy as a Paradigm

2. Survival by the Invasive Character of the Mucinous Tumor

3. Survival by Completeness of Cytoreduction

4. Survival by Prior Surgical Score

5. Survival by Absence vs. Presence of Lymph Nodes

6. Survival by Carcinoid Features

C. Colon Cancer Peritoneal Carcinomatosis

1. Survival of All Treated Patients Compared to Historical Controls

2. Survival by Completeness of Cytoreduction

3. Survival by Presence vs. Absence of Lymph Node Metastases

4. Survival by Preoperative Lesion Size

D. Abdominopelvic Sarcoma with Sarcomatosis

E. Gastric Cancer Peritoneal Carcinomatosis

F. Primary Peritoneal Surface Malignancy

1. Mesothelioma

2. Papillary Serous Cancer

3. Primary Peritoneal Adenocarcinoma

G. Recurrent and Obstructing Gastrointestinal Cancer

H. Morbidity and Mortality

I. Alternative Approaches

V. Ethical Considerations in Clinical Studies with Peritoneal Surface Malignancy

VI. References


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