Pseudomyxoma peritoni et al HOW TO TREAT PERITONEAL MALIGNANCIES

Transcription

1 Pseudomyxoma peritoni et al HOW TO TREAT PERITONEAL MALIGNANCIES

2 Case Presentation 72M 3 weeks abdominal distension and lower abdominal pain. 3 weeks constipation w/ 2-3 BM per week. Post-prandial epigastric/substernal pain, burning, and decreased appetite 30-40lb weight loss x 6months HTN, HLD, IDDM Appendectomy KCH for perforated appendicitis and peritonitis Mesenteric implants at that time on CT Path perforated mucinous cystadenoma unknown malignant potential Lost to follow-up Admitted on presentation avoiding doctors on purpose

3 Case Presentation Vitals: not interesting (Labs: not interesting) Exam:

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8 Case Presentation Taken to OR: Explore lap, evacuation of large-volume mucinous ascites (>10L) Total abdominal colectomy/omentectomy Splenectomy Cholecystectomy Peritonectomy including: Right and left diaphragmatic peritonectomy Glisson s Lesser omentum Right abdominal peritonectomy w/ reduction of inguinal hernia Left abdominal and pelvic peritonectomy HIPEC (mitomycin C) End ileostomy

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13 Case Presentation SICU Extubated POD1 re-intubated POD2 POD3 ileostomy function, started feeds POD8 pigtail placed on R for pleural effusion, bronchoscopy POD11 extubated POD13 tracheostomy POD17 still goin strong.

14 Questions?

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16 Is this really necessary???? Sad Eyes Fugly Neck

17 Methods Participants performed a series of motions in a standardized pattern

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19 Pseudomyxoma peritoni et al HOW TO TREAT PERITONEAL MALIGNANCIES

20 Outline Principals of peritoneal malignancy History of rx and the Sugarbaker Applications and outcomes Appendiceal Colorectal Gastric

21 Paradigm Shift Peritoneal disease = M1 disease (death sentence) Peritoneal disease = one form of locoregional spread (like T4) Mechanics of spread shedding as opposed to hematologic or lymphatic spread Superficial vs infiltrative (Not really model of mesothelioma)

22 Paradigm Shift Old therapy debulking and systemic chemotherapy: dismal outcomes Modern therapy cytoreductive surgery and IPC in select patients: significant survival prolongation

23 Sugarbaker Pioneered systematic cytoreduction with description of peritonectomy technique Still alive, continues to publish Wrote Cameron chapter

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25 Cytoreduction and IPC Cytoreduction ~ wide local exision Can t avoid releasing microscopic/macroscopic disease re-seeding In theory IPC kills what you can t resect Small enough (<2.5 mm) Superior to systemic Systemic effects Target tissue penetration

26 Do we do HIPEC? HIPEC a kind of IPC HIPEC EPIC (normothermic) Prevent entrapment Encapsulation within fibrotic post-surgical deposits Within 5 days Hyperthermia boosts tissue penetration and increases target tissue sensitivity CyS >>> IPC

27 CyS and IPC General Steps 1. Multidisciplinary center patient selection 2. Pre-select method and agent of IPC (HIPEC most common) 3. Explore lap w/ PCI 4. Adequate CyS 5. CCS 6. HIPEC 7. Multidisciplinary assessment adjuvant therapy

28 Patient Selection Patient factors Tumor factors

29 Peritoneal Cancer Index (PCI)

30 Cytoreductive Surgery The biggest whack Only macroscopically involved

31 Completeness of Cytoreduction (CC)

32 HIPEC

33 Applications Pseudomyxoma peritoni and appendiceal Colorectal and appendiceal Gastric Peritoneal mesothelioma Ovarian Sarcoma, small bowel, pancreas, GIST, breast, bladder, lung

34 Pseudomyxoma peritoni Dissemination of mucinous tumor of appendiceal origin Can follow native or intraoperative rupture Mucin producing, superficial DPAM vs PMCA

35 Pseudomyxoma peritoni CRS w/ HIPEC the standard of care Few RCTs or even prospective studies

36 15 papers from Improved survival w/ CRS and IPC High morbidity (~40%) Significant heterogeneity between studies Patient selection Agent used

37 2298 patients, 16 centers 2% mortality 24% morbidity

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39 PCI had impact but survival still high with PCI >20 OS 5y NO difference between agents (MMC vs oxaliplain) High-volume centers give superior outcomes CRC w/ IPC the standard of care for pseudomyxoma peritoni

40 Peritoneal Disease: Colorectal Cancer 10% present with synchronous peritoneal dz 10-20% 2 year survival w/ paliative surgery and systemic chemotherapy 8 month median survival

41 105 patients vs 23 month median survival 8 year update: 5y survival 10 vs 45% for R1 resection Problems: 5-FU/leucovorin Poor acrual

42 Peritoneal Disease: Colorectal Cancer Newer studies: Median OS months CURE in 25% Significant deflection points: CCR 0 PCI 20 Upcoming reports: CRS w/ HIPEC vs CRS alone HIPEC vs EPIC

43 You perform diagnostic laparoscopy prior to gastric cancer resection and see a peritoneal lesion on the omentum. What do you do? 1. Continue with resection, resect the lesion, throw in some HIPEC 2. Abort

44 You perform diagnostic laparoscopy prior to gastric cancer resection and see a peritoneal lesion on the omentum. What do you do? 1. Continue with resection, resect the lesion, throw in some HIPEC 2. Abort

45 Peritoneal Disease: Gastric Cancer

46 Peritoneal Disease: Gastric Cancer

47 Conclusions Peritoneal malignancies, if treated surgically, should undergo cytoreductive surgery with intraperitoneal chemotherapy CRS has been standardized, however IPC protocols vary Pseudomyxoma peritoni standard of care is CRC w/ HIPEC Colorectal cancer peritoneal mets may benefit from CRS w/ IPC in specialized centers, however the IPC element is under ongong investigation Outside of Asia, CRC and IPC for gastric cancer peritoneal mets needs further study before wide adoption