Management of Peritoneal Carcinomatosis From Colorectal Cancer
ABSTRACT
The management of peritoneal carcinomatosis from colorectal cancer is evolving. The introduction of new chemotherapeutic and biologic agents has certainly improved the outlook for many patients with metastatic colorectal cancer. Traditionally, patients with limited hepatic or pulmonary metastases were the only candidates for metastasectomy. However, patients with metastasis localized to the peritoneum have been shown to be candidates for metastasectomy with improved clinical outcomes. Cytoreductive surgery with the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) in this cohort of patients offers the only chance for long-term survival. Complete cytoreduction in combination with HIPEC for peritoneal surface disease has been demonstrated to produce survival outcomes similar to liver resection for hepatic metastases. This review will examine recent evidence pertaining to the evolving surgical oncology paradigm for management of colorectal peritoneal carcinomatosis.
Conclusions
Long-term disease-free survival is possible in selected patients with peritoneal dissemination from colon carcinoma. While this aggressive therapy is formidable, it offers the best outcome for these patients who had previously been relegated to palliative therapy. Recently the American College of Surgeons Oncology Group (ACOSOG) initiated a, “Phase III Randomized Trial Comparing Standard Systemic Therapy to Cytoreduction + Hyperthermic Intraperitoneal Mitomycin C + Standard Systemic Therapy In Patients With Limited Peritoneal Dissemination of Colon Adenocarcinoma.” The objectives of this study include to compare the overall survival of patients with advanced limited peritoneal dissemination of colon adenocarcinoma treated with systemic therapy with versus without cytoreduction surgery and hyperthermic intraperitoneal mitomycin-C. We support this and other future possible randomized studies, and are heartened by an organized effort to bring such trials to this modality.
CS and HIPEC for colorectal PC is a multimodality approach that has been established in investigational phase II trials and a single well-done phase III randomized trial to have therapeutic benefit. We approach PC similarly to isolated pulmonary or hepatic metastases, in which an aggressive surgical approach for complete resection is warranted. However, this approach should only be pursued in centers with demonstrated experts.
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