|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Journal of Clinical Oncology, Vol 22, No 1 (January 1), 2004: pp. 202 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.99.113
Peritoneal Carcinomatosis: What Can We Do About It?Surgical Oncology Service, Wake Forest University Medical Center, Winston-Salem, NC
Creighton University Cancer Center, Omaha, NE To the Editor: The article by Gilly et al [1] reporting on the use of cytoreductive surgery (CS) and intraperitoneal hyperthermic chemotherapy (IPHC) for peritoneal carcinomatosis (PC) from abdominal cancers illustrates an aggressive, multimodality approach for a disease condition often considered a terminal disease state with little hope. In a group of 240 patients, the 2-year overall survival was 79% and 44.7% for patients with complete and incomplete resection of gross disease, respectively. The postoperative mortality was 1.8% and postoperative morbidity was 28.6%. The authors used a closed technique for the chemoperfusion with intra-abdominal temperatures greater that 41°C. Our institution has been performing CS and IPHC for PC since 1991. In 2000, we published our experience with this modality for the treatment for PC from gastrointestinal origin [2]. Eighty-four patients were studied, with a median survival of 14.3 months. Significant differences in survival were seen in patients with and without malignant ascites. Patients with complete gross tumor resection had the best outcome; median survival at 1 and 3 years was 61% and 33%, respectively, and median survival was 16 months with a median follow-up of 52 months. On multivariate analysis, nonadenocarcinoma histology, an appendicial primary tumor, the absence of liver metastases, and complete resection of all gross disease were independent predictors of overall survival. Patients with a complete resection had a 3-year survival of 68%. These publications (and others) indicate a renewed interest in the treatment of disseminated abdominal malignancy. The median overall survival of patients with PC has been reported to be as short as 3 months, with few patients surviving beyond 1 year [4]. The application of CS and IPHC appears to alter the natural history of this disease process in selected patients. In the article by Gilly et al [1], only 56 of a potential 240 patients underwent this procedure, highlighting a selective approach. This procedure traditionally has been associated with an extremely high morbidity and mortality, and although the morbidity is not insignificant, Gilly and associates have shown that with careful patient selection, the perioperative mortality can be acceptable. There has been some question about whether patients with low-volume disease actually benefit from this approach or if they would have done just as well with systemic chemotherapy. It seems logical to us that those patients presenting with bulky, high-volume, unresectable PC at some time in their course had low-volume disease that could have been potentially treated with CS and IPHC. Furthermore, our study and the extensive experience with cytoreductive surgery for ovarian cancer show that patients with more complete resections (R0 and R1) have significantly better survival than those with less complete resections. Clearly, the greatest likelihood of complete resection is in patients with low-volume disease. It is clear that this is not a treatment for all patients with PC. We do believe that many patients have received benefit from this approach. A recent randomized trial comparing CS, IPHC, and systemic chemotherapy versus CS and systemic chemotherapy alone found significantly improved 2-year overall survival in the IPHC group [5]. We would suggest that prospective multi-institutional trials are needed to test the efficacy of this procedure. In addition, more precise clinical definition predicting those most likely to benefit would help physicians and patients. Authors' Disclosures of Potential Conflicts of Interest The following authors or their immediate family members have indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. Received more than $2,000 a year from a company for either of the last 2 years: Perry Shen, Celgene. REFERENCES
1. Glehen O, Mithieux F, Osinsky D, et al: Surgery combined with peritonectomy procedures and intraperitoneal chemohyperthermia in abdominal cancers with peritoneal carcinomatosis: A phase II study. J Clin Oncol 21:799-806, 2003 2. Loggie BW, Fleming RA, McQuellon RP, et al: Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for disseminated peritoneal cancer of gastrointestinal origin. Am Surg 66:561-568, 2000[Medline]
3. Shen P, Levine EA, Hall J, et al: Factors predicting survival after intraperitoneal hyperthermic chemotherapy with mitomycin C after cytoreductive surgery for patients with peritoneal carcinomatosis. Arch Surg 138:26-33, 2003 4. Sadeghi B, Arvieux C, Glehen O, et al: Peritoneal Carcinomatosis from non-gynecologic malignancies: Results of the EVOCAPE 1 multicentric prospective study. Cancer 88:358-363, 2000[CrossRef][Medline] 5. Zoetmulder FAN, Verwaal V: Hyperthermic intraperitoneal chemotherapy (HIPEC) with mitomycin C significantly improves survival in patients with peritoneal carcinomatosis of colorectal origin. Proc Am Soc Clin Oncol 21:147a, 2002 (abstr)
Related Article
Related Reply
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
