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In Reply:

Surgical Department, Centre Hospitalo-Universitaire Lyon-Sud, Pierre Benite, France

We appreciated the comments from Shen and Loggie, emphasizing the necessity of strict selection of patients with peritoneal carcinomatosis who are candidates for aggressive cytoreductive surgery and intraperitoneal chemohyperthermia (IPCH).

As we reported in our article [1], we selected our 56 patients from 240 who were referred to us for a potential therapeutic approach combining cytoreductive surgery and IPCH. Strict selection of patients is, for us, an essential key for acceptable morbidity and mortality rates. Patients older than 65 years; with poor performance status, severe renal or cardiovascular disease, extraperitoneal disease; or with evidence of unresectable disease on clinical or radiological examination were not included in our protocol.

The completeness of cytoreduction is probably the major prognostic indicator for most of the patients with peritoneal carcinomatosis, whatever the primary tumor is, and the chance to achieve a complete cytoreduction is higher in patients with low-volume disease. However, the crucial need of complete cytoreduction depends on primary tumor location as well as pathologic type of tumor. Its influence on survival is probably different in patients with carcinomatosis from colorectal malignancy compared with ovarian tumors or pseudomyxoma peritonei. For each pathologic type of carcinomatosis we have to define more clearly the role of cytoreductive surgery, IPCH, and other prognostic indicators.

Our experience, as well as that reported by Sugarbaker [2], Zoetmulder [3], and Shen and Levine [4], demonstrates that the therapeutic approach combining cytoreductive surgery and IPCH may be the most promising new treatment for peritoneal carcinomatosis for the next decade. It offers hope for cure to patients who had in the past no escape from terminal illness. Many questions still need to be answered, and phase III studies are needed to improve the selection criteria for patients who may benefit from this comprehensive management. However, phase III studies are not the only way to demonstrate the efficiency of this therapeutic approach. We recently initiated an international registry including more than 500 patients with colorectal carcinomatosis from more than 30 institutions, treated by the combined therapeutic approach of cytoreductive surgery with a curative intent and perioperative intraperitoneal chemotherapy with or without hyperthermia. A similar registry approach was used to evaluate surgery for the treatment of liver metastasis from colorectal origin [5], and may be appropriate in the setting of peritoneal carcinomatosis.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

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[Abstract/Free Full Text]

2. Sugarbaker PH: Intraperitoneal chemotherapy and cytoreductive surgery for the prevention and treatment of peritoneal carcinomatosis and sarcomatosis. Semin Surg Oncol 14:254-261, 1998[CrossRef][Medline]

3. Zoetmulder FAN, Verwaal V, Ruth S: Hyperthermic intraperitoneal chemotherapy (HIPEC) with mitomycin C significantly improves survival in patients with peritoneal carcinomatosis of colorectal origin. Proc Am Soc Clin Oncol 2002 (abstr N586)

4. 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[Abstract/Free Full Text]

5. Resection of the liver for colorectal carcinoma metastases: A multi-institutional study of indications for resection: Registry of Hepatic Metastases. Surgery 103:278-288, 1988[Medline]

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