Surgery By drAhmed Samir Surgical oncology senior registrar MD Msc MBBch Etymology Peritoneum is derived from the greek word peritonaion peri means around while ID: 930248
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Slide1
Slide2Peritoneal Nodules and
Cytoreductive
Surgery
By
dr.Ahmed
Samir
Surgical oncology senior registrar
MD,
Msc
,
MBBch
Slide3Etymology
“Peritoneum” is derived from the
greek
word peritonaion
:
peri
means "around," while
teino
means "to stretch"; thus, "peritoneum" means "stretched over.
Slide4Introduction
Peritoneal
carcinomatosis
(GI and ovarian), mesothelioma
, and
sarcomatosis
are included in the group of diseases collectively referred to, as peritoneal metastases.
It is associated with short survival and poor quality of life, and may lead to bowel obstruction, accumulation of fluid in the peritoneal cavity and pain.
NICE, 2009
Slide5CRS with HIPEC has been used with variable success to treat
pseudomyxoma
peritonei, appendiceal mucinous
neoplasias
, peritoneal
mesothelioma
, PC from gastric, colorectal, and ovarian cancer, and other primary peritoneal surface malignancies.
(Yan et al, 2009)
(Chua et al, 2010)
(
Bakrin
et al, 2012)
(Alexander et al, 2013)
Slide6It is a loco regional disease but not a metastatic process, can be taken curative intent
(
Sugarbaker
, 1989
).
Ovarian
Gastric
Colorectal
Pancreatic
Slide7PERITONEAL CARCINOMATOSIS FROM OVARIAN ORIGIN
Slide8Ovarian epithelial and primary peritoneal cancers are a major cause of mortality in developed countries
Ovarian and peritoneal carcinomas tend to be a peritoneal surface disease for a considerable part of their natural history, with systemic metastatic disease usually being observed late in the natural history of the disease.
(
Jemal
et al, 2011).
Slide9One of the most distinct features of Epithelial Ovarian Cancer is the tendency to disseminate into the peritoneal cavity and remain confined to the peritoneum and intra-abdominal viscera. This makes it an ideal target for loco-regional therapy.
HIPEC has become a useful therapeutic strategy to obtain a higher degree of
debulking
by trying to eliminate the residual microscopic component responsible for
recurrences
(
Evgenia
et al, 2015).
Slide10Slide11Slide12A meta-analysis of 6,885 patients undergoing maximal
cytoreductive
surgery (CRS) has shown a distinct survival advantage for those with maximal tumour removal and minimum residual disease
(Bristow et al, 2002).
Slide13Peritonectomy
procedures and resections that are combined to complete
cytoreduction
procedure (
Evgenia
et al, 2015).
Slide14PERITONEAL CARCINOMATOSIS FROM GASTRIC ORIGIN
Slide15Gastric cancer (GC) is the second leading cause of cancer death and the fourth most common cancer in the world
(
Parkin
et al, 1999) (Kelley et al, 2003).
The 40% of patients died for GC have hepatic metastases, while the 53-60% showed a disease progression and died with peritoneal
carcinosis
(PC). The two most important factors affecting prognosis in GC are the
serosal
invasion and the lymphatic spread (Yu et al, 1995).
Slide16PC is already present in 5-20% of patients explored for potentially curative resection also in early gastric cancer
(
Kuramoto
et al, 2009).
In contrast to lymphatic and
haematogenous
dissemination, peritoneal spread should be regarded as a
locoregional
disease extension rather than systemic metastasis (Yan et al, 2007).
Slide17Gastric cancer staging according to 8
th
edition of AJCC staging manual
(Rice et al, 2017)
Slide18A positive effect of IPC has been found on overall , peritoneal recurrence and on distant metastasis. Morbidity rate is incremented by IPC.
Loco-regional
lymph-nodes invasion in
patients affected by advanced gastric cancer is not a contraindication to IPC
(
Coccolini
et al, 2013).
Slide19PERITONEAL CARCINOMATOSIS FROM COLORECTAL ORIGIN
Slide20Globally, colorectal cancer (CRC) is the third leading cause of cancer, totaling 1.6 million incident cases in 2013, and the fourth leading cause of cancer-related mortality, accounting for 771, 000 deaths
(Fitzmaurice et al, 2015).
Peritoneal
carcinomatosis (PC) is present in about 4–15% of patients with CRC at initial diagnosis and in up to 50% in recurrent disease following curative resection
(
Segelman
et al, 2012).
Slide21Pathophysiology
of Peritoneal
Carcinomatosis
From
GI Malignancies
PC is thought to be a
locoregional
disease with two main mechanisms that result in peritoneal spread of the primary tumor: (1)
transmural
tumor invasion that results in the exfoliation of free cells, which directly spread to the peritoneum; (2) visceral perforation or surgical trauma that causes cell spillage from the bowel lumen or the dissected vasculature that harbor tumor cells in transit
(Stewart et al, 2005).
Slide22Peritoneal spread results from a cascade of events that start by the loss of cell-cell adhesion molecules ,followed by
anoikis
resistance, which is cell resistance to apoptosis and usually occurs when a normal cell loses cell matrix contact. Thereby, tumor cells migrate and adhere to the peritoneal surface through
integrin and
cadherin
proteins. Then, using
proteolytic
enzymes such as matrix
metallopeptidase, the tumor cells digest the extracellular matrix, facilitating invasion, colonization, and finally, homing to the peritoneum
(de Cuba et al, 2012)(
Schempp
et al 2014).
Slide23Colorectal cancer staging according to 8
th
edition of AJCC staging manual (Rice et al, 2017)
Slide24A multidisciplinary approach.
patients with
extraperitoneal
disease or bulky retroperitoneal disease are not eligible for CRS with HIPEC.helical CT scan with IV contrast (bulky peritoneal disease).
diffusion-weighted magnetic resonance imaging (DW-MRI) (small peritoneal implants).
(Ibrahim et al, 2017)
Slide25Only patients with disease amenable to complete
cytoreduction
(R0/1) should be considered since incomplete
cytoreduction (R2) is associated with worse survival.
Slide26PERITONEAL CARCINOMATOSIS FROM PANCREATIC ORIGIN
Slide27In comparison to other gastrointestinal malignancies, the surgery employed to date for pancreas cancer should be considered a failure as Long term survival following
pancreaticoduodenectomy
for adenocarcinoma is ten percent or less
(winter et al, 2006).The anatomic position of the pancreas deep in the retroperitoneal part of the upper abdomen causes “no touch cancer resection” to be impossible
(
Sugarbaker
, 2017).
Slide28In the process of performing the
pancreaticoduodenectomy
with clear margins, cancer cells may gain access to the peritoneal space and grow out at high density at the resection site. The phenomenon has been called tumor cell entrapment.
Peritoneal metastases occur prior to the pancreatic resection in an estimated 10% of patients. However, after the
pancreatectomy
in patients who had no peritoneal metastases at the time of resection, 50% or more patients will develop local recurrence and/ or peritoneal metastases in follow-up
(
Sugarbaker
, 2017).
Slide29Numerous trials and meta-analyses have attempted to establish a benefit for
radiochemotherapy
for pancreas cancer either before or after cancer resection. However, none of them have established this as a preferred method of treatment
(Khorana et al, 2016).
Slide30A profound effect of HIPEC
gemcitabine
used following
pancreatectomy and prior to intestinal reconstruction on cancer cells lost into the peritoneal space during the cancer resection is suggested.Reduced local recurrence and peritoneal metastases post operatively.
HIPEC
gemcitabine
shows promise to reduce peritoneal seeding in patients having pancreas cancer resection in the absence of increased morbidity and mortality.
(
Sugarbaker
, 2017).
Slide31Refrences
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Mangu, J. Berlin, et al., Potentially curative pancreatic cancer:
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SK, Royal R, Hughes MS, et al. Treatment factors associated with long-term survival after cytoreductive surgery and regional chemotherapy for patients with malignant peritoneal mesothelioma. Surgery. 2013;153:779–86.Bakrin N, Cotte E,
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