General Abdomen: Peritoneal Carcinomatosis

Peritoneal Carcinomatosis

General

  • Peritoneum Covered in Carcinomatous Masses
  • CT Shows Organ Scalloping

Pseudomyxoma Peritonei

  • Mucus & Cystic Masses
    • Subset of Peritoneal Carcinomatosis
  • Source: Appendix, Small Intestine & Ovary
    • Most Common Source: Mucinous Cystadenoma of Appendix
    • Most Common Primary Peritoneal Malignancy: Mesothelioma
  • More Common in Women

Symptoms

  • Increasing Abdominal Girth #1
  • Inguinal Hernia #2
  • Weight Loss

Peritoneal Cancer Index (PCI)

  • Grading Index Used for Research and to Objectively Describe Extent
  • Add Largest Lesion Size (0-3) in Each of 13 Regions
    • Scores Range 0-39
  • Regions:
    • Region 0: Central
    • Region 1: RUQ
    • Region 2: Epigastrium
    • Region 3: LUQ
    • Region 4: Left Flank
    • Region 5: LLQ
    • Region 6: Pelvis
    • Region 7: RLQ
    • Region 8: Right Flank
    • Region 9: Upper Jejunum
    • Region 10: Lower Jejunum
    • Region 11: Upper Ileum
    • Region 12: Lower Ileum
  • Lesion Size Score:
    • 0 = No Tumor
    • 1 = ≤ 0.5 cm
    • 2 = ≤ 5.0 cm
    • 3 = > 5.0 cm

Completeness of Cytoreduction Score

  • Scoring System Used to Grade How Complete Cytoreduction Was
  • Scores:
    • CC-0: No Disease
    • CC-1: ≤ 0.25 cm
    • CC-2: ≤ 2.5 cm
    • CC-3: > 2.5 cm

Prevention of Port Site Metastases

  • Reduced Tissue Trauma & Instrument Exchanges
  • Minimize Tumor Manipulation
  • Use of Protective Retrieval Bags
  • Use of Povidone-Iodine to Irrigate Trocar Sites & Rinse Trocar Tips
  • Remove Intraabdominal Fluid Before Trocar Removal
  • Desufflate Pneumoperitoneum Before Trocar Removal
  • Avoid CO2 Leaks & Sudden Desufflation

Treatment

  • Extraperitoneal Mets: Systemic Chemotherapy
  • No Extraperitoneal Mets: Cytoreductive Surgery & HIPEC
    • Abdominal Wall Masses Should Be Excised with the Associated Peritoneum

Peritoneal Carcinomatosis on Laparoscopy 1

CT Showing Organ Scalloping (Arrow) of Peritoneal Carcinomatosis 2

Peritoneal Cancer Index (PCI) Diagram

Intraperitoneal Chemotherapy

HIPEC (Hyperthermic Intraperitoneal Chemotherapy)
  • Heated Chemotherapeutic Drugs Infused into Peritoneal Cavity
    • Avoids Systemic Circulation Minimizing Toxicity
    • Heating Increases Penetration & Cytotoxicity
    • Most Common Agents: Oxaliplatin, Cisplatin, Doxorubicin & Mitomycin-C
  • Delivery
    • Preformed After Surgical Debulking
    • Same Operation (Adhesions Create Barrier Preventing Uniform Distribution)
    • Before Any Reconstruction or Diversion (Allow Exposure of All Resection Lines)
    • Duration: 30-120 Minutes (90 Minutes Common)
      • Abdomen is Temporarily Closed
      • “Shake & Bake” During Infusion
  • Requires No Residual Tumors > 2 mm (Chemo Unable to Penetrate) Mn
    • Goal CC-0 or CC-1
  • Contraindications:
    • Absolute:
      • Not Amenable to Complete Cytoreduction
      • Poor Performance Status
      • Disease Progression on Systemic Therapy
      • Malignant Small Bowel Obstruction
    • Relative:
      • Short-Disease Free Interval – If Metachronous
      • Peritoneal Cancer Index > 20
      • Serous Ascites
EPIC (Early Postoperative Intraperitoneal Chemotherapy)
  • Chemotherapy Given Via a Catheter or Subcutaneous Port
    • Not Heated
  • Administered on Postoperative Day #1-5 After Surgical Debulking
  • Able to Give Multiple Cycles with Longer Dwell Time
  • Greater Risk of Systemic Absorption – HIPEC Typically Favored

Mnemonics

Maximum Residual Tumor Size in HIPEC

  • Nothing Over 2 mm to Move onto 2nd Step

References

  1. Touboul C, Vidal F, Pasquier J, Lis R, Rafii A. Role of mesenchymal cells in the natural history of ovarian cancer: a review. J Transl Med. 2014 Oct 11;12:271. (License: CC BY-4.0)
  2. Singh S, Devi YS, Bhalothia S, Gunasekaran V. Peritoneal Carcinomatosis: Pictorial Review of Computed Tomography Findings. International Journal of Advanced Research. 2016;4(7):735–748. (License: CC BY-4.0)