Peritoneale Metastasen: Wann lohnt die Chirurgie und intraperitoneale Chemotherapie?

Zusammenfasssung

Bei ca. 10 % der Patienten mit gastrointestinalen Malignomen besteht bereits zum Diagnosezeitpunkt eine Peritonealkarzinose. Bei Fehlen einer Fernmetastasierung kann diese durchaus als regionale Metastasierung interpretiert werden, die nicht grundsätzlich zu therapeutischem Nihilismus führen sollte. In den vergangenen Jahren haben deshalb multimodale Behandlungskonzepte, bestehend aus maximal zytoreduktiver Chirurgie kombiniert mit intraoperativer, hyperthermer intraperitonealer Chemotherapie Bedeutung erlangt. Unter Berücksichtigung des eigenen Patientenkollektives (n = 62) im Zeitraum 1995-05/2004 werden die diesem Konzept zugrunde liegenden Überlegungen dargestellt. Bei einer im Verlauf abnehmenden Morbidität sowie einem geringen Anteil von chirurgischen Komplikationen kann dieses Therapiekonzept in spezialisierten Zentren einen kurativen Therapieansatz darstellen.

Abstract

About 10 % of patients with gastrointestinal malignancies suffer from peritoneal carcinomatosis at the time of first diagnosis. In case of absence of lesions in liver or lung, this can be interpreted as local metastasis and therefore should not lead to “therapeutical Nihilism”. In the last years multimodal therapies were established, i. e. maximal cytoreductive surgery combined with intraoperative hyperthermic intraperitoneal chemotherapy. In analyzing 62 patients from 1995-2004, the rationale of this concept and the surgical technique are described and discussed. In specialized centers the morbidity and mortality rates of these procedures are significantly reduced; thus this concept can be considered as a curative therapy regimen.

Peritonealkarzinose - Pseudomyxoma peritonei - Indikation multiviszerale Resektion - Intraperitoneale Chemotherapie

Peritonealcarcinosis - pseudomyxoma peritonei - indication for multivisceral resection - intraperitoneal chemotherapy

Literatur

• 1 Chu D Z, Lang N P, Thompson C, Osteen P K, Westbrook K C. Peritoneal carcinomatosis in nongynecologic malignancy. A prospective study of prognostic factors.  Cancer. 1989;  63 364-367
• 2 Sadeghi B, Arvieux C, Glehen O, Beaujard A C, Rivoire M, Baulieux J. et al . Peritoneal carcinomatosis from non-gynecologic malignancies: results of the EVOCAPE 1 multicentric prospective study.  Cancer. 2000;  88 358-363
• 3 Sugarbaker P H, Chang D. Results of Treatment of 385 patients with peritoneal surface spread of appendiceal malignancy.  Ann Surg Oncol. 1999;  6 727-731
• 4 Elias D, Blot F, El Otmany A, Antoun S, Lasser P, Boige V. et al . Curative Treatment of peritoneal carcinomatosis arising from colorectal cancer by complete resection and intraperitoneal chemotherapy.  Cancer. 2001;  92 71-76
• 5 Teicher B A, Kowal C D, Kennedy K A, Sartorelli A C. Enhancement by hyperthermia of the in vitro cytotoxity of mitomycin C toward hypoxic tumor cells.  Cancer Res. 1981;  41 1096-1099
• 6 Barlogie B, Corry P M, Drewinko B. In vitro thermochemotherapy of human colon cancer cells with cis-dichlorodiammineplatinum(II) and mitomycin C.  Cancer Res. 1980;  40 1165-1168
• 7 Jänicke F. Das fortgeschrittene Ovarialkarzinom: Entwicklungen der operativen und systemischen Therapie.  Deutsches Ärzteblatt. 1999;  96 A281-A288
• 8 Alexander H R, Buel J F, Fraker D. Rationale and clinical status of continous hyperthermic peritoneal perfusion for the treatment of peritoneal carcinomatosis.  PPO Updates. 1995;  9 1-9
• 9 van den Vaart P JM, van der Vange N, Zoetmulder F AN, van Goethem A R, van Tellingen O, ten Bokkel Huinink W W. et al . Intraperitoneal Cisplatin with regional hyperthermia in advanced ovarian cancer: pharmacokinetics and cisplatin DNA adduct formation in patients and ovarian cancer cell lines.  Eur J Cancer. 1998;  34 148-154
• 10 Elias D M, Ouellet J F. Intraperitoneal Chemohyperthermia - Rationale, technique, indications and results.  Surg Oncol Clin N Am. 2001;  10 915-933
• 11 Jähne J, Piso P. Peritonektomie und inraperitoneale Chemotherapie - Neue Wege zur multimodalen Therapie der Peritonealkarzinose.  Langenbecks Arch Chir Supp. 1998;  II Kongressband 1435-1437
• 12 Sugarbaker P H. Peritonectomy procedures.  Ann Surg. 1995;  221 29-42
• 13 Jähne J, Piso P, Schmoll E, Haulitschek-Hauss R. Intraoperative hypertherme intra-peritoneale Chemotherapie - Überlegungen und Aspekte zum sicheren intra- und postoperativen Umgang mit Zytostatika.  Langenbecks Arch Chir. 1997;  382 8-14
• 14 Wittkamp A J, de Bree E, van Goethem A R, Zoetmulder F AN. Rationale and techniques of intraoperative hyperthermic intraperitoneal chemotherapy.  Cancer Treat Rev. 2001;  27 365-374
• 15 Sugarbaker P H. Cytoreductive surgery and perioperative intraperitoneal chemotherapy as a curative approach to pseudomyxoma peritonei syndrome.  EJSO. 2001;  27 239-243
• 16 Ceelen W P, Hesse U, de Hemptinne B, Pattyn P. Hyperthermic intraperitoneal chemoperfusion in the treatment of locally advanced intra-abdominal cancer.  Br J Surg. 2000;  87 1006-1015
• 17 Sugarbaker P H, Steves M A, Hafner G H. Treatment of peritoneal carcinomatosis from colon or appendiceal cancer with induction intraperitoneal chemotherapy.  Reg Cancer Treat. 1993;  4 183-187
• 18 Piso P, Werner U, Bektas H, Bornscheuer A, Manns M P, Klempnauer J. Improved prognosis following peritonectomy procedures and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis of appendiceal carcinoma.  Eur J Surg Oncol. 2001;  27 286-290
• 19 Glehen O, Cotte E, Schreiber V, Sayag-Beaujard A C, Vignal J, Gilly F N. Intraperitoneal chemohyperthermia and attempted cytoreductive surgery in patients with peritoneal carcinomatosis of colorectal origin.  Br J Surg. 2004;  91 747-754
• 20 Loggie B W, Perini M, Fleming R A. Treatment and prevention of malignant ascites associated with disseminated intraperitoneal malignancies by aggressive combined-modality therapy.  Am Surg. 2000;  66 561-568
• 21 Cavaliere F, Perri P, Di Filippo F. et al . Treatment of peritoneal carcinomatosis with intent to cure.  J Surg Oncol. 2000;  74 41-44
• 22 Zoetmulder F AN, Verwaal V, Ruth S. Hyperthermic intraperitoneal chemotherapy with mitomycin C significantly improves survival in patients with peritoneal carcinomatosis of colorectal origin. ASCO 2002; Abstract 586
• 23 Pilati P, Mocellin S, Rossi C R, Foletto M, Campana L, Nitti D. et al . Cytoreductive surgery combined with hyperthermic intraperitoneal intraoperative chemotherapy for peritoneal carcinomatosis arising from colon adenocarcinoma.  Ann Surg Oncol. 2003;  10 508-513
• 24 McQuellon R P, Loggie B W, Flemming R A. Quality of life after intraperitoneal hyperthermic chemotherapy (IPHC) for peritoneal carcinomatosis.  Eur J Surg Oncol. 2001;  27 65-73
• 25 Stephens A D, Aldermann R, Chang D, Edwards G D, Esquivel J, Sebbag G. et al . Morbidity and mortality analysis of 200 treatments with cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy using the coliseum technique.  Ann Surg Oncol. 1999;  6 790-796
• 26 Elias D, Pocard M, Sideris L, Edè C, Ducreux M, Boige V. et al . Preliminary results of intraperitoneal chemohyperthermia with oxaliplatin in peritoneal carcinomatosis of colorectal origin.  Br J Surg. 2004;  91 455-456