In the last 20 years the treatment of peritoneal surface malignancies grained a special
attention of the medical and surgical world. Previously peritoneal surface malignancies
where seen as metastasized disease which could not be surgical removed due to technical
difficulties and wouldn't be treated with systemic chemotherapy because of the leak
of measurable disease. In 2003 the first randomized trial was published on the treatment
colorectal peritoneal metastasis in a more active way.([1],[2]) This trial showed a survival benefit of cyto-reductive surgery with hyperthermic
intra peritoneal chemotherapy followed by systemic chemotherapy when compared to systemic
chemotherapy alone. This study was followed by a large number of studies which showed
an even further improvement of the survival than published in the randomized trial.
Most recently another randomized trial comparing systemic chemotherapy followed by
cyto reduction and hyperthermic intraperitoneal chemotherapy to systemic chemotherapy
followed by cytoreduction without hyperthermic in-tra peritoneal chemotherapy doubted
the additional effect of hyperthermic intra peritoneal chemotherapy in patients with
peritoneal metastasis of colorectal origin.([3]) Whatever way one looks at these results it is clear from both trials that a complete
cytoreduction is the cornerstone of the treatment of peritoneal metastasis.
Ovarian carcinoma is probably the most classic tumour with spreading to the peritoneum.
Traditional this disease is treated with debulking and systemic chemotherapy. Several
studies showed that the completeness of the cytoreduction determines the outcome.([4]) This year a randomized trial was published showing a benefit of adding hyperthermic
intra peritoneal to the cytoreduction when combined with systemic chemotherapy.([5])
In both above described situations it is clear that cytoreduction, thus the complete
resection of all visible disease is key to success. Hyper thermic intra peritoneal
chemotherapy give an extra benefit in ovarian cancer patients with peritoneal metastasis
and give a benefit in colorectal cancer effected with peritoneal metastasis in the
med range disease load. Probably the difference between the two diseases is that ovarian
cancer is much more chemo sensitive to the current known chemotherapy agents and we
are leaking really effective chemotherapy for colorectal cancer.
Systemic chemotherapy might help to improve the survival combined with cytoreduction,
but we are leaking a trial comparing cytoreduction with and without systemic chemotherapy.
If we compare this situation to liver metastases surgery one should doubt whether
chemotherapy give a benefit to resection of metastatic disease because most studies
of adjuvant chemotherapy after liver metastasis do not have a overwhelming result.([6])
To conclude, surgical resection of peritoneal metastasis is the key, all treatment
around it is whether it is intra peritoneal chemotherapy or systemic chemotherapy
has not established it final position. However it is mostly likely that the combination
of everything is give the best results for the patients.
Bibliographical Record
Victor J Verwaal, Mette Møller Sørensen. Current status and future of peritoneal surface
diseases. Brazilian Journal of Oncology 2018; 14: e-BJO20181448A218R.
DOI: 10.26790/BJO20181448A218R
