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Improving Survival for patients with Peritoneal Carcinomatosis from Colorectal Cancer

Involvement of the peritoneum, or peritoneal carcinomatosis (PC) is a common method of spread of gastrointestinal and gynecologic cancers. Considered to be stage IV disease, peritoneal carcinomatosis was traditionally thought of as incurable and treated with systemic chemotherapy alone. With systemic therapy alone the median survival for patients with PC from gastrointestinal tumors has been only 3-7 months. Furthermore, up to 35% of patients with peritoneal carcinomatosis from gastrointestinal tumors have peritoneal disease only. Over the past 15 years, in an effort to provide these patients with a greater chance of survival, PC has been approached by surgical oncologists as a localized disease and select patients have been offered cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) with encouraging improvements in survival.
Multiple single institution case series, phase 1 and 2 studies, multi-institutional series, and one randomized trial have shown that CRS and HIPEC result in improved survival compared with standard treatment (systemic chemotherapy).  
This technique has been used to treat peritoneal dissemination from several malignancies; appendiceal mucinous adenocarcinoma, psuedomyxoma peritonei, ovarian, malignant mesothelioma, gastric, and colorectal carcinomatosis.  
Any patient with peritoneal carcinomatosis from the above noted malignancies who has an acceptable performance status and is without extraperitoneal disease should be evaluated by a surgical oncologist with experience in this discipline.  
Cytoreductive surgery refers to the aggressive removal or destruction of all visible tumors present throughout the peritoneal surfaces. When CRS is complete HIPEC is initiated. The abdominal cavity is temporarily closed after placing inflow and outflow catheters and attaching them to a roller-pump heat exchanger perfusion machine. Warmed saline is then circulated through the pump; a chemotherapeutic agent is then added to the perfusate and circulated through the abdominal cavity (see figure 1) At completion of the perfusion the perfusate is removed and the abdomen is re-opened and irrigated.  The patient is then transferred to the recovery room. 
In 2006, the Annals of Surgical Oncology published a Consensus statement on the role of CRS and HIPEC in treating PC of colonic origin.  In a subset of patients with metastatic disease confined to the abdomen, CRS and HIPEC have resulted in a median survival of up to 42 months when complete surgical cytoreduction is achieved.  
When faced with a patient with peritoneal carcinomatosis from any malignancy, especially colorectal cancer, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) should be considered.
As is the case with colorectal liver metastases, in the near future this treatment will become more standardized and offered around the country. As that day approaches our patients should not have to wait for the best treatments and thus we are very excited to bring this technique and treatment option to St. John Hospital and Medical Center. To refer a patient, call 313-647-3252.


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Richard N. Berri, MD
Surgical Oncology, Van Elslander Cancer Center
St. John Hospital and Medical Center
Detroit, Michigan