BACKGROUND

Peritoneal carcinomatosis (PC) is a common evolution of digestive cancer, associated with a poor prognosis Yet it is poorly documented in the literature



METHODS

Three hundred seventy patients with PC from non-gynecologic malignancies were followed prospectively: the PC was of gastric origin in 125 cases, of colorectal origin in 118 cases, of pancreatic origin in 58 cases, of unknown origin in 43 cases, and of miscellaneous origins in 26 cases A previously reported PC staging system was used to classify these 370 patients



RESULTS

Mean and median overall survival periods were 60 and 31 months, respectively Survival rates were mainly affected by the initial PC stage (98 months for Stage I with malignant peritoneal granulations less than 5 mm in greatest dimension, versus 37 months for Stage IV with large, malignant peritoneal masses more than 2 cm in greatest dimension) The presence of ascites was associated with poor survival of patients with gastric or pancreatic carcinoma Differentiation of the primary tumor did not influence the prognoses of patients with PC



CONCLUSIONS

A better knowledge of the natural history of PC is needed, in view of the many Phase I, II, and III trials currently being conducted to evaluate aggressive multimodal therapeutic approaches to treating patients with PC from non-gynecologic malignancies Cancer 2000;88:358–63 © 2000 American Cancer Society

Peritoneal carcinomatosis from non-gynecologic malignancies: results of the EVOCAPE 1 multicentric prospective study.

Only 18 cases of recurrence at the sites of cannula insertion after laparoscopy have been reported in the literature, ten of them in the past year. The period between laparoscopic surgery and presentation of wound metastasis varies widely, from 7 days to 10 months; the lesions are typically hard, craggy and painful. The most likely mechanism is direct implantation of viable exfoliated tumour cells but three aspects specific to laparoscopy may also be important. First, there may be increased exfoliation of tumour cells following manipulation by laparoscopic instruments of an unsuspected malignancy. Second, there may be repeated close contact between tumour-laden instruments and the port. Third, the passage of resected tissue through a small incision may coat the wound with potentially malignant cells.

Abdominal wall metastases following laparoscopy.

Peritoneal carcinomatosis is a common manifestation of digestive-tract cancer and has been regarded a terminal disease with a short median survival. Over the past decade, a new locoregional therapeutic approach combining cytoreductive surgery with intraperitoneal chemohyperthermia (IPCH) has evolved. Because of its limited benefits, high morbidity and mortality, and high cost, this comprehensive management plan requires accurate patient selection. Quantitative prognostic indicators are needed to assess a patient's eligibility for combined treatment, including tumour histopathology, classification of carcinomatosis extent, assessment of completeness of cytoreduction, and determination of the extent of previous surgery. Patients with pseudomyxoma peritonei and those with peritoneal dissemination of digestive-tract cancer have shown promising survival. Complete cytoreduction with no visible disease persisting is a requirement for long-term benefit. In Japan and Korea, use of IPCH as prophylactic treatment in potentially curative gastric-cancer resection has shown improved survival and lower peritoneal recurrence rates. IPCH combined with cytoreductive surgery seems to be an effective therapeutic approach in carefully selected patients, and offers a chance for cure or palliation in this condition with few alternative treatment options.

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Peritoneal carcinomatosis from digestive tract cancer: new management by cytoreductive surgery and intraperitoneal chemohyperthermia

Background: Peritoneal carcinomatosis has been regarded as a lethal clinical entity. Recently, aggressive treatments combining intraperitoneal chemohyperthermia (IPCH) with cytoreductive surgery have resulted in long-term survival in selected patients. The aim of this trial was to analyze the mortality and morbidity of 216 consecutive treatments of peritoneal carcinomatosis by IPCH by using a closed abdominal procedure combined with cytoreductive surgery.

Intraperitoneal chemohyperthermia using a closed abdominal procedure and cytoreductive surgery for the treatment of peritoneal carcinomatosis: morbidity and mortality analysis of 216 consecutive procedures.

Background: This study examined the clinical value of intraoperative peritoneal lavage for cytological examination in patients with gastric cancer. Peritoneal dissemination is the most frequent mode of recurrence for this tumor.

Methods: A retrospective of lavage findings, other factors, and outcome was performed in 1,297 patients with gastric cancer who underwent intraoperative peritoneal lavage.

Results: The 5-year survival rate of patients with positive lavage cytology was only 2%. Patients who underwent curative resection and had negative cytology had a significantly better 5-year survival rate (P <0.001). Even among patients with macroscopic peritoneal dissemination, the survival rate was significantly better with negative cytology, which reflected fewer free cancer cells in the peritoneal cavity. Serum concentrations of carcinoembryonic antigen and carbohydrate antigen 19-9 were significantly higher in patients with positive cytology. Multivariate analyses indicated that intraoperative cytological findings was an independent prognostic factor for survival, and was the most important factor for predicting peritoneal recurrence.

Conclusions: Intraoperative peritoneal lavage cytology is important in predicting survival and peritoneal recurrence in gastric cancer.

Intraoperative lavage for cytological examination in 1,297 patients with gastric carcinoma

Free cancer cells in the peritoneal cavity of 100 patients with gastric cancer were examined by means of Douglas lavage, and their viability was estimated by 3H-thymidine uptake with autoradiographical technic. Furthermore, the effect of mitomycin-C on the viability of free cancer cells in the peritoneal cavity was studied. The appearance of intraperitoneal free cancer cells was dependent on the degree of invasion of cancer to the gastric serosa; that is, free cancer cells were not found in cases without serosal invasion, but were found in 48% with serosal invasion. The viability of free cancer cells in the peritoneal cavity was relatively high, but could be suppressed remarkably by intraperitoneal administration of 10 mg of mitomycin-C.

Intraperitoneal free cancer cells and their viability in gastric cancer

A comparative light microscopic and scanning electron microscopic study of the morphogenesis of peritoneal metastasis in 34 human gastric cancers was performed. Prior to adhesion of gastric cancer cells to the peritoneum, the mesothelial cells became hemispherical and exfoliated from the peritoneum, and gastric cancer cells adhered to the naked areas of the submesothelial connective tissue. A flat metastatic tumor was formed by cancer cell proliferation in the shallow region of the peritoneum. Subsequently, after the infiltration of cancer cells into the connective and adipose tissue, the formation of a large tumor mass was observed. There was a correlation between the surface and histological structure of the metastatic tumors. In poorly differentiated cancer, the cells were isolated while in differentiated cancer, they formed nodules with indistinguishable cell boundaries.

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Morphogenesis of Peritoneal Metastasis in Human Gastric Cancer

A simple method for cellular identification of free cells by light microscopy and scanning electron microscopy.

The process and mechanism of peritoneal metastasis of tumor cells were studied experimentally by means of scanning or transmission electron microscopy, employing rat ascites hepatoma AH100B. Adhesion of tumor cells by microvilli and/or pseudopodia to the mesothelium was observed within 1 approximately 3 days after inoculation when there was no morphological changes of the mesothelial cells. Some changes of the mesothelial cells, such as irregularity, atrophy, and exfoliation, followed tumor cell adhesion 5 or 6 days after inoculation. It was noted that tumor cells adhered to the mesothelium first where no morphological changes were induced, and it is suggested that tumor cells infiltrate into the submesothelial tissue through mesothelial defects.

Shinichi Kaneshima

Papers

Intraperitoneal free cancer cells and their viability in gastric cancer

Morphogenesis of Peritoneal Metastasis in Human Gastric Cancer

A simple method for cellular identification of free cells by light microscopy and scanning electron microscopy.

A scanning electron microscopic study on the peritoneal implantation of ascites hepatoma ah100b cells in rats