INTRODUCTION: Peritoneal dissemination is a common route of spread for a number of different cancers including primary peritoneal mesothelioma and adenocarcinoma (high- and low-grade) of the gastrointestinal tract. Intra-peritoneal metastatic disease frequently results in patient discomfort, pain, and death, often in the presence of isolated regional disease. Intra-peritoneal therapy has been extensively studies as method to treat peritoneal surface malignancies. Malignant mesothelioma can be successfully treated with surgical cytoreduction and intraperitoneal chemotherapy with mean overall survival greater than 5 years, while reported 5 year survival of greater that 90% has been reported in patients with low-grade carcinoma of the appendix.
Patients and Methods: Between September 1993 and September 2006, 266 patients (M:148, F: 118; Median age: 50 y; range 15 to 78) with mesothelioma (n=94), low grade appendiceal adenocarcinoma (n=89), or high grade colonic adenocarcinoma (n=83) were treated with CHPP at the NCI. Patients underwent an exploratory laparotomy and tumor resection with or without CHPP with cisplatin (mean dose: 455mg) under one of 4 Institutional Review Board approved protocols.
Results: 218 patients underwent a perfusion. A single intraperitoneal dwell (EPIC) with fluorouracil and paclitaxel was administered postoperatively (Day 8-12) in 155 patients. Resection of a hollow viscus was necessary to achieve optimal cytoreduction in 76 patients whereas 142 patients needed only cytoreduction and omentectomy for prior to CHPP. 48 patients underwent exploratory laparotomy and lysis of adhesions only. The mean operative time was 6.92 hours (range: 1 to 12.45). The mean time to diet was 8.47 (range: 1 to 58) and the mean hospital stay was 14.2 days (range: 2-64 days). The surgery and perfusion was well tolerated with the majority of patients having no morbidity or mortality. 182 patients (68%) had no complications. The most common postoperative complications were prolonged ileus (defined as greater than 14 days; n=19; 7% of patients), wound infections (n=14; 5% of patients), and pleural effusion (n=12; 4.5% of patients). There were two deaths (1%) in the 30 day postoperative period secondary to pulmonary sepsis (n=1) and pulmonary embolism (n=1).
Conclusions: Symptoms associated with local tumor effects often result in poor outcomes for patients with peritoneal surface malignancies treated with traditional systemic chemotherapy regimens. Combined regional approaches incorporating cytoreductive surgery and intra-peritoneal chemotherapy via CHPP and EPIC is well tolerated with a low rate of mortality and morbidity.