Marti, Walter

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Re: Treatment of Peritoneal Carcinomatosisby Cytoreductive Surgery and IntraperitonealHyperthermic Chemoperfusion (IHCP):Postoperative Outcome and Risk Factorsfor MorbidityPeritoneal carcinomatosis results from intraperitonealdissemination of cells derived of primary tumoursfrom various origin. The treatment of this tumour stage isgenerally palliative. Beside ovarian cancer, peritonealcarcinomatosis from other origin does little react uponsystemic chemotherapy only. Therefore, more demand-ing therapies are being explored. To date, one of the mostsuccessful therapeutic concepts consists of radical sur-gical tumor debulking followed by intraoperatively appliedintraperitoneal hyperthermic chemotherapy.Currently several components of this therapy are underinvestigation to optimize effect and to reduce side effects.Obviously the more complete the reduction of tumor tis-sue can be achieved, the higher the chemoconcentrationin residual tumour tissue will be. In general, a cytore-duction to no macroscopic detectable disease or at leasta reduction to tumour nodules of <2.5mm of diameter wasthe goal.1 For the intraoperative intraperitoneal chemo-therapy the abdominal cavity can be temporarily closed orleft open. The latter has the advantage that local hyper-thermia and chemoperfusion within the peritoneal cavitywill be more homogeneous.2Based on the experience with the treatment of thepseudomyxoma peritoneii, using Mitomycin C in combi-nation with 5-FU as chemotherapeutic agents. However,the effect on colorectal cancer is limited and recentlyOxaliplatin and Irinotecan have been used for intraperi-toneal therapy in these diseases.3,4 Furthermore, formesotheliomas and ovarian cancer related peritonealcarcinomatosis, Paclitaxel can be used successfully, aslocal peritoneal tissue concentrations exceeds 103 timescompared to the concentrations achieved with intrave-nous application of the drug.5In the present issue, Roviello et al.6 (DOI: 10.1007/s00268-006-0038-0) report their experience (N = 61) withcytoreduction and intraperitoneal hyperthermic chemo-perfusion and present their outcome and morbidity. Intheir series, the authors confirm that the median survivalis potentially by far better after this complex therapeuticstrategy, than following systemic chemotherapy only.However, if this is the effect of aggressive cytoreductionor if it can be attributed to the intraperitoneal, chemo-therapy is still open.As expected and confirmed by this study, age (RR1.06 per year) is a significant risk factor for complicationsfollowing the presented therapy.6 One would expect ex-tent of disease, visceral anastomosis or extent of resec-tion (peritonectomy, time of duration of the procedure) asadditional significant risk factors for morbidity. Howevercompleteness of cancer resection (CCR 2/3 versus CCR0/1: RR 9.27) showed to have highest impact uponcomplication frequency in the present patient series.6 Incases where complete cytoreduction could to beachieved (CCR 2/3) the fact of high morbidity may reflectthe difficulty or ‘‘risk taking’’ of the surgical procedure toreduce tumour tissue to the desired extent in theindividual patient.In summary, Roviello et al.6 have highlighted theadvantage of surgical cytoreduction in combination withintraperitoneal hyperthermic chemotherapy in respect ofsurvival as well as the risk factors related to complica-tions. However, the treatment of peritoneal carcinoma- 2006 by the Socie´te´ Internationale de Chirurgie World J Surg (2006) 30: 2041–2042Published Online: 13 October 2006 DOI: 10.1007/s00268-006-0498-2INVITED COMMENTARYtosis is demanding, associated with substantial morbidityand is still under investigation for further improvementsand therefore should only be done in tertiary referralcentres preferentially within study protocols.REFERENCES1. Sugarbaker PH. Cytoreductive surgery and peri-operativeintraperitoneal chemotherapy as a curative approach topseudomyxoma peritonei syndrome. Eur J Surg Oncol2001;27:239–43.2. Sugarbaker PH, Chang D. Results of treatment of 385 pa-tients with peritoneal surface spread of appendiceal malig-nancy. Ann Surg Oncol 1999;6:727–731.3. Elias D, Matsuhisa T, Sideris L, et al. Heated intra-operativeintraperitoneal exaliplatin plus irinotecan after completeresection of peritoneal carcinomatosis: pharmacokinetics,tissue distribution and tolerance. Ann Oncol 2004;15:1558–1565.4. Elias D, Sideris L, Pocard M, et al. Efficacy of intraperitonealchemohyperthermia with oxaliplatin in colorectal peritonealcarcinomatosis. Preliminary results in 24 patients. AnnOncol 2004;15:781–785.5. Markmann M, Rowinsky E, Hakes T, et al. Phase I trial ofintraperitoneal taxol: a Gynecologic Oncology Group study.J Clin Oncol 1992;10:1485–1491.6. Roviello F, Marrelli D, Neri A, et al. Treatment of PeritonealCarcinomatosis by Cytoreductive Surgery and Intraperito-neal Hyperthermic Chemoperfusion (IHCP): PostoperativeOutcome and Risk Factors for Morbidity World J Surg 2006;30 (DOI: 10.1007/s00268-006-0038-0).Walter Richard Marti, MD, FACSDepartment of Visceral Surgery,University of Basel, Spitalstrasse 21,CH, 4031 Basel, Switzerlande-mail: wrmarti@uhbs.ch2042 Invited Commentary

Re: Treatment of Peritoneal Carcinomatosis by Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemoperfusion (IHCP): Postoperative Outcome and Risk Factors for Morbidity

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Re: Treatment of Peritoneal Carcinomatosis by Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemoperfusion (IHCP): Postoperative Outcome and Risk Factors for Morbidity

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