Hyperthermic Intraperitoneal Chemotherapy and Cytoreductive Surgery in the Management of Peritoneal Carcinomatosis

Rahul Rajeev, MBBS; Kiran K. Turaga, MD


Cancer Control. 2016;23(1):36-46. 

In This Article

Patient Selection

Prognostication Scores

Selecting patients for a potentially morbid surgery requires careful discussion on the possible benefits of the procedure. Tumor burden determines the completion of surgery as well as the long-term outcomes. Intraoperative staging systems, such as the PCI (13 regions, with scores ranging from 0 to 3) or Simplified PCI system (7 regions with 3 score groups), can be used to detect disease burden. Scoring systems, such as the Peritoneal Surface Disease Severity Score (PSDSS), are a noninvasive method of assigning disease burden in colon cancer.[38] PSDSS designates weighted scores for severity of disease, extent of carcinomatosis, and aggressiveness of histology, summating the scores to stratify the disease into 4 prognostic categories.[38] For example, moderately differentiated disease (3 points) with a PCI score of 12 (3 points) and mild symptoms (1 point) would be PSDSS stage 2 (4–7 cumulative points), whereas well-differentiated disease (1 point) with extensive intra-abdominal spread and a PCI score of 20 (7 points) and severe symptoms (6 points) would be PSDSS stage 4 (> 10 cumulative points).

PCI scores higher than 19 confer a poor prognosis despite cytoreductive surgery/HIPEC and are often a relative contraindication for peritoneal metastasis from CRC-PC.[38] Use of the PSDSS system as a prognostic indicator for selecting patients has been validated in multiple studies.[39,40]

Diagnostic Laparoscopy

Diagnostic laparoscopy, also called staging laparoscopy, is being increasingly used in the preoperative staging of peritoneal disease to identify patients with high peritoneal burden whose disease is considered inoperable in order to avoid unnecessary intervention. The procedure is technically feasible and associated with minimal operative morbidity and mortality.[41–43] Patients excluded from cytoreductive surgery/HIPEC by diagnostic laparoscopy are often candidates for conversion chemotherapy (using systemic chemotherapy to shrink tumors and convert unresectable disease to resectable) and repeat diagnostic laparoscopy.[43] Although port-site metastases are of concern, Valle et al[41] detected no seeding at the entry sites in their series of 351 diagnostic laparoscopy procedures. Despite the financial and diagnostic advantages of diagnostic laparoscopy, the reported usage is low in clinical practice.[44,45] We advocate wider use of diagnostic laparoscopy, especially in tumors at risk for peritoneal spread.

Diffusion-weighted Magnetic Resonance Imaging

Conventional imaging with computed tomography or magnetic resonance imaging has poor rates of perlesion sensitivity in the setting of peritoneal carcinomatosis, which varies with site and size of the tumor deposits, which can result in falsely low PCI scores.[46] In addition, patients with low-volume disease may not be detected, and the therapeutic window before they progress into high-volume disease may be lost.

Diffusion-weighted imaging better captures the contrast between normal and tumor tissue compared with conventional cross-sectional imaging modalities. Diffusion-weighted imaging translates the restrictive effect of tissue structure on the mobility of water molecules into visible signal intensity or contrast (Fig 3A–C).[47] Integrating diffusion-weighted imaging with conventional imaging has been shown to increase the rate of accuracy in the staging of ovarian cancer and in patients with peritoneal disease; however, the value of this modality must be balanced with the time, resource utilization, and patient discomfort associated with it.[47]

Figure 3.

A–C.— (A) Low-attenuation material along the perihepatic, lesser sac, and perigastric regions suggestive of mucinous ascites seen in contrastenhanced computed tomography, (B) axial, T2-weighted magnetic resonance imaging, and (C) diffusion-weighted imaging of the abdomen showing peritoneal metastases along the left lobe of the liver and anterior to the greater curvature of the stomach consistent with peritoneal implants.