Current status and future of peritoneal surface diseases

In the last 20 years the treatment of peritoneal surface malignancies grained a special attention of the medical and surgical world. Previously peritoneal surface malignancies where seen as metastasized disease which could not be surgical removed due to technical difficulties and wouldn't be treated with systemic chemotherapy because of the leak of measurable disease. In 2003 the first randomized trial was published on the treatment colorectal peritoneal metastasis in a more active way.([1],[2]) This trial showed a survival benefit of cyto-reductive surgery with hyperthermic intra peritoneal chemotherapy followed by systemic chemotherapy when compared to systemic chemotherapy alone. This study was followed by a large number of studies which showed an even further improvement of the survival than published in the randomized trial. Most recently another randomized trial comparing systemic chemotherapy followed by cyto reduction and hyperthermic intraperitoneal chemotherapy to systemic chemotherapy followed by cytoreduction without hyperthermic in-tra peritoneal chemotherapy doubted the additional effect of hyperthermic intra peritoneal chemotherapy in patients with peritoneal metastasis of colorectal origin.([3]) Whatever way one looks at these results it is clear from both trials that a complete cytoreduction is the cornerstone of the treatment of peritoneal metastasis.

Ovarian carcinoma is probably the most classic tumour with spreading to the peritoneum. Traditional this disease is treated with debulking and systemic chemotherapy. Several studies showed that the completeness of the cytoreduction determines the outcome.([4]) This year a randomized trial was published showing a benefit of adding hyperthermic intra peritoneal to the cytoreduction when combined with systemic chemotherapy.([5])

In both above described situations it is clear that cytoreduction, thus the complete resection of all visible disease is key to success. Hyper thermic intra peritoneal chemotherapy give an extra benefit in ovarian cancer patients with peritoneal metastasis and give a benefit in colorectal cancer effected with peritoneal metastasis in the med range disease load. Probably the difference between the two diseases is that ovarian cancer is much more chemo sensitive to the current known chemotherapy agents and we are leaking really effective chemotherapy for colorectal cancer.

Systemic chemotherapy might help to improve the survival combined with cytoreduction, but we are leaking a trial comparing cytoreduction with and without systemic chemotherapy. If we compare this situation to liver metastases surgery one should doubt whether chemotherapy give a benefit to resection of metastatic disease because most studies of adjuvant chemotherapy after liver metastasis do not have a overwhelming result.([6])

To conclude, surgical resection of peritoneal metastasis is the key, all treatment around it is whether it is intra peritoneal chemotherapy or systemic chemotherapy has not established it final position. However it is mostly likely that the combination of everything is give the best results for the patients.

Conflict of Interest Statement:

None.

• REFERENCES

• 1 Verwaal VJ, Bruin S, Boot H, van Slooten G, van Tinteren H. 8-year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal car-cinomatosis of colorectal cancer. 8-year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal car-cinomatosis of colorectal cancer 2008; 15 (09) 2426-32
• 2 Verwaal VJ, van Ruth S, de Bree E, van Sloothen GW, van Tinteren H, Boot H. et al. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol 2003; 21 (20) 3737-43
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• 4 Chi DS, Eisenhauer EL, Zivanovic O, Sonoda Y, Abu-Rustum NR, Levine DA, Guile MW, Bristow RE, Aghajanian C, Barakat RR. Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm. Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm 2009; 114 (01) 26-31
• 5 van Driel WJ, Koole SN, Sikorska K, Schagen van Leeuwen JH, Schreuder HWR, Hermans RHM. et al. Hyperthermic intraperitoneal chemotherapy in ovarian cancer. N Engl J Med 2018; 378 (03) 230-40
• 6 Nordlinger B, Sorbye H, Glimelius B, Poston GJ, Schlag PM, Rougier P. et al. Perioperative chemotherapy with FOL-FOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomised controlled trial. Lancet 2008; 371 (9617) 1007-16

Publication History

Received: 01 July 2018

Accepted: 15 July 2018

Article published online:
07 March 2025