Anatomy and Embryology Department University of Medicine and Pharmacy Iuliu Haåieganu, Clinicilor street Cluj Napoca, Romania Received: Accepted: Rezumat Introducere: Carcinomatoza peritoneală reprezintă un stadiu avansat al cancerelor abdominale în general şi a cancerului colorectal în particular. Singurele metode de tratament disponibile la momentul actual pentru această patologie sunt colorectal cancer esmo guideline sistemică caracter paliativ şi chirurgia citoreductivă CR asociată cu chimioterapie intraperitoneală hipertermică HIPEC.
Material şi metodă: În lucrarea de faţă am analizat prospectiv rezultatele imediate postoperatorii obţinutede către echipa noastră la primii 50 de pacienţi operaţi pentru carcinomatoză peritoneală de diferite origini. În ceea ce priveşte originea histopatologică, 30 de paciente au avut cancer ovarian; 19 pacienţi au avut carcinomatoză cu origine colorectală sau pseudomixom peritoneal de origine apendiculară.
Nu a existat mortalitate la 30 de zile.
Concluzii: Chirurgia citoreductivă urmată de chimioterapie intraperitoneală hipertermică este o procedură complexă însoţită de o incidenţă acceptabilă a complicaţiilor şi a deceselor postoperatorii, rezultatele putând fi optimizate prin management perioperator standardizat şi selecţia atentă a pacienţilor.
Rezultatele iniţiale obţinute de echipa noastră subliniază fezabilitatea acestei proceduri, cu rezultate imediate colorectal cancer esmo guideline, obţinute ca rezultat a respectării unui protocol standardizat de selecţie a pacienţilor şi a managementului perioperator. Cuvinte cheie: carcinomatoză peritoneală, cancer colorectal, cancer ovarian, pseudomixom peritoneal, chimioterapie intraperitoneală hipertermică, rezecţii multiorgan.
Abstract Introduction: Peritoneal carcinomatosis represents an advanced stage of tumor dissemination of abdominal cancers in general and colorectal cancer colorectal cancer esmo guideline particular.
The only therapeutic methods currently available for the treatment of this pathology are systemic chemotherapy palliative character and cytoreductive surgery CR with intraperitoneal chemotherapy. Colorectal cancer esmo guideline and method: In the present study we prospectively analyzed the immediate postoperative results obtained in the first 50 patients that were treated by our team for peritoneal carcinomatosis of different origin.
Results: From January till Dec we evaluated 98 patients with peritoneal carcinomatosis.
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In regard with the histopathological diagnosis, 30 patients had ovarian cancer and 19 had colorectal cancer or peritoneal pseudomixoma of appendicular origin. There was no 30 days postoperative mortality. Conclusions: Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy is a complex technique accompanied by an acceptable rate of complications and postoperative deaths, the results colorectal cancer esmo guideline optimized by a standardized perioperative management and patient selection.
The initial results obtained by our team emphasize the feasibility of this procedure, with immediate good results, as a result of a standardization protocol of patient selection and perioperative care. Bartoæ et al of the cases, the recurrence will be limited to the peritoneum 1,2. For these patients, if the treatment involves only palliative systemic chemotherapy, the median survival rate will not exceed 15 months colorectal cancer esmo guideline.
Cytoreductive surgery CR and hyperthermic intraperitoneal chemotherapy HIPEC have proven their feasibility sinceperiod in which Sugarbaker has repeatedly reported favorable outcomes for patients with peritoneal pseudomixoma 3,4.
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Since then, the technique has been applied with promising results for patients diagnosed with peritoneal carcinomatosis of ovarian, gastric and appendicular origin as well as for malignant peritoneal mesothelioma 2.
Starting from yearinternational guidelines recommends applying this treatment in experienced centers, on selected cases but only when a complete cytoreduction R0 can be obtained Taking into account the favorable results reported in the literature and the high incidence of advanced colorectal pathology diagnosed and treated in the "Professor Dr.
Octavian Fodor" Institute of Gastroenterology and Hepatology, starting we began a selection and treatment program for patients with peritoneal carcinomatosis; all these in order to implement CR surgery and HIPEC as standard treatment in our papillomavirus impfung manner 8.
Principles The Peritoneal Carcinomatosis Index PCI represents a quantification score colorectal cancer esmo guideline the extent of peritoneal neoplastic lesions, described for the first time by Sugarbaker 9. It involves the evaluation of 13 abdomino-pelvic regions central, right hypochondrium, epigastrium, left hypochondrium, left flank, right flank, right iliac fossa, pelvis, left iliac fossa, proximal jejunum, distal jejunum, proximal ileum, distal ileum and the scoring, depending colorectal cancer esmo guideline the size of the peritoneal neoplastic colorectal cancer esmo guideline.
Thus, the PCI can be colorectal cancer esmo guideline 0 and 39, this score being designed to predict the likelihood of a complete cytoreduction The success of cytoreduction is evaluated and graded at the end of the surgical procedure by establishing the "completeness of cytoreduction" CC score 11, Thus, we are talking about a CC-0 score in cases where there are no macroscopically visible tumoral deposits after cytoreduction. A CC-1 score is given when nodules smaller then 2.
After Kitayama et al. A CC-3 score is given in cases when the remnant tumors are bigger then 2. In the case of colorectal cancer esmo guideline cancer with peritoneal carcinomatosis, a complete CR CC-0 achieved with the cost of multiorgan resections and extended peritonectomies is the only option able to provide optimal results, the CC score being the main prognostic factor Intraperitoneal chemotherapy consists of an extended lavage colorectal cancer esmo guideline the peritoneal cavity with cytotoxic drugs.
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The main advantage of intraperitoneal administration of chemotherapeutic agents is the low systemic toxicity that allows prolonged exposure in higher doses of the intra-abdominal tumors with antineoplastic agents. Regarding the temperature of intraperitoneal administration of cytotoxic agents, it has been shown that above 41 C they have selective cytotoxicity on tumor cells, activating protein degradation, inhibiting the oxidative metabolism, colorectal cancer esmo guideline the ph, activating the lysosomes and the cellular apoptosis.
Moreover, temperatures above 41 C lead to augmentation of the cytotoxic effect of cytotoxic agents as well as increased absorption and penetration of the tumor tissue 2, The role of hyperthermia was highlighted in studies indicating the superiority of HIPEC versus early postoperative intraperitoneal chemotherapy EPIC or sequential postoperative intraperitoneal chemotherapy SPICboth normothermic lavage methods. The benefits of HIPEC have colorectal cancer esmo guideline translated through prolonged survival with a lower rate of recurrence and postoperative complications Achieving the optimal temperature C and maintaining it are conditioned by the presence of an increased flow of the intraperitoneal lavage, which is possible thanks to dedicated devices Colorectal cancer esmo guideline role of systemic chemotherapy remains particularly important, essentially contributing in completing the correct treatment through its neoadjuvant or adjuvant character, case depending.
Furthermore, concomitant intraoperative administration of systemic cytotoxic agents leads to an colorectal cancer esmo guideline of the cytotoxic intraperitoneal effect by reaching a bidirectional diffusion gradient. Typically, minutes before HIPEC, intravenous 5-fluorouracil and folinic acid are administrated 19, Material and Method Starting Januarywe began using this treatment on patients histopathological diagnosed with peritoneal carcinomatosis from colorectal adenocarcinoma, appendicular mucoceles, ovarian adenocarcinoma and gastric adenocarcinoma.
To establish the opportunity for surgery, we followed a standard protocol with routine multidisciplinary meetings: surgeon, anesthesiologist, oncologist.
All patients who were referred to our team were clinically and imagistically evaluated. The investigations used to assess the extent of the neoplastic disease were thoraco-abdominal CT scan with intravenous contrast agent and PET-CT when appropriate - suspicion of distant dissemination with inconclusive CT scan result.
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Except for patients with peritoneal pseudomyxoma, a PCI greater than 20 contraindicated the surgery. The surgical procedure has also been standardized.
The resection time meant the excision of all tumor deposits in block with the invaded organs multiorgan resections - MOR 12,24the goal being to obtain a CC-0 score for all patients Fig. For this purpose, when needed, vascular or urogenital resections with consecutive reconstructions were performed. In order to minimize the septic risks, the sectioning of colorectal cancer esmo guideline digestive tract was done Chirurgia, 25 A. Bartoæ et al A B Figure 1. En block multiorgan resection during cytoreductive surgery from the personal archive of the authors using mechanical suture devices staplers.
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HIPEC time was performed using the open approach with the abdominal wall suspended by Thompson autostatic retractor: the Colosseum technique Fig. The cytostatic drug was chosen according to the anatomopathological diagnosis and the literature recommendations. In patients with extensive digestive resections, those with gastric icd 10 code for papilloma back or those with poor nutritional status, jejunostomy was routinely performed.
Surgeries involving recto-sigmoid resection were completed with terminal colostomy.
The discharge of the patients colorectal cancer esmo guideline papilloma virus nella gola sintomi Figure 2. Figure 3. Postoperative follow-up required 1-month follow-up and then from 3 to 3-month periodical examinations, including clinical examination, blood count, blood biochemistry, tumor markers CEA, CA, as appropriatequality of life questionnaires EuroQol 5-D Considering that the surgical procedure CR and the intraperitoneal chemotherapy HIPEC are similar for all of the abovementioned diagnoses the procedure generally being applied on patients with peritoneal carcinomatosiswe included in our study all the colorectal cancer esmo guideline with this diagnosis, regardless of the origin of their primary tumor.
Thus, we included in our analysis the first 50 consecutive patients diagnosed with peritoneal carcinomatosis, following immediate postoperative outcomes.
Postoperative complications were classified using the Clavien- Dindo classification and were quantified up to 60 days postoperatively The quality of life form was completed at routine post-operative checks, according to the protocol.
In 15 patients, surgery was limited to exploratory laparotomy, intraoperative exploration indicating an extension of neoplastic disease that was not suitable for cytoreduction. CR and HIPEC technique have been successfully applied to 50 patients: 14 with peritoneal carcinomatosis of colorectal etiology, 5 with peritoneal pseudomyxoma of appendicular origin, 30 of ovarian origin and 1 of gastric origin.
The median age was Median body mass index ICM was. All patients had comorbidities Table 2. The carcinomatosis index ranged between 1 and The median operating time was minutes min max Blood loss was between 0 and ml with a median of ml.
Complete cytoreduction CC0 was obtained in all patients. Taking in account the Clavien-Dindo classification, 3 of the patients experienced grade IIIb complications ischemic digestive perforations and intestinal occlusion requiring surgical reintervention. One of these died 51 days postoperatively developing grade V complication. One patient developed a grade IV complication adverse effects of intraperitoneal and systemic Chirurgia, 27 A.
Bartoæ et al Table 2. Associated diseases. No 30 days postoperative mortality was recorded. One patient died 51 days after surgery, after developing late postoperative necrosis of the aponeurosis and 2 intestinal ischemic perforations, complications that led to septic and multiple organ failure. Thus, the day mortality was 1. The median stay in the intensive care unit was of 5 days min 2 - max Median hospitalization was The median follow-up was of days.
Table 3. The selection of patients who can benefit from this treatment is essential. The patient's biological status must be acceptable, with a proper performance status. Thus, colorectal cancer esmo guideline to the Karnofski score, ideal patients should have a score between 60 and Also, patient age should be an important selection criterion. The Canadian guidelines indicate 65 years as 'cut off'. Over this age, surgery is recommended only for carefully selected patients without co-morbidity, low IC and less aggressive histopathology Knowing the extent of neoplastic disease is essential in the selection of cases.
Intraoperative assessment laparoscopy or laparotomy of the extension of peritoneal carcinomatosis is the only procedure that can ultimately evaluate the opportunity and the possibility of performing a surgical procedure with a radical, oncological intend.
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Thus, PCI can estimate the extent to which complete cytoreduction can be performed, with a direct impact on survival. The final assessment of PCI can be done only by laparotomy In the same idea, HIPEC prophylaxis is also colorectal cancer esmo guideline discussion in patients considered at risk T3-T4 tumorsespecially when peritoneal lavage with histopathological extemporaneous examination is positive.
This topic is highly discussed in the literature; the ongoing studies will determine whether this attitude is justified or not 38, Tumor invasion at the level of vital, unresectable structures aorta, vena cava contraindicate the surgery. The presence of hepatic metastases is a relative contraindication, segmental resections being colorectal cancer esmo guideline.
The need for major liver resections, duodenopancrea- Chirurgia, 29 A.
Bartoæ et al colorectal cancer esmo guideline or pelvic exenteration will contraindicate the intervention, with rare exceptions limited disease, very good biological status, well differentiated histopathological forms 32, The histopathological origin of the tumor must be known before surgery; the biopsy can be taken by endoscopy, percutaneous ultrasound guided or laparoscopic approach. As a guide line, the indication of CR and HIPEC in patients with poorly differentiated or undifferentiated tumors should be established with caution, in these cases the benefits being poor.
By modest results, presence of signet ring cell, associated with other relative contraindications, limits the applicability of this technique Analyzing our data, we also noticed a much more modest outcome in relation to the presence of signet cell adenocarcinoma, the hpv virus zelftest patient that we had with this histopathology developing lymph node metastases at 6 months and died at 14 months after surgery.
Because of the small number of patients with this histopathological origin in our colorectal cancer esmo guideline were not able to draw statistical conclusions. In general, the surgery will not be performed in case of bowel occlusion, although there are reports that indicate CR and HIPEC under emergency conditions as feasible 32, The surgeon must have a good expertise in oncologic surgery, most of the time tumorresections leading to MOR, required in order to achieve R0 resection margins.
Among the postoperative complications, the infectious type ranges first Intraperitoneal chemotherapy per se can cause systemic toxicity with consecutive side effects 51, Two of the patients operated by our team developed such a complication. As a result, the analysis of our initial experience the first 50 cases indicates a morbidity and mortality that falls within colorectal cancer colorectal cancer esmo guideline guideline limits reported by centers with high experience in the field.
Of course, the final validation colorectal cancer esmo guideline the results will also come with the analysis of the survival curves and the factors that influence the long outcomes, a project that is progress in our service Chirurgia, 210 Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis: Colorectal cancer esmo guideline Initial Experience Although the papilloma alla gola sintomi indicates the feasibility of reintervention with repeated CR and HIPEC procedure for intraperitoneal tumor recurrence 54in the two cases with colorectal cancer esmo guideline tumor recurrence, we failed to repeat the procedure due to the intense adhesion syndrome and extent of neoplastic disease.