Peritoneal carcinomatosis,peritonectomy and HIPEC : a glimmer of hope.

AbstractPeritonectomy and HIPEC have gained increasing interest in the multimodal treatment of patients with peritoneal carcinomatosis of gastrointestinal origin. Pseudomyxoma peritonei, colorectal and gastric carcinoma are currently considered to represent an indication for this procedure. For staging and classification purposes the PCI-score and the CCS classification are applied. Although both staging systems are not validated they are useful for determing resectabiltity as well as prognosis. According to a consensus conference, a PCI score > 20 is considered as a selective contraindication for peritonectomy. Recent data from Japan, however, indicate that this cut-off needs to be reevaluated. It could be shown, that a PCI of </= 10 in colorectal and </=6 in gastric cancer patients result in improved long term survival. Peritonectomy and HIPEC are associated with a substantial morbidity, which is in part correlated to tumor burden. Morbidity may be as high as 60%, whereas mortality usually is around 3%, therefore not higher than after other major gastrointestinal oncological resections. These data, however, are only achieved following a learning curve. Regarding prognosis, 5-year survival rates in selected colorectal patients may be as high as 30% in some studies, but most data show a plateau of around 20% survival after the 3rd postinterventional year. Despite these promising results for a disease usually considered to be fatal, many controversial issues need to be adressed. This refers to the indication itself, the staging systems for the classification of the extent of disease, the description of the completeness of cytoreduction, the length, drugs, temperature and method of HIPEC as well as the morbidity and mortality rates of the procedure. Definite data for these questions are still missing, because most of the studies are unicentric and retrospective and do therefore not allow a definite conclusion. Additonally, pertionectomy and HIPEC need to be evaluated under the condition of comparative effectiveness research by exploring the results of systemic chemotherapy which show at least a comparable median survival due to improved chemotherapeutic regimens by adding monoclonal antibodies. These considerations elucidate the challenges of peritonectomy and HIPEC. They also demonstrate that further studies are necessary to precisely determine the value of this procedure in order to define those patients with peritoneal carcinomatosis who may benefit most. Nevertheless, peritonectomy and HIPEC represent a glimmer of hope for selected patients with peritoneal carcinomatosis of colorectal or gastric origin.