Role of diagnostic laparoscopy in patients with suspicion of colorectal peritoneal metastases to evaluate suitability for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Abstract

BackgroundThe aim of the present study was to determine the feasibility and safety of performing diagnostic laparoscopy (DLS) routinely in patients with suspicion of colorectal peritoneal metastases (PM) to evaluate suitability for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC).MethodsData for consecutive patients who underwent DLS between 2012 and 2018 were extracted retrospectively from an institutional database. The primary outcome was the degree of visibility of the abdominal cavity during DLS. Good laparoscopic evaluation of the abdominal cavity was defined as visibility of at least the regions of the diaphragm, pelvis and small bowel. Secondary outcomes were reasons for perioperative exclusion for CRS + HIPEC, major postoperative complications (Clavien–Dindo grade III or above) and difference in overall survival (OS) between patients deemed suitable or unsuitable for CRS + HIPEC. Kaplan–Meier analyses were performed.ResultsSome 184 patients were analysed. Good laparoscopic evaluation was possible in 138 patients (75·0 per cent), and 24 (13·0 per cent) had conversion to an open procedure. Ninety‐three patients (50·5 per cent) were excluded for CRS + HIPEC, most commonly because of absence of colorectal PM (34 patients, 37 per cent) or extensive disease (Peritoneal Cancer Index 20 or above) (33 patients, 35 per cent). Major complications occurred in five patients (2·7 per cent), with no postoperative deaths. Median OS was significantly decreased in patients who were excluded due to extensive disease (14 (95 per cent c.i. 10 to 18) months) compared with patients suitable for CRS + HIPEC (36 (27 to 45) months) (P < 0·001).ConclusionRoutinely performing DLS in patients with suspicion of colorectal PM to evaluate suitability for CRS + HIPEC is feasible and safe, avoiding the morbidity of an unnecessary laparotomy in patients with extensive disease.

Development and Validation of a Prognostic Nomogram for Colorectal Cancer Patients With Synchronous Peritoneal Metastasis

“…Laparoscopic exploration or laparotomy is considered the gold standard for the diagnosis of PM ( 28 ). In this study, there were significant differences in imaging diagnosis, other organ-invasion, digestive obstruction, HIPEC, and chemotherapy between the development group and the validation group (p <0.05).…”

Diagnostic and therapeutic algorithm for colorectal peritoneal metastases. A consensus of the peritoneal surface malignancies onco-team of the Italian society of surgical oncology

“…If the tumor load is high, with multiple and diffuse nodules, a simple histological confirmation and an accurate intra-operative staging (PCI and unresectability causes) is the best choice, before sending the patient to a peritoneal referral center 4 If the patient is symptomatic and peritoneal metastases is suspected, surgery should be performed according to the urgency to intervene before sending the patient to a peritoneal referral center 5 In case of obstruction, perforation or bleeding, when radical resection of the primary can be carried out safely and limited nodules are present, resection of the primary combined with peritoneal metastases is an acceptable option before sending the patient to a peritoneal referral center 6 When surgery is emergent and peritoneal metastases are diffuse, a limited palliation (primary resection only, stoma formation) with peritoneal biopsy and staging (PCI and unresectability causes) are indicated, before sending the patient to a peritoneal referral center 7 Every patient potentially eligible for CRS-HIPEC should be evaluated by a referral centre and discussed in dedicated colorectal multidisciplinary meetings 8 During colorectal multidisciplinary meetings a complete medical history, abdominal/thoracic CT scan and blood tumor markers should be available 9 CT scan with contrast enhancement medium represents the gold standard for stage patients with colorectal peritoneal metastases 10 MRI and PET scan should be considered complementary imaging for stage patients with colorectal peritoneal metastases 11 Laparoscopy is a complementary method for stage patients with colorectal peritoneal metastases and It is crucial that is performed by surgeons with experience in CRS-HIPEC 12 Only patients with pre-operative Peritoneal Cancer Index <16 and with the possibility of obtain a CC0/1 resection should be selected for CRS-HIPEC 13 Molecular gene mutation testing (RAF/RAS mutation) and microsatellite status (stable or not) are important selection factors for CRS-HIPEC 14 Performance status, extraperitoneal metastases (liver, lymph nodes), tumor site (right versus left colon) tumor differentiation, signet ring histology, ascites, symptoms of obstruction and lymph node status (N2a) of the primary in case of metachronous PM should be carefully considered potentially exclusion criteria for CRS-HIPEC 15 In patients selected for CRS-HIPEC Mitomycin C based regimen is recommended 16 Before selecting patients to CRS-HIPEC pre-operative chemotherapy should be always considered especially in presence of synchronous disease 17 Peritoneal progression during systemic chemotherapy should not be considered an absolute contraindication for CRS-HIPEC, if the selection criteria are still met 18 In very selected patients with limited metachronous peritoneal metastases and no risk factors, perioperative systemic chemotherapy could be omitted in favour of a front-line CRS-HIPEC 19 In the sub-group of patients with peritoneal metastases who have mismatch repair-deficient (dMMR) and/or microsatellite instability-high (MSI-H), the treatment with immune checkpoint inhibitor should be considered as first choice for confirming the diagnosis of peritoneal involvement, allowing a histological definition of all suspected nodules [29]. Laparoscopic exploration can assess the peritoneal cancer index (PCI) more accurately then preoperative radiological investigations [36]. Moreover, during laparoscopy, any potential cause of unresectability (mesenteric retraction or infiltration of the hepatic hilum, suprahepatic veins and Treitz ligament) can be easily identified under direct vision [37].…”

Diagnostic Laparoscopy in Patients With Peritoneal Carcinomatosis Is Safe and Does Not Delay Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy

“…7,8 Other imaging modalities, such as positron emission tomography/CT scans and magnetic resonance imaging (MRI) have not been shown to have increased sensitivity over CT scans in determining extent of disease. 9,10 Diagnostic laparoscopy (DLS) has become a widely utilized staging tool for evaluation of other gastrointestinal (GI) tumors and several studies have documented its utility in patients with PC. A single-center retrospective study in 2016 demonstrated that DLS has a positive predictive value of 83% in its ability to predict complete cytoreduction.…”

“…1 Another recent retrospective study noted a significant decrease in the rate of nontherapeutic laparotomies after introduction of preoperative DLS into the institution's diagnostic algorithm for patients with PC. 10 Additionally, several studies have demonstrated the correlation between DLS findings and PCI score based on direct visualization. 5, [10][11][12][13] However, it is unclear to what risk these benefits occur.…”

“…10 Additionally, several studies have demonstrated the correlation between DLS findings and PCI score based on direct visualization. 5, [10][11][12][13] However, it is unclear to what risk these benefits occur. In patients undergoing DLS for pancreatic or gastric cancer, the risk of associated morbidity ranges from 2 to 4%.…”