Two-step cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei with high peritoneal carcinomatosis index

Abstract

Background Complete cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is the only curative treatment for pseudomyxoma peritonei (PMP) arising from the appendix. High peritoneal carcinomatosis index (PCI) is associated with an increased risk of surgical complications. The objective of this study was to present the results of a planned two-step surgical strategy to decrease postoperative morbidity and improve resectability of patients with very high PCI. Methods All consecutive patients who underwent a planned two-step surgical approach for PMP between January 2012 and March 2020 were retrospectively included. This approach was offered for patients with low-grade PMP with PCI > 28 for which feasibility of a complete CRS in one operation was uncertain. The first surgery included a complete CRS of the inframesocolic compartment and omentectomy. HIPEC was delivered at the second surgery, after complete CRS of the supramesocolic compartment. Postoperative morbidity was assessed using the Clavien-Dindo classification and survival results were also collected. Results Eight patients underwent the two-step approach. The median PCI was 33 (29–39) and the median time between the two procedures was 111 days (90–212 days). One patient was deemed unresectable at the second surgery. The rate of major morbidity was 0% for the first step and 25% for the second step, with no mortality. Median follow-up was 53.8 months (3–73 months). Conclusion A two-step surgical management for low-grade PMP patients with very high PCI is safe and feasible, with acceptable postoperative morbidity and no compromise on oncological outcomes.

Feasibility and outcomes of cytoreductive surgery and HIPEC for peritoneal surface malignancies in low- and middle-income countries: a single-center experience of 232 cases

“…First is the disease type, and the other is the extent and volume of peritoneal spread. Based on current literature pseudomyxoma peritonei, mesothelioma, peritoneal metastases of tumors of appendicular and colorectal origin, and ovarian cancers have shown benefit with CRS and HIPEC [15][16][17][18][19][20][21][22]. CT scan of the abdomen and pelvis is used to assess volume and extent of peritoneal spread and helps to determine feasibility of optimal cytoreduction.…”

A proposal for changing nomenclature from pseudomyxoma peritonei (PMP) to abdomino-peritoneal mucinous carcinoma (APM) based on its long journey and experience from tertiary oncology center in India

“…Anatomical location is a more important determinant for CRS, not the PCI score. Organized large mucinous deposit (>3 cm) at porta hepatis, superior mesenteric artery origin, over inferior vena cava, retro-hepatic area, or multiple small bowel invasion may prevent performing optimal CRS [ 23 , 24 ].…”

Perioperative outcomes of cytoreductive surgery for tumours of colorectal or appendiceal origin with ovarian involvement

“…It has been proposed that a two‐stage approach to CRS in some instances may reduce postoperative morbidity without impacting oncological outcomes. However, this has only been shown in two small case series for patients with high volume PMP in which the first stage involved CRS of the inframesocolic compartment and omentectomy, followed by a second surgery involving CRS of the supramesocolic compartment followed by HIPEC 11,12 . To our knowledge, there have been no published studies comparing perioperative complications between patients with and without OM following peritonectomy.…”

“…CRS was performed in keeping with the Sugarbaker techniques. 12 Organ resections involved colectomy, proctectomy, small-bowel resection, hysterectomy, salpingo-oophorectomy, cholecystectomy and splenectomy. Prophylactic salpingo-oophorectomy was performed selectively, after careful preoperative discussion and consideration of fertility referral for premenopausal women.…”