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Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden

How to handle peritoneal carcinomatosis found at laparotomy. Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden. Adjuvant Chemotherapy Intraperitoneal chemotherapy (5-FU 500 mg/m 2 /day i.p.) (Leucovorin 60 mg/m 2 /day i.v.) vs

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Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden

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  1. How to handle peritoneal carcinomatosis found at laparotomy Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden

  2. Adjuvant Chemotherapy Intraperitoneal chemotherapy (5-FU 500 mg/m2/day i.p.) (Leucovorin 60 mg/m2/day i.v.) vs Surgery alone (Double - blinded) Swedish Gastrointestinal Tumour Adjuvant Therapy Group

  3. Intraperitoneal chemotherapy 100 patients included (All Dukes´ stages) Postop. recovery not affected ! Graf et. al. Int J Colorect Dis 1994; 9:35-39 Swedish Gastrointestinal Tumour Adjuvant Therapy Group

  4. Objectives Local effect on the surgical bed Early treatment start I.v. chemo does not reach the target Cytoreductive surgery + i.p chemo

  5. Isolated peritoneal carcinomatosis Colorectal cancer Ovarian cancer Mesothelioma Peritoneal pseudomyxoma Other GI malignancies Cytoreductive surgery + i.p chemo

  6. Uppsala series 1991 - 2010 Type of malignancy Pseudomyxoma 197 Colorectal cancer 259 Mesothelioma 41 Miscellaneous 46 Total 543 Cytoreductive surgery + i.p chemo

  7. Uppsala series 1991 - 2010 Many patients have had second - look operations Approx. two procedure per week in total  650 operations Cytoreductive surgery + i.p chemo

  8. What survival figures do you expect ? A: As good as for liver met ! B: Not as good as for liver met ! Cytoreductive surgery + i.p chemo

  9. If not as good as for liver metastasis, how good is it ? A: 30 - 40 % 5-years survival B: 20 - 30 % 5-years survival C: 15 - 20 % 5-years survival D: 10 - 15 % 5-years survival Cytoreductive surgery + i.p chemo

  10. Cytoreductive surgery + i.p chemo Uppsala series Colon cancer Mahteme et al Br J Cancer 2004

  11. Cytoreductive surgery + i.p chemo Uppsala series Uppsala series Colon cancer Mahteme et al Br J Cancer 2004

  12. Uppsala experience colon cancer Randomized trial Classic chemotherapy vs Cytoreductive surgery + i.p chemo Cytoreductive surgery + i.p chemo

  13. Randomized trial in Uppsala 50 patients included 46 evaluated Significant survival benefit in the cytoreduction + chemo group 30 % DSF 3-years survival Cytoreductive surgery + i.p chemo

  14. Cytoreductive surgery + i.p chemo Cashin et al E J S O 2013

  15. Sigmoid cancer. You find 3 small nodules on the surface of the liver easy to remove: A: Leave them and do a better staging B: Take them out C: Use intraoperative ultra sound. Patient stage with a good CT

  16. No good evidence but B is correct: A: Leave them and do a better staging B: Take them out C: Use intraoperative ultra sound. Patient stage with a good CT

  17. Right-sided cancer. Massive peritoneal carcinosis around the primary: A: Leave the primary for better staging B: Resect the tumour and give adjuvant chemotherapy C: Leave the primary and refer the patient to a HIPEC-unit Patient stage with a good CT

  18. This is a classic case for C: A: Leave the primary for better staging B: Resect the tumour and give adjuvant chemotherapy C: Leave the primary and refer the patient to a HIPEC-unit Patient stage with a good CT

  19. Right-sided cancer. Just a few deposits around the primary tumour: A: Leave the primary for better staging B: Resect the tumour and give adjuvant chemotherapy C: Leave the primary and refer the patient to a HIPEC-unit Patient stage with a good CT

  20. Still C is correct: A: Leave the primary for better staging B: Resect the tumour and give adjuvant chemotherapy C: Leave the primary and refer the patient to a HIPEC-unit Patient stage with a good CT

  21. Why always send all peritoneal carcinosis to a HIPEC-unit: A: Cytoreductive surgery is difficult if retroperitoneum is opened B: An increase for distant spread C: HIPEC does not work if retroperitoneum is opened Patient stage with a good CT

  22. A correct ! It is very difficult to take peritoneum out at the next operation: A: Cytoreductive surgery is difficult if retroperitoneum is opened B: An increase for distant spread C: HIPEC does not work if retroperitoneum is opened Patient stage with a good CT

  23. Special issues Laparoscopy Drainage Distant metastases Morbidity Cytoreductive surgery + HIPEC

  24. Take home message Always send the patients to a HIPEC-unit Cytoreductive surgery + HIPEC

  25. Conclusion Pseudomyxoma; Standard of care CRC; Standard of care Ovarian cancer; experimental ? Mesotelioma; Standard of care ? Gastric cancer; No Cytoreductive surgery + HIPEC

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