Implantación en Mallorca de un programa de Tratamiento multimodal de la Carcinomatosis Peritoneal mediante Quimioterapia Sistémica, Cirugía Citorreductora y Quimioterapia Intraperitoneal Hipertérmica (HIPEC)

Resumo

Introduction: Research promoted since the early nineties by Sugarbaker et al in Washington, have demonstra- ted that many tumors of colorectal and appendiceal origen with peritoneal extension, may remain limited to the abdomen during relatively long periods before developing distant metastases. These findings have radically altered the consideration of peritoneal carcinomatosis from a systemic and almost terminal state, to a loco- regional disease, with possibility of surgical and oncological rescue, and thus, increasing the survival. The results of experimental studies of radical cytoreductive surgery associated with hyperthermic intraperitoneal chemotherapy, have demonstrated better results in terms of long-term survival and quality of life than con- ventional treatments. The rationale for the current treatment of peritoneal carcinomatosis is organized around a multimodal treat- ment with three courses of action: 1. Preoperative intravenous induction chemotherapy, 2. Cytoreductive sur- gery and peritonectomy, and 3. Hyperthermic intraperitoneal chemotherapy (HIPEC). The scientific basis of this multimodal treatment is based on the synergism between the hyperthermia and several cytostatic agents (mitomycin-C, cisplatin, oxaliplatin, etc.), the direct heat cytotoxicity on tumor cells, and the pharmacokine- tic advantages of chemotherapy administered intraperitoneally. Methodology: Program Objectives were the following: 1. Development of Multimodal surgical and oncologic treatment protocol; 2. Continuing education of the multidisciplinary group; 3. Ongoing training in the hyper- thermic intraperitoneal perfusion chemotherapy; 4. Application of a Work Safety Protocol; 5. Definition of indicators; 6. Design of database for exploitation of results; 7. Monitoring of morbidity and mortality, and 8. Monitoring and analysis of survival. Clinical evaluation and preoperative tumor extension study. 1. Clinical Indications. Types of tumors; 2. Patient selection. Inclusion and exclusion criteria; 3. Preoperative Evaluation Oncology; 4. Preoperative radiological evaluation; 5. Clinical pathway algorithm; 6. Patients follow-up, and 7. Laboral safety. Results: Five years ago, we started cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for treatment of peritoneal carcinomatosis in the Hospital Son Llàtzer. 46 patients were operated (40 women and 6 men) with a mean age of 58.3 years (47-73 years). Of these 46 patients, 30 were patients with ovarian can- cer, and underwent cytoreductive surgery followed by chemotherapy without applying systemic intraperitone- al chemotherapy. The program consisted of 17 patients who underwent a total of 20 procedures. The origin of the tumor was colorectal in 11 cases, appendiceal in 4 cases, gastric in 1 case, and one case with a diffuse mul- ticystic peritoneal mesothelioma. The intraperitoneally chemotherapy administered was normothermic in 9 patients, and hyperthermic (HIPEC) in 11 cases. The perioperative mortality was 4.3% (three patients). The resectability index was 90.9%. In 17 cases (85%) it was possible to get a complete resection (CC-0). Overall morbidity was 40%. The most frequent complication was central catheter infection. Three patients required reoperation (postoperative bleeding, duodenal fistula, and segmental mesenteric ischemia). The mean operati- ve duration was 6.5 hours. The average stay was 18.2 days. The median survival of patients with peritoneal dissemination of appendiceal and colorectal origin was 27 and 31 months respectively. Overall survival of patients with peritoneal carcinomatosis of colorectal origin was at one, two, and three years 71%, 60% and 50% respectively. Conclusions: a) The application of a multidisciplinary and multimodal treatment can significantly improve sur- vival in a specific group of patients with peritoneal carcinomatosis. b) This treatment is expensive, complex and represents a significant workload for professionals and institutions, so it is essential to apply strict criteria for patient selection, based on experience and the evaluation by multidisciplinary teams. Similarly, it is essen- tial to achieve an early diagnosis, treatment of complications, patient monitoring, and continuous evaluation of morbidity outcomes and survival. c) Randomized studies currently underway will provide more evidence on the expected benefit of this treatment, and establish lines to improve results.