Management of peritoneal-surface malignancy: the surgeon's role

Background: Peritoneal surface malignancy can result from seeding of gastrointestinal cancer or abdominopelvic sarcoma; it can also occur as a primary disease, for example, peritoneal mesothelioma. In the past, this clinical situation was treated only with palliative intent. Methods: An aggressive approach to peritoneal surface malignancy involves peritonectomy procedures, perioperative intraperitoneal chemotherapy and knowledgeable patient selection. The clinical assessments necessary for valid clinical judgements include the cancer histopathology (invasive vs expansive progression), the preoperative abdominal and pelvic computed tomogram, the peritoneal cancer index and the completeness of cytoreduction score. Proper patient selection is mandatory for optimizing the results of treatment. Results: In a series of phase-II studies, appendiceal tumors with peritoneal seeding was the paradigm for success with a 75% long-term survival in properly selected patients. Carcinomatosis from colon cancer had an overall 5-year survival of 20% but with selected patients this reached 50%. Also, sarcomatosis patients overall had only a 10% 5-year survival but selected patients had a 75% survival. In all malignancies, early aggressive treatment of minimal peritoneal surface dissemination showed the greatest benefit. Conclusions: The surgeon must accept responsibility for knowledgeable management of peritoneal surface dissemination of cancer. A curative approach has been demonstrated in large phase-II studies. Adjuvant studies with perioperative intraperitoneal chemotherapy in diseases where peritoneal surface spread occurs are indicated.