The peritoneum is a thin membrane lining the inside of our abdominal (peritoneal) cavity which enables some organs (eg. intestines) to be suspended and remain somewhat mobile within the abdomen.
Several cancers such as ovarian cancer, colorectal cancer, appendiceal cancer, or mesothelioma have a tendency to spread to the peritoneum. This is known as metastatic cancer when the cancer had originated from somewhere else. Rarely, the cancer can originate in the peritoneum itself and is known as primary peritoneal cancer. Regardless of the origin, peritoneal cancer (or peritoneal carcinomatosis) is considered advanced or stage IV cancer.
Before the introduction of surgical treatment, peritoneal cancer was regarded a terminal event with the conventional treatment being systemic chemotherapy with a palliative intent. Such patients did not survive beyond a few months of the diagnosis. But in the early 1990s, Professor Sugarbaker showed improved survival after surgically removing these peritoneal cancers followed by a ‘heated chemotherapy bath’ within the peritoneal cavity. This eventually led to the development and adoption of cytoreductive surgery and heated intraperitoneal chemotherapy (CRS and HIPEC) for peritoneal cancers. Today, it has become the established treatment for peritoneal metastasis arising from many gastrointestinal cancers and peritoneal mesothelioma. There is also increasing evidence for the treatment of peritoneal metastasis from ovarian cancers.
Peritoneal metastasis, when it first occurs, is often a silent disease. As the cancer progresses and volume of disease increases within the peritoneal cavity, symptoms become evident. These may include:
Because it can originate from different primary cancers, it is difficult to state the incidence of peritoneal cancer. However it has been estimated that up to 30% of colorectal patients and 20% of gastric cancer patients will develop peritoneal metastasis, and almost half of serous ovarian cancers present initially with spread to the peritoneum and/or nodes.
A diagnosis of peritoneal cancer may be suspected based on the history and physical examination. This is then followed by a series of tests that include:
A histological diagnosis is often necessary before treatment is instituted. A biopsy of the cancer is thus obtained through:
The treatment plan for peritoneal cancer is tailored according to the different circumstances in which the patient presents. For instance, a patient presenting with peritoneal cancer as a recurrence following previous surgery/chemotherapy requires a different treatment plan to one who presents with peritoneal cancer as a first cancer diagnosis.
The management of peritoneal cancer is complex and requires a team-approach consisting of specialists from different disciplines: medical oncologist, surgical oncologist, anaesthetist, dietitian, nursing etc. A multi-disciplinary tumour board is often convened to obtain a consensus on a suitable treatment plan. The patient may be recommended to undergo a few cycles of chemotherapy before CRS and HIPEC or surgery may be offered upfront.
CRS and HIPEC is the accepted treatment for peritoneal cancers arising from appendiceal and colorectal cancers as well as peritoneal mesothelioma. It is a complex and extensive open operation performed by a surgical oncologist who has received special training and has experience managing these types of cancers. Some of the surgical risks include:
In addition, the post-operative recovery is often prolonged requiring complex care; patients may be at risk for complications arising during this period. Following surgery, patients are often recommended to undergo more chemotherapy.
Cancer-fighting is a long journey that you do not undertake alone but instead be supported and guided by a dedicated team of doctors working alongside with you.
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