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Peritoneal carcinomatosis from a colorectal primary represents one of several metastatic pathways. Colorectal cancers may spread by lymphatic and hematogenous dissemination in addition to contiguous and transperitoneal spread. The most common metastatic sites include the liver, lung, regional lymph nodes, and peritoneum. Although peritoneal carcinomatosis is often considered a late stage of disease progression, transcoelomic spread of colorectal cancer is reported to be encountered in 7% of patients undergoing primary surgery.1
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Several factors impact the overall prognosis of colorectal cancer at presentation including local tumor extent, regional lymph node metastases, the presence of mesenteric tumor deposits, and completeness of resection. Residual tumor after definitive surgical therapy is an adverse prognostic factor for patients with colorectal cancer. Patients who are diagnosed with early-stage colorectal cancer (stage I to III) and undergo successful tumor resection have a 60% to 90% 5-year survival. However, the 5-year survival drops to 8% in patients with stage IV disease. Patients particularly with peritoneal carcinomatosis have a very poor prognosis, with median survival ranging from 6 to 12 months with chemotherapy alone.2,3
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Cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to have a role in patients with peritoneal carcinomatosis secondary to colorectal cancer. Traditionally, malignant seeding of the peritoneal cavity had been thought to indicate abdominal contamination, and complete tumor resection was not considered as a potential treatment option. In the 1930s, CRS was first advocated by Meigs4 for patients with ovarian cancer. In the 1960s and 1970s, Munnell5 and Griffiths6 further developed cytoreduction techniques, demonstrating a survival benefit in patients with ovarian cancer who underwent more radical surgery. Sugarbaker7 later demonstrated the benefit of cytoreduction followed by HIPEC in patients with peritoneal disease from various gastrointestinal cancers. Since that time, several studies have been performed investigating the efficacy of CRS/HIPEC using a wide variation of intraperitoneal chemotherapies for multiple peritoneal malignancies including appendiceal cancer, colorectal cancer, and peritoneal mesothelioma.
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A comprehensive evaluation is critical in determining the appropriate management of patients with peritoneal carcinomatosis. Patient selection is a key factor to optimize those patients best suited for CRS. Imaging studies, including computed tomography (CT) scans and magnetic resonance imaging (MRI), are commonly used to evaluate the extent of peritoneal disease to guide the appropriate treatment. Diagnostic laparoscopy also plays a role in determining disease extent and may be useful in those patients with indeterminate imaging studies. The goal of surgical cytoreduction is to remove all gross tumor, leaving no residual disease behind. However, radical cytoreduction is associated with increased morbidity, and the degree of morbidity is clearly related to the extent of surgical resection. Some studies quote morbidity after CRS/HIPEC to be as high as 40% to 60%.8,9
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Despite the high surgical morbidity, patients with peritoneal carcinomatosis from colorectal cancer undergoing CRS/HIPEC have been shown to have an improved overall survival and progression-free survival compared to those patients receiving systemic chemotherapy ...