Advanced Cancers - Carcinomatosis - Cytoreductive Surgery + HIPEC
At times a cancer can spread outside of the gastrointestinal tract and seed onto the surface of the abdominal lining (called the peritoneum) leaving several implants of cancer throughout the belly. This type of cancer spread is called Carcinomatosis. This is a form of spread of an advanced cancer.
The most common originating organ sites that can cause this kind of spread are the appendix, the colon, the stomach, the ovaries and the pancreas. There is another entity that originates directly from this abdominal lining (the peritoneum itself) called mesothelioma. Carcinomatosis is treated very differently depending on the originating source.
In most cases, chemotherapy is required. In some rare cases, patients that have carcinomatosis due to mesothelioma, colon cancer or appendix cancer may be candidates for a special surgical procedure called Cytoreductive Surgery and HIPEC (Hyperthermic Intraperitoneal Chemotherapy). This is an extensive surgery where all of the implants and possible other organs are removed to clear the disease and on the same day of surgery, very hot chemotherapy is circulated in the abdomen to kill all of the remaining cells. This is a very specilaized procedure only done in a few centers in Canada.
Not all types of Carcinomatosis are the same and therefore a detailed consultation with your physician/surgeon is very important once the diagnosis has been made.
Dr. Carolyn Nessim actively consults on Carcinomatosis through the Ottawa Hospital Regional Cancer Center.
Frequently asked questions
They cannot seem to find the location of the originating tumor, Now what?
When you are initially diagnosed with carcinomatosis, the first step is to identify the primary tumor that caused it. This is done with blood tests looking for specific tumor markers, a gastroscopy to look in the stomach and a colonoscopy to look in the colon. At times, all of these tests are negative and a clear primary source cannot be identified. This is unfortunately a frequent occurrence where the primary tumor is at times not identifiable. This may because , the primary source was the appendix that has now ruptured or an ovarian tumour that has now ruptured and thus cannot be seen on imaging nor on a colonoscopy. If a primary source cannot be identified by the tests mentioned above than a biopsy is necessary to make a diagnosis to guide treatment.
How is a biopsy performed?
If there is a large enough implant in the abdomen, a CT guided biopsy may be doable to obtain a diagnosis. If not accessible by CT Scan or the biopsy is inconclusive then a Diagnostic Laparoscopy and Assessment and biopsy is the next step.
What is a diagnostic laparoscopy?
This is a short surgical intervention performed under general anesthetic. A camera is placed into the abdomen and with some instruments, biopsies of the implants can be done to obtain a diagnosis. At the same time, the surgeon will evaluate the extent of the disease and calculate a PCI (Peritoneal Carcnimatosis Index) score. This score allows the surgeon to decide if you are a candidate for Cytoreductive Surgery and HIPEC. This will be discussed in detail with you with your surgeon.
What are the criteria to be a candidate for Cytoreductive Surgery + HIPEC?
Being generally healthy with few co-morbidites is important to be able to undergo this procedure. The PCI score mentioned above must be low enough to ensure that ALL of the disease can be removed, leaving no disease behind. The original source must be the appendix, the colon or mesothelioma. If the originating source is the stomach or the pancreas, then you are not a candidate for this surgery, as these cancers do not benefit from this procedure. There should be no evidence of spread to the liver or the lung, ONLY implants on the peritoneum. Limited liver disease may be considered and should be discussed with your surgeon. This is just a general summary. Deciding if a patient is a candidate for this procedure is a complex one and will be discussed in detail with your oncology team.
Do I need other chemotherapy as well?
This depends on the type of tumour that has caused the carcinomatosis type spread, If it is a low grade mucinous tumour of the appendix, then this is very slow growing disease with a good prognosis and cytoreductive surgery and HIPEC alone is required. For these low grade mucinous tumours a surgery can be performed even at a higher PCI score of 25-30. If it is, however, an adenocarcinoma of the appendix or colon this is a more serious diagnosis. PCI score must be less than 15 or so to qualify for cytoreductive surgery and HIPEC. PCI scores higher than 20 do not benefit from this operation. Most patients in this category will undergo 6 months of chemotherapy prior to Cytoreductive Surgery and HIPEC, to determine the biology of the disease, if the disease shrinks or stays stable then you are a candidate. Your care will be managed by a Mulitdisciplinary Team including a Surgical Oncologist and Medical Oncologist specialized in this disease.