A 32-year old female without any concomitant disordres underwent laparotomy because of intestinal obstruction caused by colon tumor located just below the splenic flexure. The visceral peritoneum of small and large intestine, stomach and mesentery were covered with small sized metastatic tumors - typical peritoneal carcinomatosis. We performed loop ileostomy without excision of primary tumor to solve intestinal obstruction. Intraoperative histopathology (specimen from greater omentum) revealed adenocarcinoma. What would be the best solution for her? Chtx? What type of systemic chtx? Resection followed by Hypec? Would you recommend any center offering experimental protocols?
What you have done is the best that could be done in an emergency setting, however, regarding further mx, I think resection f/b Hypec should be a good option...
I would evaluate patient's overall clinical condition and performance status. If she is fit for a resection and HIPEC I would offer her this option.
Congratulation! You did the best you can do!! Don' t resect the primary in combinatio with some kind of peritonectomy!!!
To answer your qustion: I personally prefer some scheme of chemotherapy without bevacizumab, if later on HIPEC might be an option. So you can use standard chemotgerapy like FolFIri with/without cetuximab ( mutational status of K-RAS and N- RAS hàs to be considered. This should be planned as neoadjuvant treatmen in cases of severe involvment of small bowel. If there are only a few small nodule, you can resect the tumor together with the carinomatosis and perform HIPEC as a singke stage procedure. In Poland there are some centres offering HIPEC, so I think it is preferable to contact the center, whicht is very close to your hospital.
Firstly, very good that you minimized your procedure by just performing an ileostomy and not getting carried away by attempting a resection.
Regarding management: if the peritoneal metastases are as extensive as I surmise based on your description, i.e. the small intestine is completely covered, I am afraid any attempt at cytoreductive surgery and HIPEC will yield a grossly incomplete cytoreduction, which will only increased the morbidity associated with the procedure without adding anything to survival. If, on the other hand, approx 1-1.5 meters of small bowel can be salvaged, cytoreductive surgery + HIPEC should definitely be considered, especially in a patient of this age. Her nutritional status has to be maintained carefully.
If cytoreductive surgery + HIPEC are not an option based on the extent of disease, she may have (limited) benefit from systemic palliative chemotherapy; however, the chances of her disease actually going into partial regression, making cytoreduction + HIPEC a possibility, are virtually non-existent. Most studies show that chemotherapy may decrease the size of peritoneal tumour nodules, but not the extent of their distribution. Another option to consider is performing a palliative omentectomy and bilateral oophorectomy; ovarian metastases develop in a significant proportion of female patients with peritoneal metastases and are unfortunately relatively chemoresistant. The omentum can become a large metastatic mass, leading to obstructive complaints.
I hope this helps and good luck with this unfortunate and young patient.
according to NCCN guideline, colon cancer with peritonal metastasis ,the tumor considered inoperable and there is no place for tumor resection unless for palliative reason .
Thanks a lot for your help. We would just like to do anything and give her any option of treatment so that she could fight.
why not chemotheraphy+ targeted therapy after testing for ALL RAS. with a baseline PETCT for tumour volume.