Peritoneal carcinomatosis is a frequent manifestation of several types of cancer of different origin: gynecological, digestive, extra-abdominal and primary peritoneal. In this article we will learn about the diagnosis, treatment options and prognosis of this disease.
What is peritoneal carcinomatosis?
Peritoneal carcinomatosis or peritoneal metastasis is a stage of advanced cancer that occurs when cancer cells spread throughout the peritoneum, the membrane that lines the abdominal cavity and internal abdominal organs.
Causes and risk factors
The origin of this tumor is usually associated with the spread of tumors of abdominal origin such as stomach, colon, ovary, appendix through the peritoneum, although it can also come from extra-abdominal organs, such as breast cancer, lung cancer, melanoma…. It can also develop as a primary tumor such as peritoneal mesothelioma or primary peritoneal carcinoma.
- Almost 75 percent of patients with ovarian cancer develop peritoneal carcinomatosis.
- Approximately 20-50 percent of patients with advanced gastric cancer develop peritoneal carcinomatosis.
- Peritoneal carcinomatosis occurs in about 10-15 percent of patients with advanced colorectal cancer.
Symptoms and signs
The symptomatology of this tumor is often nonspecific, delaying the diagnosis of the disease. The most common symptoms are:
- Abdominal pain.
- Abdominal distention.
- Digestive problems.
- Lack of appetite and weight loss.
- Fatigue and weakness.
Diagnosis of peritoneal carcinomatosis
Diagnosis of peritoneal carcinomatosis is essential to determine the extent of the disease and to plan appropriate treatment. The main techniques include computed tomography (CT), magnetic resonance imaging (MRI) and laparoscopy, each with its specific advantages and limitations.
Tests and procedures :
- Computed tomography (CT). Computed tomography is an imaging procedure that uses special x-ray equipment to create detailed images, or scans, of internal regions of the body. Its usefulness in determining the extent of carcinomatosis is limited because it is not capable of seeing small implants.
- Magnetic resonance imaging (MRI). Magnetic resonance imaging is a diagnostic imaging technique that provides high resolution, allowing precise differential diagnoses to be made.
- Laparoscopy. Laparoscopy is a minimally invasive technique that facilitates exploration by direct visualization of the implants inside the abdominal cavity and analysis of different conditions in internal organs.
Importance of early diagnosis :
The complexity of the disease and nonspecific symptoms result in diagnosis of the disease at advanced stages. However, early diagnosis of peritoneal carcinomatosis is crucial to improve treatment options and patient prognosis.
Treatment options for peritoneal carcinomatosis
Cytoreduction surgery.
Cytoreduction surgery is a comprehensive surgery to remove as many tumor nodules as possible from the peritoneum. It consists of a combination of peritonectomy techniques (removal of the peritoneum) and other organs to remove all visible disease from the abdomen.
Hyperthermic Intraperitoneal Chemotherapy (HIPEC).
HIPEC consists of the administration of chemotherapy at a temperature between 40-43ºC for a specific time, between 60-120 minutes, at the end of the cytoreduction surgery procedure. The objective is to eliminate microscopic disease and possible tumor cells that may be free in the abdomen after cytoreduction surgery.
Pressurized Intraperitoneal Aerosolized Chemotherapy (PIPAC).
PIPAC is a treatment indicated for patients with cancer with abdominal spread, who are not candidates for treatment with HIPEC and cytoreduction. Applying the chemotherapy converted into an aerosol or spray and with pressure, improves penetration into the tumor nodules, without the chemotherapy passing into the blood (or a minimal amount).
Electrostatic Precipitation Pressurized Intraperitoneal Aerosol Chemotherapy (ePIPAC).
To the aerosolized and pressurized chemotherapy is added the latest ePIPAC technology, which consists of adding electrostatic precipitation to increase the penetration of the chemotherapy into the tumor nodules and improve the distribution of the chemotherapy inside the abdomen.
Other treatments
- Systemic chemotherapy. The standard treatment for peritoneal carcinomatosis is palliative systemic chemotherapy, although it is not free of side effects. The results obtained are limited, due to the existence of the peritoneoplastic barrier, which hinders the passage of chemotherapy to the peritoneal cavity.
- Targeted therapy. This type of treatment targets specific cancer cells that present certain molecular characteristics. Targeted therapy can be used alone or in combination with chemotherapy.
- Immunotherapy. This type of treatment helps the body’s immune system fight cancer. Immunotherapy may be used alone or in combination with other treatments.
- Palliative care. Palliative care is also an important part of treatment for peritoneal carcinomatosis. They can help relieve pain and other symptoms of the disease.
Prognosis and survival
Until 10 years ago, peritoneal cacinomatosis was considered an orphan disease, with limited therapeutic options and poor prognosis. The main reasons are related to diagnosis at an advanced stage and limited clinical response to most conventional therapeutic options, such as systemic chemotherapy. -The use of systemic chemotherapy has shown less efficacy in the peritoneum than in other organs, as it receives only 3% to 6% of the blood flow.
Major surgical innovations over the past two decades, including peritonectomy procedures and multivisceral resections to obtain complete cytoreduction and the application of intraperitoneal chemotherapy to address microscopic residual disease, have significantly improved the prognosis of these diseases. In selected patients, long-term survival and even cure have become possible and the overall prognosis appears to be equivalent to that of patients with metastatic disease in other organs (such as the liver or lungs). In addition to therapies with curative intent, the development of less invasive and better tolerated treatments may also provide symptomatic relief and improved quality of life.
Trials and cohort studies show that the survival of patients with peritoneal metastases of different primary origins treated with a combination of locoregional and systemic therapy has improved compared to historical data for patients who received palliative treatment.
Also, advanced techniques such as PIPAC show very promising results in slowing disease progression, reducing symptoms and prolonging life. Approximately 16% of patients treated with PIPAC have such a significant response that they may be treated with surgery and HIPEC.
Research and clinical trials
IVOQA offers the possibility of participating in clinical trials in which the most novel therapies against cancer are tested, always within national or international trials in collaboration with the most prestigious international institutions in the fight against cancer.
Peritoneal carcinomatosis represents today a healthcare challenge due to its presentation in advanced stages and the complexity of its intervention. Early diagnosis is crucial to improve prognosis and treatment options, which should incorporate specialized surgical techniques such as cytoreduction and HIPEC, as well as innovations in intraperitoneal chemotherapy such as PIPAC and ePIPAC.
IVOQA has become a reference center in the integral and personalized treatment of oncology patients. The Institute offers highly innovative techniques for patients with advanced cancer, such as peritoneal carcinomatosis, which are not available in other cancer units.
References: Cortés-Guiral, D., Hübner, M., Alyami, M. et al. Primary and metastatic malignant neoplasms of the peritoneal surface. Nat Rev Dis Primers 7 , 91 (2021). https://doi.org/10.1038/s41572-021-00326-6. https://doi.org/10.1038/s41572-021-00326-6
