Peritoneal-based Malignancies

Peritoneal based Malignancies - Treatments

An individual with peritoneal based malignancies should be assessed by a multi-disciplinary team of specialists to determine which modality of treatment is best suited for them. All cases seen at SingHealth institutions are reviewed at a weekly multi-disciplinary tumour board, where decisions on treatment are made following discussions, so that care is holistically managed.

In the case of peritoneal based malignancies, not all patients are suitable for surgery. Those who typically are suitable for surgery are:

Patients with tumours that arise from the peritoneum.
Patients who have primary tumours in the ovary, colon and appendix, who have no evidence of distant metastasis.
Patients who are medically fit for surgery and anaesthesia.

Treatment for peritoneal based malignancies includes cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). New treatment in the form of pressurized intraperitoneal aerosolized chemotherapy (PIPAC) has emerged as an option in patients with extensive peritoneal disease that is deemed not suitable for resection.

Cytoreductive surgery (CRS)

CRS aims is to remove all visible tumours in the abdomen. Intra-abdominal organs that have tumours which can be safely removed, will be resected to ensure no disease remains. In addition, surgery to remove the involved peritoneum will be performed.

Hyperthermic intraperitoneal chemotherapy (HIPEC)

Once CRS is completed, HIPEC is administered in the operating room to treat any microscopic tumours that may be present. During this process, the chemotherapy drug is heated and kept at a temperature of 42 degrees Celsius. The heat is used to help increase the penetration of chemotherapy drug into the tissues. The chemotherapy is circulated into the abdominal cavity and then out for a constant flow using a specialised pump that moves the heated chemotherapy solution. This is done over a period of time after which the abdominal cavity is washed and the procedure is completed.

Patients with extensive peritoneal disease that cannot be completely removed may not be suitable for CRS and HIPEC. These patients may be identified pre-operatively after imaging scans or may only be identified during surgery. Disease on the peritoneum may be very small and can be difficult to detect on imaging prior to surgery.

During surgery, the surgeon may decide not to proceed if tumour spread is too extensive or if too much of the bowel has to be removed. In these cases, surgery to remove as many tumours as possible to lessen symptoms, may be an option for some patients.

Pressurized intraperitoneal aerosolized chemotherapy (PIPAC)

PIPAC is another way of introducing chemotherapy into the abdomen for patients with advanced peritoneal based malignancies. It is done with laparoscopy technique under general anaesthesia. No organs are resected during the procedure. Biopsies will be taken prior to infusion of chemotherapy.

This procedure may be repeated multiple times with or without conventional chemotherapy given in between treatment.