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Mucinous adenocarcinoma of the small bowel with peritoneal seeding
EJSO 2002; 28: 19–23 doi:10.1053/ejso.2001.1196, available online at http://www.idealibrary.com on
Mucinous adenocarcinoma of the small bowel with peritoneal seeding P. Marchettini and P. H. Sugarbaker The Washington Cancer Institute, Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010
Aims: Small bowel adenocarcinoma has an extemely poor prognosis because of delayed diagnosis and the presence of advanced disease. Carcinomatosis associated with a small bowel primary cancer has not been reported to be successfully treated in the past. Methods: The clinical information prospectively recorded on six patients with carcinomatosis from small bowel adenocarcinoma was reviewed. All of these patients were treated with an aggressive local–regional strategy that utilized cytoreductive surgery plus peri-operative intraperitoneal mitomycin C and 5-fluorouracil. Results: Disease control in the abdomen and pelvis was achieved in four of these patients. Their median survival was 12 months with one patient alive and well at 4.5 years. Conclusions: Small bowel adenocarcinoma continues to provide a surgical challenge. Complete resection of all visible disease combined with intraperitoneal chemotherapy to eradicate microscopic residual disease should be considered as an option in patients with carcinomatosis. 2002 Harcourt Publishers Ltd Key words: small bowel adenocarcinoma; carcinomatosis; cytoreduction; intraperitoneal chemotherapy.
INTRODUCTION The small bowel is the least common site for adenocarcinoma of the gastrointestinal tract. It accounts for only approximately 1% of all gastrointestinal neoplasms.1–8 This low incidence accounts for a low index of suspicion for this cancer. Also, the lack of uncomplicated endoscopic access to the small bowel may lead to a delay in diagnosis long after initial symptoms have occurred.9,10 Not only is there a delay in diagnosis but also the wall of the small bowel is thin compared to the stomach and colon. These clinical characteristics account for a high incidence of peritoneal seeding at the time of initial treatment of this cancer.1,7,8 Over the past decade, management plans for definitive treatment of peritoneal carcinomatosis from appendiceal malignancy, colon cancer and gastric cancer have been published. No reports regarding success with attempts to eradicate seeding from small bowel adenocarcinoma have been published. This study reports six patients treated for small bowel adenocarcinoma with
Correspondence to: Paul H. Sugarbaker, MD, FACS, FRCS, The Washington Cancer Institute, Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010. Tel: 202-877-3908; Fax: 202-8778602; E-mail: [email protected] 0748–7983/02/010019+05 $35.00/0
carcinomatosis and through a single patient presentation describes in detail the management plan now in use.
CASE REPORT In late 1999 a 51-year-old white male presented with abdominal discomfort and a 7 kg weight loss. Preoperatively, an abdominal ultrasound and abdominal CT revealed a mass thought to be arising from the mesentery. At laparotomy, a 15 cm proximal jejunal mass was found along with omental seeding. The primary tumour mass was resected with the adjacent small bowel. A debulking of the extension of this mass onto the mesentery was performed along with a partial greater omentectomy, an appendectomy and a cholecystectomy. Gross disease on peritoneal surfaces remained. Pathological examination confirmed a mucinous adenocarcinoma of the small bowel with omental spread (T4N0M1, AJCC stage IV). The post-operative course was uneventful. The patient was treated with two cycles of systemic 5-fluorouracil and leucovorin. In January 2000, a follow-up CT scan of the abdomen revealed a recurrent tumour mass in the mesenteric fat of the anterior abdomen (Fig. 1). This was biopsied under CT control and confirmed as a mucinous adenocarcinoma. At re-laparotomy, mucinous tumour nodules were found beneath the old abdominal incision, in the residual greater omentum, in the gallbladder bed 2002 Harcourt Publishers Ltd
20
P. MARCHETTINI AND P. H. SUGARBAKER
Figure 1 Abdominal CT showing a mass in the mesenteric fat of the anterior abdomen.
and in the cul-de-sac of Douglas. Mucinous tumour nodules were layered out in the abdominal adhesions. The mass imaged on CT was an 8-cm diameter tumour involving the mesentery of the jejunum. The surgical procedure included an excision of tumour from the abdominal wall with extensive parietal peritonectomy, a resection of the mesenteric mass, a complete greater omentectomy and lesser omentectomy and a pelvic peritonectomy with rectosigmoidectomy. After the peritoneal cavity was free of all visible evidence of tumour, an attempt to eradicate microscopic residual disease was initiated. The skin edges were tented up on a self-retaining retractor to allow the administration of heated intraperitoneal chemotherapy. Mitomycin C at 12.5 mg/m2 in 3 L of 1.5% dextrose peritoneal dialysis solution at 42°C was perfused for 90 min using a Tenckhoff catheter and four suction drains (Fig. 2). A small bowel and colorectal anastomosis was completed after the intraperitoneal chemotherapy. On post-operative days 1–5, the patient received early postoperative intraperitoneal chemotherapy with 650 mg/ m2 of 5-fluorouracil.11 His post-operative period was unremarkable and he was discharged on his fifteenth post-operative day.15 Pathological examination of the resected specimens showed the presence of a mucinous adenocarcinoma with peritoneal mucinous carcinomatosis (Fig. 3). There was a metastasis in a lymph node adjacent to the mesenteric mass (Fig. 4). The patient remained on oral nutrition and had a performance status of 0. For adjuvant treatment, an intraperitoneal port was inserted for intraperitoneal 5fluorouracil. This was combined with systemic mitomycin C. The patient died 11 months later of pneumonia. Post mortem examination revealed no evidence of small bowel adenocarcinoma. The clinical features and survival of six patients with small bowel adenocarcinoma with carcinomatosis treated at this institution are shown in Table 1. The median
Figure 2 Heated intraoperative intraperitoneal chemotherapy by the Coliseum Technique. This surgical manoeuvre is an attempt to eradicate microscopic residual disease after all evidence of cancerous mass and the surrounding carcinomatosis have been resected. The skin edges are elevated on a self-retaining retractor using a #2 monofilament suture. A warm chemotherapy solution is infused through a single catheter and pumped out through four drains. The surgeon is protected from chemotherapy exposure by a face shield, double elbow length gloves and a plastic sheet over the abdomen that is above a laser smoke evacuator tubing.
survival was 12 months. The Kaplan–Meier survival distribution is shown in Fig. 5. There is one prolonged survivor who has an excellent quality of life. Two of the six had progression of carcinomatosis despite our aggressive local–regional treatments. In four patients these strategies were sufficient to eradicate clinical evidence of carcinomatosis. In our attempt to achieve local control, two of the six patients required repeat cytoreductions.
DISCUSSION The management of patients suffering from primary small bowel malignancies, including adenocarcinoma is poorly defined. These tumours are rare and they are usually diagnosed at an advanced stage. Consequently these neoplasms have a poor prognosis. Peritoneal
CARCINOMATOSIS FROM SMALL BOWEL ADENOCARCINOMA
21
Figure 3 Histologic examination of a tumour nodule on the peritoneal surface of the jejunum showing mucinous adenocarcinoma (haemotoxin and eosin. 50×).
Figure 4 Histologic examination of a lymph node adjacent to the mesenteric mass showing infiltration by mucinous adenocarcinoma (haemotoxin and eosin. 50×).
22
P. MARCHETTINI AND P. H. SUGARBAKER
Table 1 Clinical features and survival of six patients with small bowel adenocarcinoma with carcinomatosis. Survival was measured from the time of cytoreductive surgery with peri-operative intraperitoneal chemotherapy Patient
Age
Sex
Tumour location
Tumour type
Re-operations
Survival
Cause of death
1 2 3 4 5 6
57 40 51 30 42 54
F F M M M M
Terminal Ileum Proximal Jejunum Proximal Jejunum Terminal Ileum Terminal Ileum Jejunum
Intestinal Mucinous Mucinous Mucinous Intestinal Mucinous
None None None One None Two
6 months 12 months 11 months 57 months 57 months 19 months
Systemic disease Systemic disease Pneumonia Progressive carcinomatosis NA Progressive carcinomatosis
1.0
Survival
0.8
0.6
0.4
0.2
0
10
20
30
40
50
60
Time (months)
Figure 5 Survival of six patients with carcinomatosis from perforated small bowel adenocarcinoma who had cytoreductive surgery with peri-operative intraperitoneal chemotherapy. Two of the six patients died of progressive intraabdominal disease. Four of the six were maintained disease free in the abdomen and pelvis as a result of these aggressive local–regional treatments.
carcinomatosis is a frequent manifestation of small bowel adenocarcinoma.1,7,8 In an attempt to improve the management of these patients, an aggressive surgical approach was used. This strategy may cure a small proportion of patients and maximally palliate others if carcinomatosis from a small bowel primary is similar in disease progression to carcinomatosis from colon cancer.12 A complete removal of all visible evidence of disease is the first requirement of a successful intervention. The resection must include the primary tumour and the peritoneal seeding utilizing peritonectomy procedures.13 When a complete cytoreduction can be achieved, a heated intraoperative intraperitoneal chemotherapy with mitomycin C followed by an early post-operative intraperitoneal chemotherapy with 5-fluorouracil should be utilized as a part of this aggressive treatment to eradicate all microscopic disease and induce a response on macroscopic disease.11 Not all patients will benefit from this aggressive approach. The patient must have a high performance
status and a lack of comorbid diseases so that the extensive surgery combined with peri-operative intraperitoneal chemotherapy is tolerated without major morbidity or mortality. There should be no metastases to liver or to systemic sites such as lung or bone marrow. When the abdomen has been opened and the small bowel inspected, a judgment must be made regarding the function of the small bowel post-operatively. If the carcinomatosis is so extensive on small bowel surfaces that enteral nutrition will not return then the aggressive approach is not indicated. Finally, the small bowel primary tumour must be definitively resected; if it is wrapped around vital structure such as the superior mesenteric artery and vein, then the aggressive approach is contraindicated. The prognosis of patients with peritoneal seeding from small bowel adenocarcinoma is not available because of the small number of patients treated to date. However, relevant information can be obtained by analogy from the study of the results of treatment of peritoneal dissemination from other gastrointestinal malignancies. The largest number of patients treated with this aggressive approach had peritoneal carcinomatosis from appendiceal cancer. The data clearly shows that the more complete the cytoreduction, the more effective the longterm control of the disease. In the group of patients with peritoneal seeding from appendiceal cancer, the 5year survival rate was 80% when the residual disease after surgery was microscopic. It was 20% when complete surgical removal was not possible.14 Similar observations were made in the treatment of the peritoneal carcinomatosis from colon and rectal cancer. A recent study showed a 5-year survival of patients with peritoneal carcinomatosis from colon and rectal cancer of 40% when a complete cytoreduction was obtained. It was 0% at 5 years when cytoreduction was incomplete.12 Another study showed that a complete cytoreduction combined with peri-operative intraperitoneal chemotherapy seems to prolong the survival of patients with peritoneal mesothelioma and sarcomatosis.15,16 The literature offers some interesting information that may support our aggressive local–regional treatments in the management of this advanced disease. Recent studies showed that the patients with small bowel
CARCINOMATOSIS FROM SMALL BOWEL ADENOCARCINOMA adenocarcinoma who received potentially curative complete resection had a much longer median survival than those who received an incomplete resection or no resection. Also survival was not affected by the location of the tumour, sex of the patient, race of the patient, grade of the tumour, or the use of adjuvant systemic chemotherapy.3 In the study of North and Pack3 the completeness of resection status was a prognostic factor when considering the primary malignant tumours of the small bowel of other histologic types.
11.
REFERENCES
12.
1. DiSario JA, Burt RW, Vargas H, McWhorter WP. Small bowel cancer: epidemiological and clinical characteristics from a population-based registry. Am J Gastroenterol 1994; 89: 699–701. 2. Cusack JC, Tyler DS. Small bowel malignancies and carcinoid tumors In: Berger DH, Feig BW, Fuhrman GM, eds. The M.D. Anderson Surgical Oncology Handbook. Boston: Little, Brown; 1995: 142–59. 3. North JH, Pack MS. Malignant tumors of the small intestine: a review of 144 cases. American Surgeon 2000; 66: 46–51. 4. Brucher BL, Roder JD, Fink U, Stein HJ, Busch R, Siewert JR. Prognostic factors in resected primary small bowel tumors. Digest Surg 1998; 15: 42–51. 5. Kusumoto H, Takahashi I, Yoshida M, et al. Primary malignant tumors of the small intestine: Analysis of 40 Japanese patients. J Surg Oncol 1992; 50: 139–43. 6. Ojha A, Zacherl J, Scheuba C, Jakesz R, Wenzl E. Primary small
7. 8. 9. 10.
13. 14. 15. 16.
23
bowel malignancies: single-center results of three decades. J Clin Gastroenterol 2000; 30: 289–93. Sinar DR. Small bowel neoplasms (other than carcinoid and lymphoma). In: Sleisinger MH, Fordtran JS, eds. Gastrointestinal diseases, 5th ed. Philadelphia: Saunders, 1993: 1393–401. Gabos S, Berkel J, Band P, Robson D, Whittaker H. Small bowel cancer in Canada. Int J Epidemiol 1993; 22: 198–206. Miles RM, Crawford D, Duras S. The small bowel tumor problem: an assessment based on a 20 year experience with 116 cases. Ann Surg 1979; 189: 732–40. Norberg KA, Emas S. Primary tumors of the small intestine. Am J Surg 1981; 142: 569–73. Sugarbaker PH. Management of peritoneal surface malignancy using intraperitoneal chemotherapy and cytoreductive surgery: Manual for Physicians and Nurses. 3rd ed. Grand Rapids, Michigan: The Ludann Company, 1998. Sugarbaker PH. Successful management of microscopic residual disease in large bowel cancers. Cancer Chemoth Pharmacol 1999; 43 (Suppl): 15–25. Sugarbaker PH. Peritonectomy procedures. Ann Surg 1995; 22: 29–42. Sugarbaker PH, Chang D. Results of treatment of 385 patients with peritoneal surface spread of appendiceal malignancy. Ann Surg Oncol 1999; 6: 727–31. Sebbag G, Yan H, Shmookler BM, Chang D, Sugarbaker PH. Results of treatment of 33 patients with peritoneal mesothelioma. Br J Surg 2000; 87: 1587–93. Berthet B, Sugarbaker TA, Chang D, Sugarbaker PH. Quantitative methodologies for selection of patients with recurrent abdominopelvic sarcoma for treatments. Eur J Cancer 1999; 35: 413–9.
Accepted for publication 8 August 2001
Mucinous adenocarcinoma of the small bowel with peritoneal seeding P. Marchettini and P. H. Sugarbaker The Washington Cancer Institute, Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010
Aims: Small bowel adenocarcinoma has an extemely poor prognosis because of delayed diagnosis and the presence of advanced disease. Carcinomatosis associated with a small bowel primary cancer has not been reported to be successfully treated in the past. Methods: The clinical information prospectively recorded on six patients with carcinomatosis from small bowel adenocarcinoma was reviewed. All of these patients were treated with an aggressive local–regional strategy that utilized cytoreductive surgery plus peri-operative intraperitoneal mitomycin C and 5-fluorouracil. Results: Disease control in the abdomen and pelvis was achieved in four of these patients. Their median survival was 12 months with one patient alive and well at 4.5 years. Conclusions: Small bowel adenocarcinoma continues to provide a surgical challenge. Complete resection of all visible disease combined with intraperitoneal chemotherapy to eradicate microscopic residual disease should be considered as an option in patients with carcinomatosis. 2002 Harcourt Publishers Ltd Key words: small bowel adenocarcinoma; carcinomatosis; cytoreduction; intraperitoneal chemotherapy.
INTRODUCTION The small bowel is the least common site for adenocarcinoma of the gastrointestinal tract. It accounts for only approximately 1% of all gastrointestinal neoplasms.1–8 This low incidence accounts for a low index of suspicion for this cancer. Also, the lack of uncomplicated endoscopic access to the small bowel may lead to a delay in diagnosis long after initial symptoms have occurred.9,10 Not only is there a delay in diagnosis but also the wall of the small bowel is thin compared to the stomach and colon. These clinical characteristics account for a high incidence of peritoneal seeding at the time of initial treatment of this cancer.1,7,8 Over the past decade, management plans for definitive treatment of peritoneal carcinomatosis from appendiceal malignancy, colon cancer and gastric cancer have been published. No reports regarding success with attempts to eradicate seeding from small bowel adenocarcinoma have been published. This study reports six patients treated for small bowel adenocarcinoma with
Correspondence to: Paul H. Sugarbaker, MD, FACS, FRCS, The Washington Cancer Institute, Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010. Tel: 202-877-3908; Fax: 202-8778602; E-mail: [email protected] 0748–7983/02/010019+05 $35.00/0
carcinomatosis and through a single patient presentation describes in detail the management plan now in use.
CASE REPORT In late 1999 a 51-year-old white male presented with abdominal discomfort and a 7 kg weight loss. Preoperatively, an abdominal ultrasound and abdominal CT revealed a mass thought to be arising from the mesentery. At laparotomy, a 15 cm proximal jejunal mass was found along with omental seeding. The primary tumour mass was resected with the adjacent small bowel. A debulking of the extension of this mass onto the mesentery was performed along with a partial greater omentectomy, an appendectomy and a cholecystectomy. Gross disease on peritoneal surfaces remained. Pathological examination confirmed a mucinous adenocarcinoma of the small bowel with omental spread (T4N0M1, AJCC stage IV). The post-operative course was uneventful. The patient was treated with two cycles of systemic 5-fluorouracil and leucovorin. In January 2000, a follow-up CT scan of the abdomen revealed a recurrent tumour mass in the mesenteric fat of the anterior abdomen (Fig. 1). This was biopsied under CT control and confirmed as a mucinous adenocarcinoma. At re-laparotomy, mucinous tumour nodules were found beneath the old abdominal incision, in the residual greater omentum, in the gallbladder bed 2002 Harcourt Publishers Ltd
20
P. MARCHETTINI AND P. H. SUGARBAKER
Figure 1 Abdominal CT showing a mass in the mesenteric fat of the anterior abdomen.
and in the cul-de-sac of Douglas. Mucinous tumour nodules were layered out in the abdominal adhesions. The mass imaged on CT was an 8-cm diameter tumour involving the mesentery of the jejunum. The surgical procedure included an excision of tumour from the abdominal wall with extensive parietal peritonectomy, a resection of the mesenteric mass, a complete greater omentectomy and lesser omentectomy and a pelvic peritonectomy with rectosigmoidectomy. After the peritoneal cavity was free of all visible evidence of tumour, an attempt to eradicate microscopic residual disease was initiated. The skin edges were tented up on a self-retaining retractor to allow the administration of heated intraperitoneal chemotherapy. Mitomycin C at 12.5 mg/m2 in 3 L of 1.5% dextrose peritoneal dialysis solution at 42°C was perfused for 90 min using a Tenckhoff catheter and four suction drains (Fig. 2). A small bowel and colorectal anastomosis was completed after the intraperitoneal chemotherapy. On post-operative days 1–5, the patient received early postoperative intraperitoneal chemotherapy with 650 mg/ m2 of 5-fluorouracil.11 His post-operative period was unremarkable and he was discharged on his fifteenth post-operative day.15 Pathological examination of the resected specimens showed the presence of a mucinous adenocarcinoma with peritoneal mucinous carcinomatosis (Fig. 3). There was a metastasis in a lymph node adjacent to the mesenteric mass (Fig. 4). The patient remained on oral nutrition and had a performance status of 0. For adjuvant treatment, an intraperitoneal port was inserted for intraperitoneal 5fluorouracil. This was combined with systemic mitomycin C. The patient died 11 months later of pneumonia. Post mortem examination revealed no evidence of small bowel adenocarcinoma. The clinical features and survival of six patients with small bowel adenocarcinoma with carcinomatosis treated at this institution are shown in Table 1. The median
Figure 2 Heated intraoperative intraperitoneal chemotherapy by the Coliseum Technique. This surgical manoeuvre is an attempt to eradicate microscopic residual disease after all evidence of cancerous mass and the surrounding carcinomatosis have been resected. The skin edges are elevated on a self-retaining retractor using a #2 monofilament suture. A warm chemotherapy solution is infused through a single catheter and pumped out through four drains. The surgeon is protected from chemotherapy exposure by a face shield, double elbow length gloves and a plastic sheet over the abdomen that is above a laser smoke evacuator tubing.
survival was 12 months. The Kaplan–Meier survival distribution is shown in Fig. 5. There is one prolonged survivor who has an excellent quality of life. Two of the six had progression of carcinomatosis despite our aggressive local–regional treatments. In four patients these strategies were sufficient to eradicate clinical evidence of carcinomatosis. In our attempt to achieve local control, two of the six patients required repeat cytoreductions.
DISCUSSION The management of patients suffering from primary small bowel malignancies, including adenocarcinoma is poorly defined. These tumours are rare and they are usually diagnosed at an advanced stage. Consequently these neoplasms have a poor prognosis. Peritoneal
CARCINOMATOSIS FROM SMALL BOWEL ADENOCARCINOMA
21
Figure 3 Histologic examination of a tumour nodule on the peritoneal surface of the jejunum showing mucinous adenocarcinoma (haemotoxin and eosin. 50×).
Figure 4 Histologic examination of a lymph node adjacent to the mesenteric mass showing infiltration by mucinous adenocarcinoma (haemotoxin and eosin. 50×).
22
P. MARCHETTINI AND P. H. SUGARBAKER
Table 1 Clinical features and survival of six patients with small bowel adenocarcinoma with carcinomatosis. Survival was measured from the time of cytoreductive surgery with peri-operative intraperitoneal chemotherapy Patient
Age
Sex
Tumour location
Tumour type
Re-operations
Survival
Cause of death
1 2 3 4 5 6
57 40 51 30 42 54
F F M M M M
Terminal Ileum Proximal Jejunum Proximal Jejunum Terminal Ileum Terminal Ileum Jejunum
Intestinal Mucinous Mucinous Mucinous Intestinal Mucinous
None None None One None Two
6 months 12 months 11 months 57 months 57 months 19 months
Systemic disease Systemic disease Pneumonia Progressive carcinomatosis NA Progressive carcinomatosis
1.0
Survival
0.8
0.6
0.4
0.2
0
10
20
30
40
50
60
Time (months)
Figure 5 Survival of six patients with carcinomatosis from perforated small bowel adenocarcinoma who had cytoreductive surgery with peri-operative intraperitoneal chemotherapy. Two of the six patients died of progressive intraabdominal disease. Four of the six were maintained disease free in the abdomen and pelvis as a result of these aggressive local–regional treatments.
carcinomatosis is a frequent manifestation of small bowel adenocarcinoma.1,7,8 In an attempt to improve the management of these patients, an aggressive surgical approach was used. This strategy may cure a small proportion of patients and maximally palliate others if carcinomatosis from a small bowel primary is similar in disease progression to carcinomatosis from colon cancer.12 A complete removal of all visible evidence of disease is the first requirement of a successful intervention. The resection must include the primary tumour and the peritoneal seeding utilizing peritonectomy procedures.13 When a complete cytoreduction can be achieved, a heated intraoperative intraperitoneal chemotherapy with mitomycin C followed by an early post-operative intraperitoneal chemotherapy with 5-fluorouracil should be utilized as a part of this aggressive treatment to eradicate all microscopic disease and induce a response on macroscopic disease.11 Not all patients will benefit from this aggressive approach. The patient must have a high performance
status and a lack of comorbid diseases so that the extensive surgery combined with peri-operative intraperitoneal chemotherapy is tolerated without major morbidity or mortality. There should be no metastases to liver or to systemic sites such as lung or bone marrow. When the abdomen has been opened and the small bowel inspected, a judgment must be made regarding the function of the small bowel post-operatively. If the carcinomatosis is so extensive on small bowel surfaces that enteral nutrition will not return then the aggressive approach is not indicated. Finally, the small bowel primary tumour must be definitively resected; if it is wrapped around vital structure such as the superior mesenteric artery and vein, then the aggressive approach is contraindicated. The prognosis of patients with peritoneal seeding from small bowel adenocarcinoma is not available because of the small number of patients treated to date. However, relevant information can be obtained by analogy from the study of the results of treatment of peritoneal dissemination from other gastrointestinal malignancies. The largest number of patients treated with this aggressive approach had peritoneal carcinomatosis from appendiceal cancer. The data clearly shows that the more complete the cytoreduction, the more effective the longterm control of the disease. In the group of patients with peritoneal seeding from appendiceal cancer, the 5year survival rate was 80% when the residual disease after surgery was microscopic. It was 20% when complete surgical removal was not possible.14 Similar observations were made in the treatment of the peritoneal carcinomatosis from colon and rectal cancer. A recent study showed a 5-year survival of patients with peritoneal carcinomatosis from colon and rectal cancer of 40% when a complete cytoreduction was obtained. It was 0% at 5 years when cytoreduction was incomplete.12 Another study showed that a complete cytoreduction combined with peri-operative intraperitoneal chemotherapy seems to prolong the survival of patients with peritoneal mesothelioma and sarcomatosis.15,16 The literature offers some interesting information that may support our aggressive local–regional treatments in the management of this advanced disease. Recent studies showed that the patients with small bowel
CARCINOMATOSIS FROM SMALL BOWEL ADENOCARCINOMA adenocarcinoma who received potentially curative complete resection had a much longer median survival than those who received an incomplete resection or no resection. Also survival was not affected by the location of the tumour, sex of the patient, race of the patient, grade of the tumour, or the use of adjuvant systemic chemotherapy.3 In the study of North and Pack3 the completeness of resection status was a prognostic factor when considering the primary malignant tumours of the small bowel of other histologic types.
11.
REFERENCES
12.
1. DiSario JA, Burt RW, Vargas H, McWhorter WP. Small bowel cancer: epidemiological and clinical characteristics from a population-based registry. Am J Gastroenterol 1994; 89: 699–701. 2. Cusack JC, Tyler DS. Small bowel malignancies and carcinoid tumors In: Berger DH, Feig BW, Fuhrman GM, eds. The M.D. Anderson Surgical Oncology Handbook. Boston: Little, Brown; 1995: 142–59. 3. North JH, Pack MS. Malignant tumors of the small intestine: a review of 144 cases. American Surgeon 2000; 66: 46–51. 4. Brucher BL, Roder JD, Fink U, Stein HJ, Busch R, Siewert JR. Prognostic factors in resected primary small bowel tumors. Digest Surg 1998; 15: 42–51. 5. Kusumoto H, Takahashi I, Yoshida M, et al. Primary malignant tumors of the small intestine: Analysis of 40 Japanese patients. J Surg Oncol 1992; 50: 139–43. 6. Ojha A, Zacherl J, Scheuba C, Jakesz R, Wenzl E. Primary small
7. 8. 9. 10.
13. 14. 15. 16.
23
bowel malignancies: single-center results of three decades. J Clin Gastroenterol 2000; 30: 289–93. Sinar DR. Small bowel neoplasms (other than carcinoid and lymphoma). In: Sleisinger MH, Fordtran JS, eds. Gastrointestinal diseases, 5th ed. Philadelphia: Saunders, 1993: 1393–401. Gabos S, Berkel J, Band P, Robson D, Whittaker H. Small bowel cancer in Canada. Int J Epidemiol 1993; 22: 198–206. Miles RM, Crawford D, Duras S. The small bowel tumor problem: an assessment based on a 20 year experience with 116 cases. Ann Surg 1979; 189: 732–40. Norberg KA, Emas S. Primary tumors of the small intestine. Am J Surg 1981; 142: 569–73. Sugarbaker PH. Management of peritoneal surface malignancy using intraperitoneal chemotherapy and cytoreductive surgery: Manual for Physicians and Nurses. 3rd ed. Grand Rapids, Michigan: The Ludann Company, 1998. Sugarbaker PH. Successful management of microscopic residual disease in large bowel cancers. Cancer Chemoth Pharmacol 1999; 43 (Suppl): 15–25. Sugarbaker PH. Peritonectomy procedures. Ann Surg 1995; 22: 29–42. Sugarbaker PH, Chang D. Results of treatment of 385 patients with peritoneal surface spread of appendiceal malignancy. Ann Surg Oncol 1999; 6: 727–31. Sebbag G, Yan H, Shmookler BM, Chang D, Sugarbaker PH. Results of treatment of 33 patients with peritoneal mesothelioma. Br J Surg 2000; 87: 1587–93. Berthet B, Sugarbaker TA, Chang D, Sugarbaker PH. Quantitative methodologies for selection of patients with recurrent abdominopelvic sarcoma for treatments. Eur J Cancer 1999; 35: 413–9.
Accepted for publication 8 August 2001