In Reply: Pseudomyxoma Peritonei: Debulk or Maximal Cytoreduction?
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Transcript of In Reply: Pseudomyxoma Peritonei: Debulk or Maximal Cytoreduction?
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LETTER TO THE EDITOR
In Reply: PseudomyxomaPeritonei: Debulk orMaximal Cytoreduction?
TO THE EDITORS:
Thank you for asking us to respond to Dr. Pocard and
colleagues’ comments on the adoption of a two-step proce-
dure for pseudomyxoma peritonei. This was made in
response to our study published in the Annals of Surgical
Oncology.1 Our study critically evaluated the perioperative
outcomes of 145 patients with pseudomyxoma peritonei who
were treated with cytoreductive surgery and perioperative
intraperitoneal chemotherapy. Many patients presented with
advanced disease (mean PCI = 20) and underwent a lengthy
surgical procedure (mean duration = 10 h). The mortality
rate in this group of patients was 3%, and the grade III/IV
morbidity rate was 45%. Two independent predictors of a
poor perioperative outcome were identified: ASA score C 3
and operation length C 10 h. As stated by Pocard and col-
leagues, these data are concordant with French data as well as
other centers offering this treatment modality. In the French
multicentric study conducted by the Association Francaise
de Chirurgie of 301 patients with pseudomyxoma peritonei
undergoing cytoreductive surgery and intraperitoneal che-
motherapy, Elias et al. reported a mortality rate of 4.4% and
severe morbidity rate of 40%.2
In light of the strong association between ASA status
and duration of operation with poor perioperative outcome,
Pocard and colleagues have suggested that because ASA
status may not be reduced other than by altering nutritional
status, a rather novel strategy to reduce operation length to
improve perioperative outcome should be adopted. This
strategy adopts the principles of ‘‘damage control surgery,’’
which is restricted to emergency cases. Firstly, we are
pleased to report that in patients who are manifesting
symptoms of a bowel obstruction secondary to peritoneal
carcinomatosis, we do electively admit these patients for
in-hospital total parenteral nutrition feeding preoperatively
to manage bowel obstruction. Secondly, damage control
surgery, a principle of trauma surgery, when applied for
abdominal trauma is performed by surgical repair of major
visceral tears followed by intensive unit care. Once the
patient is stable, a second operation is then undertaken to
repair any remaining smaller tears. The advantage of this
approach serves to provide a second-look operation,
allowing a more extensive surgery to be undertaken when
the patient is more stable for which there is less likelihood
of an adverse outcome. There is no evidence to support the
efficacy of this approach in abdominal trauma as reported in
a Cochrane review.3 In the context of a malignant disease
such as pseudomyxoma peritonei, we have not adopted the
strategy of performing debulking surgical procedures such
as omentectomy, subtotal colonic resection, and ileocolonic
anastomosis or ileostomy unless the patient is not fit for a
surgical cytoreduction. It has been reported that two-stage
procedures may result in disease progression that make it
impossible to perform a complete cytoreduction.4 Debul-
king surgery and the associated negative outcomes in
pseudomyxoma peritonei is well established for the fol-
lowing reasons: alteration of the surgical planes for a
complete peritonectomy, adhesions that develop require
additional time for adhesiolysis in the second operation and
form a bed for tumor cell entrapment, incomplete cytore-
duction has been well regarded as a negative prognostic
factor for survival, and harboring residual disease is a risk
factor for developing malignant transformation of the
mucinous neoplasm from low to high grade.5 For these
reasons, we have advocated that general surgeons who
encounter an unexpected appendiceal malignancy at the
time of appendectomy should at most perform an appen-
dectomy, partial caecetomy, or right hemicolectomy
without undertaking any tumor debulking surgery to limit
the amount of surgical dissection performed. Murphy et al.
from the Basingstoke peritonectomy unit have proposed an
algorithm for which large appendiceal tumors [2 cm
should be treated by right hemicolectomy.6 If the tumor is
\2 cm, and the base of the appendix and mesoappendix is
clear, only appendectomy should be performed. If there is
evidence of mucinous ascites, appendectomy or, if not
possible, tissue biopsy alone should be sufficient prior to
referral to a specialist center for diagnostic workup. We
believe this management algorithm is appropriate. The
majority of the patients we treat have undergone tumor
debulking surgery, which may explain the morbid results.
However, in recent years, surgeons have became aware of
the biology of this unique disease for which a favorable
outcome may be achieved through cytoreductive surgery
and hyperthermic intraperitoneal chemotherapy; prudent
recognition of the manifestation of this disease by surgeons
in our country has led to early referral of patients. From our
peritonectomy database, we have undertaken retrospective
Ann Surg Oncol (2011) 18:284–285
DOI 10.1245/s10434-010-1194-x
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chart reviews to compare upfront cytoreduction compared
with delayed cytoreduction and to study the critical time
points of pseudomyxoma peritonei surgery. These manu-
scripts are being prepared for publication.
We appreciate the Hippocratic Oath, Primum non n
ocere (First, do no harm), and the strategy propose by
Dr. Pocard. Clearly a randomized trial of tumor debulking
versus complete cytoreductive surgery and hyperthermic
intraperitoneal chemotherapy according to an intention to
treat analysis to evaluate progression-free survival would
be an attractive study. However, the knowledge of the poor
outcome from debulking surgery makes it difficult for a
peritonectomy surgeon to commit to such a randomization.
At the current time, our experience has informed us that the
best possible outcome for patients with pseudomyxoma
peritonei is to undergo a complete cytoreduction and
hyperthermic intraperitoneal chemotherapy to achieve the
longest possible survival that is achievable despite under-
going an operation with a significant risk of developing a
severe postoperative complication compared with suffering
the consequence of ongoing subacute bowel obstruction
and ascites from the manifestations of peritoneal carcino-
matosis and its debilitating symptoms. Further, this
treatment is no longer regarded as experimental therapy.
Akshat Saxena, BMedSc, Terence C. Chua, BSc (Med)
(Hons), MBBS, and David L. Morris, MD, PhD
Department of Surgery, Hepatobiliary and Surgical
Oncology Unit, University of New South Wales, St George
Hospital, Sydney, Australia
e-mail: [email protected]
Published Online: 7 July 2010
� Society of Surgical Oncology 2010
REFERENCES
1. Saxena A, Yan TD, Chua TC, Morris DL. Critical assessment of
risk factors for complications after cytoreductive surgery and
perioperative intraperitoneal chemotherapy for pseudomyxoma
peritonei. Ann Surg Oncol. 2010;17:1291–301.
2. Elias D, Gilly F, Quenet F, Bereder JM, Sideris L, Mansvelt B,
et al. Pseudomyxoma peritonei: A French multicentric study of
301 patients treated with cytoreductive surgery and intraperitoneal
chemotherapy. Eur J Surg Oncol. 2010;36:456–62.
3. Cirocchi R, Abraha I, Montedori A, Farinella E, Bonacini I,
Tagliabue L, et al. Damage control surgery for abdominal trauma.
Cochrane Database Syst Rev. 2010;1 (CD007438).
4. De Simone M, Scuderi S, Vaira M, Costamagna D, Barone R,
Fiorentini G, et al. Treatment of pseudomyxoma peritonei with
two times—cytoreduction and hyperthermic antiblastic peritoneal
perfusion (HAPP). J Exp Clin Cancer Res. 2003;22:25–8.
5. Jarvinen P, Jarvinen HJ, Lepisto A. Survival of patients with
pseudomyxoma peritonei treated by serial debulking. ColorectalDis. 2009. doi:10.1111/j.1463-1318.2009.01947.x.
6. Murphy EMA, Farquharson SM, Moran BJ. Management of an
unexpected appendiceal neoplasm. Br J Surg. 2006;93:783–92.
Pseudomyxoma Peritonei: Debulk or Maximal Cytoreduction? 285