Peritoneal Tumors: Integrated Treatment and Intraperitoneal Chemotherapy. Interview with Dr. Roberto Verzaro

Peritoneal tumor or peritoneal carcinomatosis. How to deal with pathology by combining surgical treatment with hyperthermal intraperitoneal chemotherapy. To explain this type of innovative and multidisciplinary approach is Dr. Roberto Verzaro, oncologist surgeon, coordinator in UPMC Salvator Mundi International Hospital of general surgery.

Dr. Roberto Verzaro, we know that in your professional life you have had the opportunity to gain a lot of experience in the field of surgery and oncology, especially abdominal.

Yes, over the years I have had the opportunity to develop considerable experience in the field of peritoneal tumor surgery, also thanks to the long collaboration with UPMC surgeons, in particular with Dr. Bartlett. The University of Pittsburgh is a world leader in the treatment of abdominal cancers including peritoneal cancers.

In UPMC Salvator Mundi International Hospital you work with patients suffering from peritoneal carcinomatosis, a disease that actually highlights a group of pathologies judged until a few years ago inoperable. Can we say that something has changed today?

Let's start by saying that the spread of the tumor inside the peritoneum – a membrane that covers all the organs contained in the abdomen – is vast and distributed in an almost uniform way and that the surgeon at the time of opening the abdomen is faced with a picture of unresectable disease with radical intent. It should also be added that very often peritoneal cancer is an extension of a neoplastic disease already present in another organ (classic example: ovarian cancer) and therefore to be considered as a metastatic disease. Faced with such a picture, the surgeons were therefore unarmed. It made no sense to remove even up to 90% of the tumor present in the peritoneum and perhaps leave a minimum number of neoplastic cells given the rapid, and often even more aggressive, growth and expansion of residual cancer cells. Recently, with the support of evident data that have emerged in the scientific literature, the oncologist surgeon has modified his strategy in the face of this pathology. It removes the peritoneum in most of its extension, removes all the tumor masses present inside the abdominal cavity and the non-essential abdominal organs (example: some intestinal loops, stomach, spleen) thus obtaining a significant "cytoreduction" of the tumor (reduction in the amount of cancer cells). The task of destroying the residual cancer cells (both microscopic, therefore invisible, and visible but not resectable in size and quantity) is at this point up to an anticancer drug (mitomycin C or cis-platinum for example) that is circulated in the abdomen for a sufficient period of time (between 90 and 120 minutes) conveyed with a liquid heated to 42 – 43 ° C . Hyperthermia and tumor medication act synergistically to kill residual neoplastic cells.

The recent change in the approach to the treatment of peritoneal cancer is, therefore, in following hyperthermic chemotherapy with surgery, is it correct?

Yes, precisely this technique is defined with the acronym HIPEC, from the English Hyperthermic Intra-Peritoneal Chemotherapy or Hyperthermic Intraperitoneal Chemotherapy.

What kind of outcome can be achieved with the HIPEC technique and for what treatment indications?

HipEC ensures excellent results for primary tumors of the peritoneum, incurable before the clinical introduction of this method, good results for metastatic tumors of the ovary or appendix and in other forms of cancer (colon for example) seems to be able to guarantee a non-negligible palliative result.

So, dr. Verzaro, as he previously said, often peritoneal cancer manifests itself as an extension of an ovarian cancer, but can it also be caused by other types of cancer?

The tumors often associated with peritoneal carcinomatosis, in addition to tumors of the ovary, are: primary tumors of the peritoneum (pseudomyxoma peritonei), cancer of the appendix and tumors of the colon.

Do they generally affect men or women more?

Primary tumors of the peritoneum (pseudomyxoma peritonei) are more frequent in women.

How can you recognize, what are the symptoms of peritoneal carcinomatosis?

The symptoms of peritoneal carcinomatosis are very variable and depend on the extent of the disease and the primary tumor. Usually patients are already followed for a tumor in another organ and therefore the symptoms are diagnosed early: they consist of bloating and abdominal distension, ascites, pain and symptoms from intestinal sub-occlusion. In case of primary tumors, the onset may be more subtle and initially may be represented by diarrhea, vague abdominal pain, abdominal distension, loss of appetite and so on. As the disease progresses, ascites manifests itself in all its severity, and the patient resorts to medical care.

What instrumental examination do you consider useful for the diagnosis of peritoneal cancer?

The CT scan of the abdomen is undoubtedly the most useful method for the diagnosis of peritoneal carcinomatosis even if, sometimes, the extent of the disease can be underestimated on CT examination. There is an index (Peritoneal Carcinomatosis Index: PCI) that is associated with the severity of the disease. If it is very high, the chance of achieving good results with surgical treatment associated with intraperitoneal chemotherapy decreases. It can be calculated with the reading of the CT scan or, more accurately, during laparoscopy or exploratory laparotomy for the suspicion of peritoneal carcinomatosis.

We have already talked about the treatment of peritoneal cancer. The integration between several professional figures appears to be fundamental, is it so?

The surgical treatment of peritonectomy, cytoreduction and HIPEC is associated with any oncological therapies in the pre and post operative period. In these patients only a multidisciplinary work, which includes numerous figures including the anesthesiologist, nutritionist, oncologist, psychologist, professional nurse and others, can allow to achieve important goals in the care and support of the patient suffering from peritoneal carcinomatosis. In UPMC Salvator Mundi there are all these professional figures, who work in a team dedicating themselves entirely to the treatment of this pathology.

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