En estudios de asignación aleatoria, cuando se compara la cirugía de citorreduccion más quimioterapia hipertér- mica intraperitoneal con la quimioterapia convencional, se ha encontrado una supervivencia de 22,3 meses, en comparación con 12,6 meses, respectivamente 5,18, con una razón de riesgo (HR) de 0,55. En otro estudio se encontró una supervivencia de 81 % (IC95%: 68-90 %) a favor de la quimioterapia hipertérmica intraperitoneal, comparada con la quimioterapia convencional paliativa (65 %) (IC95%: 55-74 %) 14.
Existen muy pocos datos sobre el uso de la escala de gravedad (PSDSS) en estos pacientes. Esta revisión y el flujograma son una primera propuesta de enfoque diagnóstico y terapéutico de los pacientes con carci- nomatosis peritoneal de origen en el colon, teniendo en cuenta que el tratamiento multidisciplinario es el estándar de tratamiento del cáncer y que el compromiso peritoneal a causa del cáncer colorrectal era considera- do en épocas anteriores como una señal inevitable de fracaso terapéutico.
La actual propuesta constituye un planteamiento interesante desde el punto de vista del pronóstico de los pacientes. Sin embargo, es pertinente la realización de futuros estudios que proporcionen información clínica y que permitan validar el flujograma planteado.
Este flujograma propuesto utiliza la información recolectada en otros artículos sobre el pronóstico de los pacientes con carcinomatosis peritoneal, partiendo de la idea y la evidencia clínica diaria de que no todos los casos de carcinomatosis peritoneal tienen similares características y que factores como el estado funcional, el comportamiento biológico (grado, compromiso ganglionar) y el compromiso peritoneal evaluados en el índice de PSDSS, orientan a manejar de una forma individualizada a los que padecen esta compleja enfermedad para optimizar el tratamiento con citorreducción y quimioterapia hipertérmica intraperitoneal, de tal manera que se logre disminuir el riesgo de complicaciones en quienes no se beneficiarían de esta propuesta terapéutica.
A diagnostic and therapeutic proposal in peritoneal carcinomatosis originating in the large bowel
Abstract
Abstract Introduction. Colorectal cancer is the fourth leading cause of cancer worldwide, with an incidence of 17.2 per 100,000 population, and in Colombia the incidence is 10.6 per 100,000, associated with high mortality. Metastatic cancer to the peritoneum is considered a systemic condition, for which only palliative chemotherapy is offered due to the poor prognosis. Cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy is great option for these patients, optimizing their condition and overall survival.
Objective. The aim of this article is to propose a flowchart for the selection of patients with colorectal carcinomatosis using the severity score scale of surface peritioneal disease for the proper administration of intraperitoneal hyperthermic chemotherapy.
Material and methods. We completed a systematic search for articles in the PubMed, EMBASE and COCHRANE data bases with the MESH terms “colorectal cancer”, “peritoneal metastases” and “peritoneal carcinomatosis”, encountering four articles based on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy that assessed the patients characteristics, the treatment received, and the follow-up.
Results and discussion. We propose a flow diagram based on the clinical, imaging and histological characteristics, that allows classifying the severity of the disease, and therefore define those that can benefit from systemic chemotherapy versus hyperthermic intraperitoneal chemotherapy, and thus reduce complications rates and optimize management.
Key words: colonic neoplasms; neoplasm metastasis; peritoneal neoplasms; hyperthermia, induced; mortality.
Bibliografía
1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127:2893-917.
2. Bravo K, Collazos T, García L, Correa P, Collazos P. Trends of cancer incidence and mortality in Cali. Colombia Médica. 2012;43:246-55.
3. Lemmens VE, Laver YL, Verwaal VJ, Rutten HJ, Coebergh JW, de Hingh IH. Predictors and survival of synchronus peritoneal carcinomatosis of colorectal origin: A population-based study. Int J Cancer. 2011;128:2717-25.
4. Jayne DG, Fook S, Loi C, Seow-Choen F. Peritoneal Carcino- matosis from colorectal cáncer. Br J Surg. 2002;89:1545-50.
5. Knorr C, Reingruber B, Meyer T, Hohenberger W, Stremmel C. Peritoneal carcinomatosis of colorectal cancer: Incidence, prognosis, and treatment modalities. Int J Colorectal Dis. 2004;19:181-7.
6. Verwaal VJ, van Ruth S, de Bree E, van Sloothen GW, van Tinteren H, Boot H, et al. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus sys- temic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol. 2003;21:3737-43.
7. Esquivel J, Sticca R, Sugarbaker P, Levine E, Yan TD, Alexander R, et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malig- nancies of colonic origin: A consensus statement. Ann Surg Oncol. 2007;14:128-33.
8. Jacquet P, Jelinek JS, Steves MA, Sugarbaker PH. Evaluation of computed tomography in patients with peritoneal carcinoma- tosis. Cancer. 1993;72:1631-6.
9. Coakley FV, Choi PH, Gougoutas CA, Pothuri B, Venkatraman E, Chi D, et al. Peritoneal metastases: Detection with spiral CT in patients with ovarian cancer. Radiology. 2002;223:495-9.
10. Esquivel J, Chua TC, Stojadinovic A, Melero JT, Levine EA. Accuracy and clinical relevance of computed tomography scan interpretation of peritoneal cancer index in colorectal cancer peritoneal carcinomatosis: A multi-institutional study. J Surg Oncol. 2010;102:565-70.
11. Elias D, Lefevre JH, Chevalier J, Brouquet A, Marchal F, Classe JM, et al. Complete cytoreductive surgery plus intraperitoneal chemo-hyperthermia with oxaliplatin for peritoneal carcinoma- tosis of colorectal origin. J Clin Oncol. 2009;27:681-5.
12. Pelz JO, Chua TC, Esquivel J, Stojadinovic A, Doerfer J, Morris D, et al. Evaluation of best supportive care and systemic chemotherapy as treatment stratified according to the retrospective peritoneal surface disease severity score (PSDSS) for peritoneal carcinomatosis of colorectal origin. Biomed Central Cancer. 2010;10:689.
13. Elias D, Gilly F, Boutitie F, Quenet F, Bereder JM, Mansvelt B, et al. Peritoneal colorectal carcinomatosis treated with surgery and perioperative intraperitoneal chemotherapy: Retrospective analysis of 523 patients from a multicentric French study. J Clin Oncol. 2010;28:63-8.
14. Chua TC, Morris DL, Esquivel J. Influence of modern sys- temic therapies as adjunct to cytoreduction and perioperative intraperitoneal chemotherapy for patients with colorectal peri- toneal carcinomatosis. A multicenter study. Ann Surg Oncol. 2011;18:1560-6711.
15. Cercek A, Saltz L. Factors dictating outcomes in patients with colorectal cancer and peritoneal carcinomatosis: Selection, resection, or convection? J Clin Oncol. 2012;30:226-8.
16. Chua T, Morris D, Esquivel J. Impact of the peritoneal surface disease severity score on survival in patients with colorectal cancer peritoneal carcinomatosis undergoing complete cytore- duction and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2010;17:1330-6.
17. Weber T, Roitman M, Link K. Current status of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis from colorectal cancer. Clin Colorectal Cancer. 2012;11:167-76.
18. Glehen O, Kwiatkowski F, Sugarbaker PH, Elias D, Levine EA, De Simone M, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: A multi- institutional study. J Clin Oncol. 2004;22:3284-92.
19. Pelz J, Stojadinovic A, Nissan A, Hohenberger W, Esquivel J. Evaluation of a peritoneal surface disease severity score in patients with colon cancer with peritoneal carcinomatosis. J Surg Oncol. 2009;99:9-15.
20. Cardoso M, Sarotto L, Todeschini H, Giménez M. Evalu- ación de la carcinomatosis peritoneal de origen colorectal durante una laparotomía o laparoscopia. Rev Argent Resid Cir. 2010;14:56-9.
21. Turaga K, Levine E, Barone R, Sticca R, Petrelli N, Lambert L, et al. Consensus guidelines from the American Society of Peritoneal Surface Malignancies on standardizing the delivery of hyperthermic intraperitoneal chemotherapy (HIPEC) in colorectal cancer patients in the United States. Ann Surg Onco. Fecha de consulta: 21 de junio de 2013. Disponible en: https:// link.springer.com.ezproxy.uniandes.edu.co:8080/content/ pdf/10.1245%2Fs10434-013-3061-z.pdf.
22. Losa F, Barrios P, Salazar R, Torres-Melero J, Benavides M, Massuti T, et al. Cytoreductive surgery and intraperitoneal chemotherapy for treatment of peritoneal carcinomatosis from colorectal origin. Clin Transl Oncol. Fecha de consulta: 6 de junio de 2013. Disponible en: https://link.springer.com.ezproxy. uniandes.edu.co:8080/content/pdf/10.1007%2Fs12094-013- 1053-x.pdf.
23. De Cuba EM, Kwakman R, Knol DL, Bonjer HJ, Meijer GA, Te Velde EA. Cytoreductive surgery and HIPEC for peritoneal metastases combined with curative treatment of colorrectal liver metastases: Systematic review of all literature and meta-analysis of observational studies. Cancer Treat Rev. 2013;39:321-7.
Correspondencia: Mauricio García, MD
Correo electrónico: maurogmora@hotmail.com
Bogotá, D.C., Colombia
