III Convegno Congiunto delle SocietàLombarda e Triveneta di Chirurgia

La carcinosi peritoneale da ca colorettale.Storia naturale, scenari clinici ed impatto prognostico

D.Foschi

Dipartimento di Scienze Cliniche L.SaccoUniversità di Milano

Desenzano 12 maggio 2012

Pathogenesis of peritoneal minimal residual disease

WP Ceelen, 2009

D

K.L. Sodek, 2012

Disease progression and metastatic spread

Author N. Patients P.C.

Russell (1984) 94 5 %Minsky (1988) 294 4 %Jayne (2002) 2756 7.7 %Lemmens (2010)* 18.738 4.8 %Mulsow (2011) 3138 4.8 %

Incidence of synchronous peritoneal carcinomatosis

W.E. Lemmens, Int J Cancer, 2011

Synchronous Peritoneal Carcinomatosis and Colorectal cancer

Anni 1995-2008

4.8%

43.6% 56.4%

W.E. Lemmens, Int J Cancer, 2011

General characteristics of patients with synchronous P.C.

0.1%

0.3%

21%

3.4%

Risk of P.C. : Multivariable logistic regression

W.E. Lemmens, Int J Cancer, 2011

Meta-analysis of overall and local recurrence for – vs + preresection PFCC

Rekhraj S,2008

Meta-analysis of overall and local recurrence for – vs + postresection PFCC

Rekhraj S,2008

PROGNOSTIC FACTORS FOR SURVIVAL IN P.C. FROM C.R.C.

Median (mos) Mean (mos) P value

Synchronous P.C. 4.1 6.0 P = 0.78

Not synchronous P.C. 5.3 6.2 NS

Initial pTNM staging

T1,T2 (n = 4) 7.3 9.3 T3 (n = 76) 5.3 7.2 P = 0.5 T4 (n = 38) 3.4 4.7 NS

Lymph node involvement

N0 8.7 10.2 P = 0.13 N+ 7 6.8 NSPC staging Stage I 12.5 14.3 Stage II 8.3 8.4 Stage III 4.4 6.0 P = 0.001 Stage IV 2.7 4.4Differentiation WD and MD 3.2 5.3 P = 0.9 PD and UD 5.5 5.3 NSAscites Yes 3.7 5.1 P = 0.6 No 5.1 6.5 NSLiver metastases Yes 4.4 6.1 P = 0.4 No 5.9 6.1 NS

B.Sadeghi, 2000 Cancer

Prognostic factors in metachronous ascites

DZJ Chu, Cancer, 1989

M:6 mnt

Crude survival of synchronous peritoneal carcinomatosis

V.E. Lemmens,2010

Incidence of metachronous peritoneal carcinomatosis

Author year N.Patients Met.P.C.

Cass 1976 280 28%Malcom 1981 285 13%Mendenhall 1983 140 12%Gilbert 1984 31 3%Tong 1984 64 44%Gunderson 1985 91 21%Jayne 2002 2756 4.8%________________________________________________Gilbert(autopsy ser.) 1984 45 40%Russell (autopsy ser.) 1985 53 36%________________________________________________Mulsow (CRC-PC) 2011 31 74%Matsuda (CRC-PC) 2012 31 77%

Logistic regression analysis for metachronous peritoneal carcinomatosis

Odds ratio P

Clinical

Liver metastasis 2.84 (1.7 – 4.6) <0.001

Histological

Tumor stage 2.74(1.6-4.5) <0.001Nodal stage 2.47(1.6-3.8) <0.001Venous invasion 2.07(1.1-2.3) <0.012Perineural invasion 1.57(1-2.3) <0.032

Jayne DG, 2002

Risk factors for metachronous P.C.

pT4Positive peritoneal cytologyPeritoneal seedingOvarian InvolvementPerforation of the tumorRupture of a necrotic tumor massIntraoperative tumor spill

Risk factors for metachronous P.C.

N.Patients Synchronous P.C. Ovarian Metastase Perforated tumorTot n:41 n:25 n: 8 n:8

% + P.C. 15(60%) 5 (62%) 3 (37%)

PCI 9±6 7±5 5±2

D. Elias, 2011

Risk of local recurrence after inadvertent rectal perforation

M.T. Eriksen, 2004

Synchronous colorectal PCN:153

Complete resectionN:31

Non complete resectionN:122

All recurrencesN:24 (77%)

1° site of recurrence

Intra-peritoneal aloneN. 8 (25.8%)

P.C. – extraperitonealN:1 (3.2%)

Extra-peritoneal aloneN:15 (48.4%)

Matsuda, 2012

Risk of metachronous carcinomatosis after CRC-PC resection

ROSMIF

TNF-αIL-1, -6, -8, -10

TGF-αbFGFTGF-β

Pathophysiology of ascites accumulation

K.L. Sodek, 2012

SurvivaL of P.C. after standard treatment or CRS-HIPEC