Intraperitoneal chemotherapy for prevention and treatment of peritoneal carcinomatosis from colorectal origin

SUMMARY The peritoneal surface remains an important failure site for patients with colorectal cancer. Peritoneal metastases of colorectal cancer are at present considered equal to distant metastatic disease. Consequently, peritoneal carcinomatosis is treated with systemic chemotherapy and surgery only to palliate complications such as obstruction. Despite the development of new chemotherapeutic agents and combinations, the results remain disappointing with a limited impact on survival. Colorectal carcinoma cells are relatively resistant to chemotherapy. Intraperitoneal chemotherapy seems to be an attractive approach in the treatment of highrisk colorectal cancer and peritoneal carcinomatosis of colorectal origin providing high local drug concentration with limited systemic side effects. Adjuvant early postoperative intraperitoneal chemotherapy is worthwhile considering as a treatment option after resection of high-risk colorectal cancer. Meta-analysis of randomized trials demonstrates a positive impact of this adjuvant treatment on overall survival and regional tumor control. In the treatment of peritoneal carcinomatosis postoperative intraperitoneal chemotherapy leads to inadequate exposure of the peritoneal surface. Only intraoperative continuous peritoneal perfusion chemotherapy performed with direct cytotoxic drugs such as MMC and cisplatin may overcome this problem. The limited limited drug penetration in tissue implies the need for extensive cytoreductive surgery. Additionally, the latter form of regional chemotherapy can be performed under hyperthermic conditions. Hyperthermia has a direct cytotoxic effect and enhances the activity and penetration depth of many cytotoxic drugs. The results of phase II studies of cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal origin suggest that an increased median survival can be achieved with this approach, especially in patients with no macroscopic or small volume residual disease.