Peritoneal Cancer Treatment & Management
- Author: Wissam Bleibel, MD; Chief Editor: N Joseph Espat, MD, MS, FACS more...
Multimodality therapy is currently the most commonly accepted therapeutic approach to peritoneal mesothelioma. This includes using the combination of surgical cytoreduction, intraperitoneal perioperative chemotherapy, and hyperthermia. Intraperitoneal chemotherapy greatly enhances drug concentrations in the peritoneal cavity and decreases its systemic toxicity. See the videos below.
In addition to the intraoperative use of heated chemotherapeutic drugs such as cisplatin, mitomycin, or doxorubicin, newer techniques include adding immunotherapeutic agents such as interleukins and interferons. While the median survival with traditional therapeutic options ranges between 4 and 12 months, the application of multimodality therapy has shown promising results with increased survival approaching 60 months.
For patients with unresectable or recurrent malignant mesothelioma, palliative systemic chemotherapy (with different regimens such as cisplatin plus pemetrexed) should be considered. Other antineoplastic agents that may be used include cisplatin plus paclitaxel or mitomycin, doxorubicin, and irinotecan. Furthermore, intraperitoneal instillation of radioactive colloidal gold (Au 198) has been reported to improve symptoms of peritoneal mesothelioma.
Primary peritoneal carcinoma is treated similarly to ovarian cancer, with cytoreduction and chemotherapy. Multimodality treatment consisting of tumor debulking followed by chemotherapy regimens based on 5-fluorouracil, doxorubicin, or cisplatin has been shown to have high response rate and improvement of median survival. Furthermore, the use of newer antineoplastic agents such as taxanes, topoisomerase I inhibitors, gemcitabine, and vinorelbine, alone or in combinations (eg, gemcitabine/cisplatin, irinotecan/cisplatin, docetaxel/gemcitabine, gemcitabine/carboplatin) has increased median survival to 8-11 months. In addition to the use of chemotherapeutic agents, recent studies have shown some benefit of antiangiogenic drugs such as bevacizumab and erlotinib.
It is generally accepted that all patients with good performance status should be considered for a trial of empiric chemotherapy, preferably with a regimen containing newer drugs. The combination of paclitaxel and carboplatin is a reasonable first-line therapy with possible benefit from adding a third agent (etoposide or gemcitabine). Supportive measures should be considered in patients with poor performance status.
See the list below:
Treatment of primary peritoneal carcinoma consists of total abdominal hysterectomy and bilateral salpingo-oophorectomy as needed, with debulking of tumor and follow-up chemotherapy.
Treatment of malignant peritoneal mesothelioma consists primarily of surgical palliation. Complete surgical resection is rarely, if ever, feasible and has not been shown to afford a survival benefit in the absence of additional therapy. If laparoscopy is used to help make the initial diagnosis, confine port sites to the abdominal midline because port site recurrence has been described, requiring extensive abdominal wall resection. 
Benign cystic mesothelioma tends to recur even with aggressive surgical removal; however, among recorded cases, no deaths have been attributable to this disorder.
Iin patients with desmoplastic small cell tumors, the combination of aggressive surgical debulking and systemic chemotherapy with cyclophosphamide, doxorubicin, and vincristine interspersed with ifosfamide, etoposide, and mesna (P6 protocol) appears to lead to an improved outcome. However, surgical excision is recommended only for nonmetastatic disease. 
Treatment of peritoneal and GI hemangiomas has involved surgical removal.
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