Peritoneal Cancer Treatment & Management

Updated: Dec 22, 2019
  • Author: Wissam Bleibel, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Treatment

Medical Care

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.

Dr. Oliver Zivanovic, MD, PhD, discusses the role of hyperthermic intraperitoneal chemotherapy in ovarian cancer. Courtesy of Memorial Sloan-Kettering Cancer Center.
Dr. Oliver Zivanovic, MD, PhD, demonstrates hyperthermic intraperitoneal chemotherapy for ovarian cancer. Courtesy of Memorial Sloan-Kettering Cancer Center.

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 from 4 to 12 months, the application of multimodality therapy has shown promising results with increased survival approaching 60 months. [18]

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.

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.

In November 2014, the FDA approved bevacizumab (Avastin) for platinum-resistant, recurrent, epithelial ovarian cancer in patients who received no more than two prior chemotherapy regimens. It is indicated for use in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan. [19] In December 2016, bevacizumab’s indication was expanded to include treatment of platinum-sensitive recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer, in combination with carboplatin and either paclitaxel or gemcitabine, followed by bevacizumab alone. [20, 21]

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 the addition of a third agent (etoposide or gemcitabine) providing possible benefit. Supportive measures should be considered in patients with poor performance status.

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Surgical Care

Treatment of primary peritoneal carcinoma consists of total abdominal hysterectomy and bilateral salpingo-oophorectomy as needed, with debulking of tumor and follow-up chemotherapy. 

Cytoreductive surgery (CRS) is the removal of macroscopic peritoneal tumors. It may involve multiple peritonectomy and visceral resection procedures. Electrosurgery is used to limit bleeding from the vascular peritoneal surface. [10]

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. [22]

Benign cystic mesothelioma tends to recur even with aggressive surgical removal; however, among recorded cases, no deaths have been attributable to this disorder.

In 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. [23]

Treatment of peritoneal and GI hemangiomas has involved surgical removal.

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Long-Term Monitoring

Follow up to evaluate patients for complications of the cancer, spread of the cancer, and possible complications of therapy. Screening for known associated cancers and cancer syndromes is essential.

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