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Peritoneal Cancer

What is peritoneal cancer?

Cancer that has spread to the lining surfaces of the peritoneal (abdominal) cavity from ovarian cancer, primary colorectal cancer, appendiceal cancer, or mesothelioma and pseudomyxoma peritonei—known as peritoneal carcinomatosis—are cancers that are frequently referred to as peritoneal cancers. Whether peritoneal cancer starts in the peritoneum or spreads from somewhere else (colon, appendix, ovary), it is considered advanced (stage IV) once it’s in the peritoneum and might be referred to as peritoneal carcinomatosis.

Who is at risk for peritoneal cancer?

It’s not known exactly what causes peritoneal cancer, though the process begins when a series of mutations in peritoneal cells results in out-of-control growth.  This could be related to a prior cancer that has now spread to the peritoneum or another cancer type known as a primary peritoneal cancer.
What are the symptoms?

Patients in the early stages of the disease will often have few symptoms until the disease is fairly advanced. When symptoms occur, they are often vague and nonspecific, with symptoms of abdominal swelling, diffuse abdominal pain, urinary frequency and a sense of fullness when eating. Other symptoms may include bowel changes (more frequent constipation), abnormal vaginal bleeding, an abdominal mass or unintended weight loss.
As the disease progresses, fluid may build up in the abdomen, causing abdominal discomfort, nausea and vomiting, and shortness of breath. Fatigue is also common.
Complications of peritoneal cancer may include bowel obstructions (sometimes necessitating a stoma, or hole between the intestine and the outside of the body), and urinary tract obstruction (due to blockage of the ureters by tumors), sometimes requiring a stent or nephrostomy tube (a tube from the kidney to the outside of the body).

How is it diagnosed?

Many different tests can be used to diagnose a patient with peritoneal carcinomatosis that started from another organ such as the appendix, colon, stomach, ovaries or cancers that originated in the peritoneum (primary peritoneal or mesothelioma).
Obtaining a history regarding your symptoms is frequently very helpful and this is followed by a physical exam. On physical examination, your surgeon can sometimes feel tumor nodules in the abdomen or fluid (ascites).

Checking your tumor markers, which are blood tests that may be elevated when patients have this type of cancer, can also be helpful.
Imaging studies are helpful in evaluating patients who have symptoms suggestive of peritoneal carcinomatosis. Patients have either a CT scan or MRI of the abdomen and pelvis to confirm the presence of new or recurrent disease in the peritoneum. These imaging studies are done to assess the extent of disease in the abdomen. PET-CT can also be done to determine if disease has spread outside the abdominal cavity, such as the lungs.

Laparoscopy is performed to confirm the diagnosis and determine if a patient is a candidate for cytoreductive surgery and HIPEC. Laparoscopy is a minimally invasive procedure where, through small incisions, samples of tumor (biopsies) are removed and sent to pathology to confirm a diagnosis. Fluid in the abdominal cavity also can be sampled to look for the presence of cancer cells. This procedure is also used to evaluate the extent of disease in the peritoneal cavity and to calculate the peritoneal carcinomatosis index (PCI) which is used to determine if a patient is a candidate for cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (HIPEC). PCI also correlates with a patient’s prognosis.

How is it treated?

Depending on your tumor type, you may be a candidate for surgery to remove all of the tumor, known as cytoreduction, and followed by HIPEC. This technique, which combines surgery with chemotherapy, has revolutionized the treatment of cancers in the abdominal (peritoneal) lining that stem from colon, gastric, ovarian and appendiceal cancers, as well as mesothelioma and pseudomyxoma peritonei. HIPEC is essentially a chemotherapy “bath” that delivers heated chemotherapy directly into the abdominal cavity, where it penetrates the diseased tissue directly. This targeted contact of the heated drug kills the tumor nodules, which increases absorption of the chemotherapy solution. There is substantial clinical evidence that HIPEC is an effective treatment for patients with pseudomyxoma peritonei, mucinous adenocarcinoma of the appendix and peritoneal mesothelioma. Additionally, peritoneal metastases from colon cancer can be successfully treated in a significant number of patients.
There is a possibility that you may require intravenous or oral chemotherapy before or after your surgery based on your specific tumor type. This will be determined by your treatment team.
Additional therapies may also be utilized in the treatment of your specific tumor type. Targeted therapy may be used to treat some advanced primary peritoneal carcinoma. Sometimes a targeted therapy drug is combined with a chemotherapy drug. Hormonal therapy may be given in addition to chemotherapy to treat advanced primary peritoneal carcinoma. Lastly, radiation therapy is sometimes used to treat advanced primary or recurrent peritoneal carcinoma.

When should I call my provider?

You should call your healthcare provider if you have symptoms including unexplained weight loss, anorexia, abdominal pain, bloating, nausea or vomiting, or changes in bowel habits.

Key points about peritoneal cancer
  • Many of the cancers treated with HIPEC are diseases treated by multiple disciplines in medicine and surgery. It is important that a patient discusses HIPEC therapy with their oncologist and surgeon, who can guide their therapy appropriately.
  • HIPEC has several advantages over standard chemotherapy:
    • It is a single treatment done in the operating room, instead of multiple treatments over several weeks.
    • 90% of the drug stays within the abdominal cavity (directly to the cancer area), decreasing toxic effects on the rest of the body.
    • It allows for a more intense dose of chemotherapy.

If surgery is not an option, based on the characteristics of location of the tumors and the impossibility of removing all visible cancer, we will work with you to recommend other options—which may include targeted therapy or immune therapy to personalize your cancer treatment.

HIPEC at Cedars-Sinai

HIPEC is an alternative and innovative method of delivering chemotherapy, which is commonly used to treat many types of cancer, to the body. Unlike traditional chemotherapy that is delivered intravenously, HIPEC delivers chemotherapy directly into the abdomen making it a good option for cancers that originated in or have spread to the abdominal cavity.

How does HIPEC work?

First, your surgeon removes any visible tumors from the abdomen. Next, HIPEC delivers heated chemotherapy directly inside the abdomen to help destroy any remaining cancer cells and very small tumors that cannot be seen by the surgeon. This is because the chemotherapy circulates inside the abdomen, allowing it to reach more places. The goal of HIPEC is to prevent these cells from growing into new tumors and causing the cancer to return.

What are the benefits of HIPEC procedures?

  • HIPEC allows for a higher concentration of chemotherapy to be delivered into the abdomen more effectively and safer than standard chemotherapy, which is delivered intravenously.
  • This type of chemotherapy is best at killing cancer cells that are too small to be seen with the naked eye.
  • Chemotherapy delivered through HIPEC causes fewer side effects than intravenous chemotherapy. This is because the high concentrations of chemotherapy solution are unable to cross what is known as the peritoneal plasma barrier.
  • Experts say that pairing surgery and HIPEC together may be more beneficial than chemotherapy alone.

Am I a candidate for HIPEC?

Typical HIPEC patients are those with certain Stage IV abdominal cancers. Many are seeking an alternative to traditional chemotherapy or radiation therapy, as these options offer limited success treating advanced abdominal cancers. Patients also may have been told that no other treatment will work, but are still hoping to find a solution.