Cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal carcinomatosis: if at first you don't succeed....

The management and outcomes of stage IV colorectal cancer have changed significantly over the past 5–10 years. The advent of relatively effective, multimodality regimens of 5-fluorouracil and leucovorin combined with cytotoxic agents (e.g., oxaliplatin or irinotecan) and targeted therapies (e.g., bevacizumab or cetuximab) has resulted in unprecedented rates of both tumor response and patient survival. Simultaneously the indications for surgery in the management of hepatic and pulmonary metastases from colorectal cancer continue to expand. However, for patients with carcinomatosis from colorectal cancer, the view remains generally nihilistic for a number of reasons. First, the historical life expectancy of patients with colorectal carcinomatosis was a dismal 6–7 months. Second, surgery has traditionally not been shown to play any significant role other than selective palliation. Third, despite the overall results of the more efficacious chemotherapy regimens, the actual benefit to patients with carcinomatosis has yet to be determined. Consequently, while evidence-based guidelines recommending neoadjuvant chemotherapy followed by surgery for the management of patients with hepatic and pulmonary metastases are readily available, there are no management guidelines for patients with carcinomatosis. Despite this daunting backdrop, significant efforts are being made to improve the outcome of patients with carcinomatosis. One such effort is the use of a combined treatment approach involving cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC). Currently, this approach is gaining recognition as a treatment option for a variety of peritoneal surface-based malignancies. Significant improvements in disease-free and overall survival from CRS and PIC have been demonstrated in patients with peritoneal dissemination of appendiceal and ovarian cancers and diffuse malignant peritoneal mesothelioma. In fact, CRS and PIC are considered by many to be the standard of care for select patients with peritoneal-based disease from these malignancies. CRS and PIC have also been used in the treatment of carcinomatosis from colorectal cancer with some centers publishing 5-year survival rates of 30% or higher. For such a historically hopeless clinical situation, these results seem almost miraculous. Consequently, and despite a paucity of high-level evidence, a consensus statement has been published advocating the use of CRS and PIC in select colorectal patients with carcinomatosis. In ‘‘Failure Analysis of Recurrent Disease Following Complete Cytoreduction and Perioperative Intraperitoneal Chemotherapy in Patients with Peritoneal Carcinomatosis from Colorectal Cancer,’’ Bijelic et al. 15 are the first to analyze the anatomic distribution, timing, and outcomes of recurrent peritoneal disease after complete cytoreduction and PIC for peritoneal carcinomatosis from colorectal cancer. The data are derived from a single-institution experience, spanning Received July 10, 2007; accepted July 11, 2007; published online: August 29, 2007. Address correspondence and reprint requests to: Paul F. Mansfield, MD; E-mail: ansmith@mdanderson.org