Surgery as adjuvant therapy? The treatment of peritoneal metastases from gastrointestinal malignancy.

The authors review the outcome of 64 patients treated with surgical debulking and intraperitoneal chemotherapy (FUDR and Leucovorin). The median survival of the group was 34 months and the 5-year survival rate was 28%. There were no treatment-related mortalities and morbidity was generally minor. Complete gross resection of peritoneal metastases was the only factor associated with long-term survival. Pestieau and Sugarbaker2 recently reported remarkably similar findings in a cohort of 104 patients with colorectal carcinoma treated with cytoreductive surgery, intraperitoneal hyperthermic chemotherapy, and early postoperative intraperitoneal 5-FU. Using a different intraperitoneal chemotherapy regimen, Pestieau and Sugarbaker’s group also found that the ability to achieve complete cytoreduction was the most significant predictor of outcome. Although Culliford et al. have demonstrated that longterm survival is achievable for some patients with peritoneal metastases from colon carcinoma, the retrospective nature of the study makes any conclusions about the impact of therapy risky. It is certainly conceivable, perhaps even likely, that favorable tumor biology may have played a larger role in the outcome of this cohort than did the therapy itself. The patient cohort represents those treated at Memorial Sloan-Kettering Cancer Center over a 12-year period. One would assume they represent far less than 1% of patients with colon carcinoma treated at Memorial during that period, though the denominator is not specified. To their credit, the authors readily acknowledge the probable impact of biology and patient selection on their results. The similar findings of the Pestieau and Sugarbaker group argue that biology and perhaps surgical cytoreduction are more important than the specific peritoneal chemotherapy regimen. It is unfortunate that the authors have not provided any information as to the selection criteria that were used to place patients on this treatment regimen. Were there exclusion criteria such as history of prior bowel obstruction, perforated malignancy, etc.? What performance status was considered acceptable for these patients? Although the authors provide numerical data on recurrence and survival, no specifics of the patterns of failure are provided. This would at least provide a measure of the effectiveness of this treatment regimen in achieving “local” disease control in the peritoneum. The limitations of the current study are common to most retrospective analyses. The importance of the paper lies in the paradigm it presents: that of using surgery as adjuvant to what has been considered the more “standard treatment” of peritoneal metastases, chemotherapy. As the authors point out, surgical debulking or cytoreduction of peritoneal metastases has been successfully applied in the management of ovarian carcinoma. Ovarian carcinoma differs from most other gastrointestinal malignancies in two significant ways, however. The pattern of metastasis is largely limited to the peritoneum and most importantly, response rates to cytotoxic chemotherapy Received August 22, 2001; accepted September 4, 2001. From the Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio. Address correspondence to: Andrew M. Lowy, MD, The Barrett Cancer Center, University of Cincinnati Medical Center, 234 Goodman Street, Cincinnati, OH 45219-0772; Fax: 513-584-0459; E-mail: lowyam@healthall.com. Annals of Surgical Oncology, 8(10):754–755 Published by Lippincott Williams & Wilkins © 2001 The Society of Surgical Oncology, Inc.