There is now a substantial body of published evidence of the survival benefits conferred by cytoreductive surgery (peritonectomy) and perioperative intraperitoneal chemotherapy comprising hyperthermic intraperitoneal chemotherapy and early postoperative intraperitoneal chemotherapy for the treatment of peritoneal carcinomatosis. The technique of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is described in the Box. Here, we, the clinicians at the St George Hospital Peritoneal Surface Malignancy Program, who have had more than 12 years of experience in this treatment, provide a review of this topic.

Peritoneal carcinomatosis refers to the dissemination of tumour onto the surfaces of the peritoneum. If left untreated, it is considered a terminal disease with a mean survival time for affected patients of 6 months.1 Over the past decade, the clinical view of peritoneal carcinomatosis has evolved from it being regarded as a terminal and untreatable condition that is palliated with systemic chemotherapy and bypass surgery, to a locoregional disease that is potentially curable in a defined group of patients after aggressive cytoreductive surgery and perioperative intraperitoneal chemotherapy.

Unlike liver resection for colorectal liver metastases, for which there is no randomised clinical trial to justify its use, the current literature provides level I evidence to suggest the routine use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in suitable patients with colorectal cancer peritoneal carcinomatosis. Two randomised controlled trials and a multi-institutional study of 506 patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy have been conducted. The body of these current results, and results from other non-randomised clinical series, as previously summarised,2 have shown a median survival time ranging from 13 to 29 months, and a 5-year survival rate ranging from 11% to 19%. To date, we have treated 60 patients with colorectal peritoneal carcinomatosis at our unit with a median survival time of 33 months and a 3-year survival rate of 38%.3

Pseudomyxoma peritonei or “jelly-belly” is a clinical syndrome characterised by the production and accumulation of mucinous ascites within the peritoneal cavity after the rupture of a mucinous tumour in the appendix. For patients treated in our unit who had favourable findings on histological examination of the tumour (disseminated peritoneal adenomucinosis), the median survival time for 73 patients was 97 months, with a 5-year survival rate of 70%. In patients with unfavourable histological findings (peritoneal mucinous carcinomatosis), the median survival time for 11 patients was 33 months, with a 3-year survival rate of 30%.4 These outcomes are similar to those published for 863 patients, who had median survival times ranging from 51 to 156 months, and a 5-year survival rate ranging from 52% to 96%.5 Long-term survival results, with a 10-year survival rate of 21%, have also been reported in a series of patients treated with debulking surgery.6 However, this treatment is associated with high rates of recurrence.

The incidence of malignant mesothelioma is rising in Australia as a consequence of widespread exposure to asbestos in the 1970s. A third of malignant mesothelioma arises from the peritoneum. A recent systematic review of cytoreductive surgery and perioperative intraperitoneal chemotherapy for malignant peritoneal mesothelioma from seven observational studies reported a median survival time ranging from 34 to 92 months, with a 1-year survival rate of 60%–80% and a 3-year survival rate of 43%–65%.7 In a recent report of 20 consecutive patients from our institution, the overall median survival time was 30 months, with a 3-year survival rate of 46%. In patients who had favourable prognostic features (complete cytoreduction and epithelioid tumour), the median survival time was 87 months, with a 1-year survival rate of 90%.8

The 5-year survival rate of patients with advanced ovarian cancer is less than 25%.9 Intraperitoneal chemotherapy is the standard of care following a Gynecologic Oncology Group (GOG) Phase III trial that compared intravenous chemotherapy with intravenous plus intraperitoneal chemotherapy in Stage III ovarian cancer.10 However, the adoption of this therapy into standard practice has been slow, perhaps because of its poor tolerability.11 A systematic review of 15 studies of 512 patients with primary advanced ovarian cancer and recurrent ovarian cancer reported an overall median survival time of 29–64 months. In patients with an optimal cytoreduction, survival time ranged from 29 to 66 months, with a 3-year survival rate of 35%–63% and a 5-year survival rate of 12%–66%.12 In our unit, we have only treated patients with recurrent ovarian cancer who are not responsive to conventional treatment options. In 12 patients with recurrent ovarian cancer and peritoneal carcinomatosis whom we have treated with cytoreductive surgery and early postoperative intraperitoneal chemotherapy, the median survival was 36 months, with a 3-year survival rate of 39%.

St George Hospital in Sydney is the only high-volume specialist institution offering cytoreductive surgery and hyperthermic intraperitoneal chemotherapy treatment in Australia. Despite the limited number of randomised trials of these therapies, there is strong evidence from Phase II studies of the survival benefits. The unit’s mortality rate has been 3% in the last 210 patients and we have demonstrated a learning curve effect.13 Our treatments are in accordance with the consensus statements from the Peritoneal Surface Oncology Group International.14-16 We emphasise that, in carefully selected patients, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is able to offer the hope of prolonged survival for cancer patients who are diagnosed with what many still regard as a terminal disease.