Preoperative patient selection plays a pivotal role for the success of CRS and HIPEC regarding clinical as well as oncological patient outcome. Thus, preoperative diagnostics including physical examination, laboratory parameters, tumor markers (CA19-9, CEA, CA125, CA72-4), computed tomography of the chest, abdomen and pelvis with intravenous and oral/rectal contrast and endoscopy with or without endoluminal ultrasonography (colorectal and gastric cancer) are indispensable (Table
2). In some cases additional ultrasound, abdominal magnetic resonance imaging (MRI) and/or PET-CT may be helpful depending on the primary tumor and tumor dissemination [
17]. However, Esquivel et al. have shown that preoperative CT-PCI does not correlate with the intraoperative PCI. In 52 patients with peritoneal carcinomatosis of colonic origin from 19 international centers the mean CT-PCI was 8.6 vs. 13.2 (Esquivel, SSO 2008). In our experience a leading reason for incomplete macroscopic cytoreduction is the intraoperative finding of disseminated tumor spots in the small bowel region. Thus, staging laparoscopy should be performed if necessary to determine tumor dissemination especially in patients with peritoneal carcinomatosis from gastric cancer but not in patients with DMPM because of the high risk of port side metastasis [
18,
19]. Anyway, the tumor entity should be taken into account. Whereas for example patients with peritoneal carcinomatosis of colonic origin with a PCI ≤ 20 qualify for CRS and HIPEC, the PCI in patients with gastric cancer should be < 10 or ≤15 [
20,
21]. In patients with pseudomyxoma peritonei arising from mucinous neoplasms PCI > 20 is no absolute exclusion criteria. In these patients tumor grading, extent of mesenteric invasion, liver metastasis and age play an important role in conjunction with PCI [
22]. The Peritoneal Surface Malignancy Group defined eight clinical and radiological variables that increase the probability of complete macroscopic cytoreduction in patients with peritoneal carcinomatosis of colonic origin: (1) ECOG performance status ≤ 2, (2) no evidence of extra-abdominal disease, (3) up to three small, resectable parenchymal hepatic metastases, (4) no evidence of bilary obstruction, (5) no evidence of ureteral obstruction, (6) no evidence of intestinal obstruction at more than one site, (7) small bowel involvement: no evidence of gross disease in the mesentery with several segmental sites of partial obstruction and (8) small volume disease in gastro-hepatic ligament [
20,
23]. In patients with DMPM extra-abdominal and hepatic metastasis, histology, nuclear grade and mitotic count are crucial prognostic factors for preoperative patient selection and oncological outcome [
18]. Most experts exclude patients with distant metastasis from primary and recurrent gastric cancer [
21]. The ovary consensus panel (OCP) found no absolute contraindications for CRS and HIPEC in patients with ovarian cancer regarding tumor dissemination or metastasis. The access should be individually evaluated. Nevertheless, heart failure and pulmonary compromise preclude the combined treatment concept [
24].
Table 2
Preoperative diagnostic workup.
Clinical investigation Laboratory testing incl. tumor markers Computed tomography (CT) of the chest, abdomen and pelvis with oral, rectal and intravenous contrast |
Tumor-specific essential diagnostics
|
CRC: complete colonoscopy GC: gastroscopy |
Useful additional diagnostics (case-dependent)
|
Ultrasonography Magnetic resonance imaging (MRI) Positron emission tomography (PET)/PET-CT Diagnostic laparoscopy |