Panuganti Bharat, Chang Ea-Sle, Helm Cyril W, Schwartz Theresa, Hsueh Eddy C, Piao Jinhua, Lai Jinping, Veerapong Jula
Department of Surgery, University of California-San Diego, La Jolla, CA, USA.
Department of General Surgery, Saint Louis University, Saint Louis, MO, USA.
Gastroenterology Res. 2018 Jun;11(3):247-251. doi: 10.14740/gr1029w. Epub 2018 May 31.
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are combined to treat peritoneal surface malignancies (PSM). The objective of cytoreduction is to eradicate macroscopic disease, while HIPEC addresses residual microscopic disease. Currently, there are no protocols guiding treatment of cirrhotic patients with PSM. We report the case of a cirrhotic patient with signet ring cell (SRC) appendiceal adenocarcinoma who underwent normothermic, as opposed to hyperthermic intraperitoneal chemotherapy (IPC). A 50-year-old woman with compensated class A cirrhosis and chronic hepatitis B and C underwent a right hemicolectomy in 2007 and adjuvant chemotherapy in 2008 for appendiceal SRC adenocarcinoma. In 2011, she was found to have peritoneal disease after a laparotomy. She subsequently experienced intolerance to chemotherapy, with stable disease on serial restaging. In light of her cirrhosis, the decision was made to perform CRS and IPC without hyperthermia to treat her residual disease. In 2012, she underwent CRS (omentectomy, total abdominal hysterectomy, left salpingo-oophorectomy) and IPC with mitomycin C. Thirty-day postoperative morbidity included delayed abdominal closure (Clavien-Dindo Grade IIIb), prolonged ventilator support (IIIa), vasopressor requirements (II), and confusion (II). The patient's liver function remained stable. Eight months later, she had evidence of recurrence on computed tomography. Twenty-two months later, she developed an extrinsic compression secondary to evolving disease, requiring a palliative endoscopic stent. The patient expired from her disease 29 months after her CRS and IPC. The criteria guiding selection of suitable candidates for CRS continues to evolve. Concomitant compensated cirrhosis in patients with PSM should not constitute a reason independently to exclude CRS with intraperitoneal chemotherapy, given the oncologic benefits of the procedure.
细胞减灭术（CRS）与腹腔内热灌注化疗（HIPEC）联合用于治疗腹膜表面恶性肿瘤（PSM）。细胞减灭的目的是根除肉眼可见的病灶，而HIPEC则针对残留的微小病灶。目前，尚无针对肝硬化合并PSM患者的治疗方案。我们报告一例患有印戒细胞（SRC）阑尾腺癌的肝硬化患者，该患者接受了常温而非热灌注腹腔内化疗（IPC）。一名50岁女性，患有代偿性A级肝硬化以及慢性乙型和丙型肝炎，于2007年接受了右半结肠切除术，并于2008年因阑尾SRC腺癌接受了辅助化疗。2011年，剖腹手术后发现她患有腹膜疾病。随后她对化疗不耐受，经连续重新分期病情稳定。鉴于她的肝硬化情况，决定进行CRS和非热灌注的IPC来治疗她的残留疾病。2012年，她接受了CRS（网膜切除术、全腹子宫切除术、左侧输卵管卵巢切除术）以及丝裂霉素C的IPC治疗。术后30天的并发症包括腹部延迟闭合（Clavien-Dindo IIIb级）、呼吸机支持时间延长（IIIa级）、需要血管加压药（II级）以及出现意识模糊（II级）。患者的肝功能保持稳定。八个月后，计算机断层扫描显示她有复发迹象。二十二个月后，由于病情进展出现外部压迫，需要进行姑息性内镜支架置入。该患者在接受CRS和IPC治疗29个月后因疾病死亡。指导选择CRS合适候选者的标准仍在不断发展。鉴于该手术的肿瘤学益处，PSM患者合并代偿性肝硬化不应单独构成排除CRS联合腹腔内化疗的理由。
