peritoneal karsinomatosiz, hipec eus
TRANSCRIPT
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Peritoneal karsinomatozis, HIPEC ve EUS
Prof. Dr. Hakan Yanar
İstanbul Tıp Fakültesi
Genel Cerrahi Anabilim Dalı
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• 75 th Anual University of MinnosetaColon&Rectal Surgery Principles Course Ekim 27-27, 2012
• 8 th World Congress on Peritoneal SurfaceMalignancies 31 Ekim - 2 Kasım 2012
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• Gastrointestinal kanserin peritonealmetastazlarını nasıl önleriz?
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• Farkındalık
• Aşılama
• Davranışları düzenleme (alkol, sigara, tek eşlilik)
• Tarama gastroskopi, kolonoskopisi
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• PERİTONEAL METASTAZLAR VE LOKAL-REGİONAL HASTALIK, GI kanserin aynı doğal gidişi
• Primer sarkom → mezenter etrafı nodüleryada mezo kökü fuziform rekürrensler
• GI kanser küründe major engel
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Primer GI kanser tanısında metastaz oranları
Primer tümör Peritoneal metastaz % si
Kolon 8.5 Sjo, 2011
Rektum 25.8 Shepard, 1995
Mide 5-20 Ikeguchi, 1994
Pankreas 26 Dragovich, 2012
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Primer GI kanser tanısında metastaz oranları
Primer tümör İzole peritonealmetastaz %
Kombine peritonealmetastaz %
Kolon 67 33
Rektum 29 54
Pankreas 15 61
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NIH çalışması, 1985: Uzun dönem IP 5- FU
Rekürrens Peritoneal rekürrens
• IP 5-FU: %13 2/10
• IV 5-FU: %11 10/11
Sugerbaker 1985
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Genişletilmiş lenfadenektomi ile birlikte
• Total mezokololik eksizyon
• Total mezorektal eksizyon
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Endikasyonlar
• Kolorektal, over ve gastrik kansere bağlı PK
• Apendiks psödomiximo peritonei
• Peritoneal mezotelyoma
• Endometrium kanserine bağlı PK
• Peritoneal sarkomatozis
• Palyatif massif assit
• Adjuvan HIPEC: Primer organ kanserinin ve peritoneal metastazların R0 rezeksiyonu sonrası
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Tam sitoredüksiyon şansı ne zaman yok?
• Karın dışı hastalık
• Çok yüksek PKİ
• 3’ ten fazla KC metastazı
• Yaygın portal pedikül tutulumu
• Çok odaklı intestinal obstruksiyon
• Mezenter kökünde ciddi tutulum
• Frozen pelvis, üreter invazyonu
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• Peritoneal Cancer Index (PCI)
• Completeness of Cytoreduction (CCR) Score
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Komplet sitoredüksiyon için yapılan işlemler
• PERİTONEKTOMİ
• Anterior parietal peritonektomi
• Sol üst kadran peritonektomi
• Sağ üst kadran peritonektomi
• Pelvik peritonektomi
• Omental bursektomi
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Komplet sitoredüksiyon için yapılan işlemler
• REZEKSİYONLAR
• Eski skarlar, göbek, epigastrik yağ dokusu
• Omentum majus ve dalak
• KC Glisson kapsülü üzeri tümör
• Uterus, overler, rektosigmoid kolon
• Safra kesesi, omentum minus
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Proaktif second look cerrahi -colon adeno ca
• Peritoneal yüzeylerde biopsi ile kanıtlanmış kanser, T4
• Peritoneal nodüllerde pozitif biopsi• Pozitif biopsi yada patolojik genişlemiş over• Pozitif peritoneal sitoloji• Perfore tümör (spontan yada kolonoskopi
esnasındaiatrojenik)• Komşu organ tutulumu yada fistül formasyonu• Cerrahi sınır (+) • Rezeksiyon esnasında tümörün perfore olması
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Müsinöz apendiks neoplazmları
• Rüptüre apendiks mukoselinin daha fazla psödomiksoma peritonei ye neden olması
• Apendektomi tekniğinde ilerlemeler ile daha az mukus yayılımı
• CRS ve HIPEC ile erken müdahale
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Proaktif second look cerrahi -apendiks adeno ca
• Çekum yada diğer anatomik bölgelerde pozitif cerrahi sınır
• Peritoneal nodüllerde pozitif biopsi
• Pozitif biopsi yada patolojik genişlemiş over
• Pozitif peritoneal sitoloji
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Perfore apandisit &Pseudomyxoma peritoneiPMP: disseminated peritonealadenomucinosis (DPAM) – the benign variantve peritoneal mucinous carcinomatosis(PMCA) – the malignant variant
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PK Kolorektal Kanser
• Son zamanlarda yayınlanan bir sistematik review
• Ortalama sağ kalım: 13-29 ay
• 5 yıllık sağ kalım: %11-19
• Tam SRC
– ortalama sağ kalımın 28-60 ay
– 5 yıllık sağ kalım %22 - 49 Yan TD et al. J Clin Oncol 2006;24:4011-9
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• 23 Fransız Merkezi
• 1990-2007
• 523 hasta SRC+HİPEK
• Median Sağ kalım 30.1 ay
• 5 yıllık sağ kalım % 27
• Tam SRC 5 yıllık sağ kalım %79
• Mortalite %3, Morbidite %23
Peritoneal colorectal carcinomatosis treated with surgery and perioperative intraperitoneal chemotherapy: retrospective analysis of 523 patients from a multicentric French study.Elias D, Gilly F, Boutitie F, Quenet F, Bereder JM, Mansvelt B, Lorimier G, Dubè P, Glehen O
J Clin Oncol. 2010 Apr 1;28(10):1808
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Copyright © American Society of Clinical Oncology
Elias, D. et al. J Clin Oncol; 28:63-68 2010
Fig 1. Overall and disease-free survival rates of the 523 patients with peritoneal carcinomatosis of colorectal origin
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Copyright © American Society of Clinical Oncology
Elias, D. et al. J Clin Oncol; 28:63-68 2010
Fig 2. Prognostic impact of the extent of carcinomatosis (ie, peritoneal cancer index; P < .001) on overall survival
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Copyright © American Society of Clinical Oncology
Elias, D. et al. J Clin Oncol; 28:63-68 2010
Fig 3. Prognostic impact of the completeness of the surgery (P < .001) on overall survival
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• The study compared the outcome in patients with advanced colonic cancer at high risk of peritoneal metastases (mucinous or signet-ring cell) without peritoneal or systemic spread, treated with standard colectomy or a more aggressive combined surgical approach. The study included patients with colonic cancer with clinical T3/T4, any N, M0, and mucinous or signet ring cell histology. The 25 patients in the experimental group underwent hemicolectomy, omentectomy, bilateral adnexectomy, hepatic round ligament resection, and appendectomy, followed by HIPEC. The control group comprised 50 patients treated with standard surgical resection during the same period in the same hospital by different surgical teams. Outcome data, morbidity, peritoneal recurrence rate, and overall, and disease-free survival, were compared.
• Sammartino 2012 GPR
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• Peritoneal recurrence developed in 4% of patients in the experimental group and 22% of controls without increasing morbidity (P < 0.05). Actuarial overall survival curves disclosed no significant differences, whereas actuarial disease-free survival curves showed a significant difference between groups (36.8 versus 21.9 months, P < 0.01). A more aggressive preventive surgical approach combined with HIPEC reduces the incidence of peritoneal recurrence in patients with advanced mucinous colonic cancer and also significantly increases disease-free survival compared with a homogeneous control group treated with a standard surgical approach without increasing morbidity.
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Site of recurrence
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Disease free survival
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• Yüksek peritoneal ve loko rejyonel nüks riski bulunan rektum tm de ne yapalım?
• PROMAC PM study ?
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Gastric cancer 2012
• Yu et all 1998 Ann Surg EPIC vs HIPEC tablo ekle
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PK Mide Kanseri
• Peritonektomi ve HİPEK sonrası uzun sağ kalım mide kanseri kökenli karsinomatozda, düşük yayılımın olduğu ve R0 rezeksiyon yapıldığında mümkündür
• Maalesef söz konusu durum ile ilgili veriler sınırlıdır ve çok az sayıda merkezin bu alanda deneyimi mevcutturYonemura Y et al. Br J Surg 2005; 92: 370-5
Glehen O et al. Arch Surg 2004;139:20-6
Hall JJ et al. J Gastrointest Surg 2004;8:454-63
• Geleneksel:
• Ortalama sağ kalım 6 ay
• 5 yıllık sağ kalım %0
Sadeghi B et al. Cancer 2000;88:358-63
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PK Mide Kanseri
• Sayag ve ark., Evre I ve II karsinomatozisi olan hastalar için 3 yıllık sağ kalım oranını %41 olarak bildirmiştir
Sayag-Beaujard AC et al. Anticancer Res 1999;19:1375-82
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PK Mide Kanseri
• SRC + HİPEK yapılan 85 hastalık bir seride
• 1 yıllık sağ kalım % 43
• 5 yıllık sağ kalım %11
Yonemura Y et al. Surgery 1996;119:437-44
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PK Mide Kanseri
• Bununla birlikte birkaç daha kötü ve uyumsuz sonuç da bildirilmiştir
Shen P et al. Curr Probl Cancer 2009;33:125-41
• Genel olarak bu çalışmalar tam sitoredüksiyonun uzun sağ kalımdan sorumlu olduğunu açıkça göstermektedir
• SRC + HİPEK etkinliği ise hala tam olarak açıklığa kavuşturulamamıştır
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Tristan Yan’s conclusion:
• Gastrik kanser
• HIPEC with or without EPIC after resection of primary gastric cancer is associated with an improved overall survival. There was an increased risk of intraperitoneal abscess.
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• Batı da kabul edilmedi
• Tüm çalışmalar Asya dan
• Hasta paternleri çok değişik
• Maliyet ve morbidite çok yüksek
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Sugarbaker 2012 indikasyonları
• Peritoneal yüzeylerde biopsi ile kanıtlanmış kanser, T4
• Peritoneal nodüllerde pozitif biopsi
• Pozitif biopsi yada patolojik genişlemiş over
• Pozitif peritoneal sitoloji
• N2 (+) lenf nodu
• T3 ya da T4 endoskopik tümör
• Linitis plastika
• Signet ring patoloji
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Pankreas kanseri 2012
• IP Gemcitabine
• Rezektabl Adjuvan HIPEC Gemcitabine
• 5 yıllık survi %36
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PK Peritoneal Mezotelyoma
• Geleneksel: Ortalama sağ kalım ≤ 12 ay
• Hastalığı peritoneal yüzeyde sınırlandırmak için son yıllarda tedavi seçeneği olarak SRC + HİPEK kombinasyonuna artan bir ilgi mevcuttur
• Bazı prospektif çalışmalar sağ kalımın artığını rapor etmiştir
Stewart JH et al. Ann Surg Oncol 2005;12:765-77
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PK Peritoneal Mezotelyoma
• Son bir sistematik review difüz malign peritoneal mezotelyamada SRC + HİPEK için mevcut kanıtları değerlendirdi:
• Palyatif cerrahi ve sistematik KT uygulanan geçmişteki kontrollerle karşılaştırıldığında sağ kalımın daha iyi olduğu sonucuna varmıştır
Yan TD et al. Ann Oncol 2007;18:827-34
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• Malign barsak tıkanıklığının optimal tedavisi
• Kolorektal cerrahi alan infeksiyonları Nasıl önlerim? Tedavi ederim? (Ertepenem, suplemental O2, glikoz, traş)
• Incurable kolorektal kanserde primer tümör rezeke edilmeli mi?
• Rekurrent rektal kanser→Maximal invazivecerrahi. MR, PET, Flap
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• Germline polimorfizm paterni neoadjuvan KT RT ye prediktif olabilir mi?
• Hemoroidal hastalık: Transanal hemoroidal
de-arterilizasyon
• Pilonoidal sinus: Should I open or I close?
Of course you should!
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Endorektal MR yada ERUS
• Anterior mezorektal plan→ ERUS
• Anal sfinkterler → ERUS
• Pelvik yan duvar ve lateral levator mezorektalplanlar → MR
• Gereksiz RT-KT yi önler → ERUS, T2-T3 iyi ayırır
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