Annals of Surgical Oncology

, Volume 23, Issue 4, pp 1261–1270 | Cite as

Resectability of Peritoneal Carcinomatosis: Learnings from a Prospective Cohort of 533 Consecutive Patients Selected for Cytoreductive Surgery

  • Kayvan Mohkam
  • Guillaume Passot
  • Eddy Cotte
  • Naoual Bakrin
  • François-Noël Gilly
  • Stanislas Ledochowski
  • Lorraine Bernard
  • Pierre-Jean Valette
  • Olivier Glehen
  • Pascal Rousset
Gastrointestinal Oncology



The aim of this study was to identify the risk factors and causes of unresectability in a large cohort of patients with peritoneal carcinomatosis (PC) selected for cytoreductive surgery (CRS), and to assess the contribution of the different imaging modalities to the patient-selection process.


The pre- and intraoperative data of 533 consecutive patients with PC planned for CRS at a single institution were reviewed. All patients underwent computed tomography (CT) magnetic resonance imaging and/or positron emission tomography/CT within the 2 days prior to surgery.


Among the 533 patients, 436 (82 %) underwent complete CRS, 86 (16 %) underwent exploratory laparotomy without CRS because of multiple small-bowel involvement (n = 31), invasion of different digestive segments (n = 15), an elevated PC index (n = 14), invasion of the mesenteric root (n = 12), or another cause (n = 14), and 11 (2 %) did not undergo laparotomy because of disease progression on preoperative imaging findings. On univariate analysis, elevated levels of tumor markers and a short delay between the last cycle of chemotherapy and the scheduled surgery were identified as predictors of unresectability for the colonic PC population, while a younger age was identified in patients with gastric PC. Multivariate analysis disclosed the use of neoadjuvant chemotherapy and a younger age as independent predictors of unresectability in the colonic PC population.


The current modalities for the assessment of PC resectability, including functional imaging examinations, have a low impact on patient selection for CRS. New tools are needed to decrease the rate of open–close procedures.


Peritoneal Carcinomatosis Staging Laparoscopy Peritoneal Cancer Index Hepatoduodenal Ligament Pseudomyxoma Peritonei 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



No sources of funding were used to assist in the preparation of this study.

Conflict of interest

Kayvan Mohkam, Guillaume Passot, Eddy Cotte, Naoual Bakrin, François-Noël Gilly, Stanislas Ledochowski, Lorraine Bernard, Pierre-Jean Valette, Olivier Glehen, and Pascal Rousset have no commercial interests to disclose.


  1. 1.
    Sadeghi B, Arvieux C, Glehen O, et al. Peritoneal carcinomatosis from non-gynecologic malignancies: results of the EVOCAPE 1 multicentric prospective study. Cancer. 2000;88:358–63.CrossRefPubMedGoogle Scholar
  2. 2.
    Witkamp AJ, de Bree E, Kaag MM, et al. Extensive cytoreductive surgery followed by intra-operative hyperthermic intraperitoneal chemotherapy with mitomycin-C in patients with peritoneal carcinomatosis of colorectal origin. Eur J Cancer. 2001;37:979–84.CrossRefPubMedGoogle Scholar
  3. 3.
    Glehen O, Kwiatkowski F, Sugarbaker PH, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. J Clin Oncol. 2004;22:3284–92.CrossRefPubMedGoogle Scholar
  4. 4.
    Verwaal VJV, van Ruth SS, de Bree EE, et al. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol. 2003;21:3737–43.CrossRefPubMedGoogle Scholar
  5. 5.
    Verwaal VJ, Bruin S, Boot H, van Slooten G, van Tinteren H. 8-year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer. Ann Surg Oncol. 2008;15:2426–32.CrossRefPubMedGoogle Scholar
  6. 6.
    Goere D, Malka D, Tzanis D, et al. Is there a possibility of a cure in patients with colorectal peritoneal carcinomatosis amenable to complete cytoreductive surgery and intraperitoneal chemotherapy? Ann Surg. 2013;257:1065–71.CrossRefPubMedGoogle Scholar
  7. 7.
    Elias D, Goere D, Dumont F, et al. Role of hyperthermic intraoperative peritoneal chemotherapy in the management of peritoneal metastases. Eur J Cancer. 2014;50:332–40.CrossRefPubMedGoogle Scholar
  8. 8.
    Cotte E, Passot G, Gilly F-N, Glehen O. Selection of patients and staging of peritoneal surface malignancies. World J Gastrointest Oncol. 2010;2:31–35.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Low RN, Barone RM, Lucero J. Comparison of MRI and CT for predicting the Peritoneal Cancer Index (PCI) preoperatively in patients being considered for cytoreductive surgical procedures. Ann Surg Oncol. 2015;22:1708–15.CrossRefPubMedGoogle Scholar
  10. 10.
    Cotton F, Pellet O, Gilly FN, Granier A, Sournac L, Glehen O. MRI evaluation of bulky tumor masses in the mesentery and bladder involvement in peritoneal carcinomatosis. Eur J Surg Oncol. 2006;32:1212–16.CrossRefPubMedGoogle Scholar
  11. 11.
    Satoh Y, Ichikawa T, Motosugi U, et al. Diagnosis of peritoneal dissemination: comparison of 18F-FDG PET/CT, diffusion-weighted MRI, and contrast-enhanced MDCT. AJR Am J Roentgenol. 2011;196:447–53.CrossRefPubMedGoogle Scholar
  12. 12.
    Sugarbaker PH. Intraperitoneal chemotherapy and cytoreductive surgery for the prevention and treatment of peritoneal carcinomatosis and sarcomatosis. Semin Surg Oncol. 1998;14:254–61.CrossRefPubMedGoogle Scholar
  13. 13.
    Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. Cancer Treat Res. 1996;82:359–74.CrossRefPubMedGoogle Scholar
  14. 14.
    Elias D, Glehen O, Pocard M, et al. A comparative study of complete cytoreductive surgery plus intraperitoneal chemotherapy to treat peritoneal dissemination from colon, rectum, small bowel, and nonpseudomyxoma appendix. Ann Surg. 2010;251:896–901.CrossRefPubMedGoogle Scholar
  15. 15.
    Elias D, Souadka A, Fayard F, et al. Variation in the peritoneal cancer index scores between surgeons and according to when they are determined (before or after cytoreductive surgery). Eur J Surg Oncol. 2012;38:503–08.CrossRefPubMedGoogle Scholar
  16. 16.
    Glehen O, Mohamed F, Gilly FN. Peritoneal carcinomatosis from digestive tract cancer: new management by cytoreductive surgery and intraperitoneal chemohyperthermia. Lancet Oncol. 2004;5:219–28.CrossRefPubMedGoogle Scholar
  17. 17.
    Chéreau E, Ballester M, Selle F, Cortez A, Daraï E, Rouzier R. Comparison of peritoneal carcinomatosis scoring methods in predicting resectability and prognosis in advanced ovarian cancer. Am J Obstet Gynecol. 2010;202:178.e1–e10.CrossRefGoogle Scholar
  18. 18.
    Esquivel J, Chua TC, Stojadinovic A, et al. Accuracy and clinical relevance of computed tomography scan interpretation of peritoneal cancer index in colorectal cancer peritoneal carcinomatosis: a multi-institutional study. J Surg Oncol. 2010;102:565–70.CrossRefPubMedGoogle Scholar
  19. 19.
    Duez A, Cotte E, Glehen O, Cotton F, Bakrin N. Appraisal of peritoneal cavity’s capacity in order to assess the pharmacology of liquid chemotherapy solution in hyperthermic intraperitoneal chemotherapy. Surg Radiol Anat. 2009;31:573–78.CrossRefPubMedGoogle Scholar
  20. 20.
    Yan TD, Sim J, Morris DL. Selection of patients with colorectal peritoneal carcinomatosis for cytoreductive surgery and perioperative intraperitoneal chemotherapy. Ann Surg Oncol. 2007;14:1807–17.CrossRefPubMedGoogle Scholar
  21. 21.
    Franiel T, Diederichs G, Engelken F, Elgeti T, Rost J, Rogalla P. Multi-detector CT in peritoneal carcinomatosis: diagnostic role of thin slices and multiplanar reconstructions. Abdom Imaging. 2008;34:49–54.CrossRefGoogle Scholar
  22. 22.
    de Bree E, Koops W, Kröger R, van Ruth S, Witkamp AJ, Zoetmulder FAN. Peritoneal carcinomatosis from colorectal or appendiceal origin: correlation of preoperative CT with intraoperative findings and evaluation of interobserver agreement. J Surg Oncol. 2004;86:64–73.CrossRefPubMedGoogle Scholar
  23. 23.
    Koh J-L, Yan TD, Glenn D, Morris DL. Evaluation of preoperative computed tomography in estimating peritoneal cancer index in colorectal peritoneal carcinomatosis. Ann Surg Oncol. 2009;16:327–33.CrossRefPubMedGoogle Scholar
  24. 24.
    Low RN, Barone RM. Combined diffusion-weighted and gadolinium-enhanced MRI can accurately predict the peritoneal cancer index preoperatively in patients being considered for cytoreductive surgical procedures. Ann Surg Oncol. 2012;19:1394–401.CrossRefPubMedGoogle Scholar
  25. 25.
    Passot G, Glehen O, Pellet O, et al. Pseudomyxoma peritonei: role of 18F-FDG PET in preoperative evaluation of pathological grade and potential for complete cytoreduction. Eur J Surg Oncol. 2010;36:315–23.CrossRefPubMedGoogle Scholar
  26. 26.
    Torkzad MR, Casta N, Bergman A, Ahlström H, Påhlman L, Mahteme H. Comparison between MRI and CT in prediction of peritoneal carcinomatosis index (PCI) in patients undergoing cytoreductive surgery in relation to the experience of the radiologist. J Surg Oncol. 2015;111:746–51.CrossRefPubMedGoogle Scholar
  27. 27.
    Pfannenberg C, Königsrainer I, Aschoff P, et al. 18F-FDG-PET/CT to select patients with peritoneal carcinomatosis for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2009;16:1295–303.CrossRefPubMedGoogle Scholar
  28. 28.
    Hynninen J, Kemppainen J, Lavonius M, et al. A prospective comparison of integrated FDG-PET/contrast-enhanced CT and contrast-enhanced CT for pretreatment imaging of advanced epithelial ovarian cancer. Gynecol Oncol. 2013;131:389–94.CrossRefPubMedGoogle Scholar
  29. 29.
    Klumpp BD, Schwenzer N, Aschoff P, et al. Preoperative assessment of peritoneal carcinomatosis: intraindividual comparison of 18F-FDG PET/CT and MRI. Abdom Imaging. 2013;38:64–71.CrossRefPubMedGoogle Scholar
  30. 30.
    Gemer O, Gdalevich M, Ravid M, et al. A multicenter validation of computerized tomography models as predictors of non-optimal primary cytoreduction of advanced epithelial ovarian cancer. Eur J Surg Oncol. 2009;35:1109–12.CrossRefPubMedGoogle Scholar
  31. 31.
    Rivard JD, Temple WJ, McConnell YJ, Sultan H, Mack LA. Preoperative computed tomography does not predict resectability in peritoneal carcinomatosis. Am J Surg. 2014;207:760–64 (discussion 764–5).CrossRefPubMedGoogle Scholar
  32. 32.
    Denzer U, Hoffmann S, Helmreich-Becker I, et al. Minilaparoscopy in the diagnosis of peritoneal tumor spread: prospective controlled comparison with computed tomography. Surg Endosc. 2004;18:1067–70.CrossRefPubMedGoogle Scholar
  33. 33.
    Pomel C, Appleyard TL, Gouy S, Rouzier R, Elias D. The role of laparoscopy to evaluate candidates for complete cytoreduction of peritoneal carcinomatosis and hyperthermic intraperitoneal chemotherapy. Eur J Surg Oncol. 2005;31:540–43.CrossRefPubMedGoogle Scholar
  34. 34.
    Varnoux C, Huchon C, Bats AS, et al. Diagnostic accuracy of hand-assisted laparoscopy in predicting resectability of peritoneal carcinomatosis from gynecological malignancies. Eur J Surg Oncol. 2013;39:774–79.CrossRefPubMedGoogle Scholar
  35. 35.
    van Oudheusden TR, Braam HJ, Luyer MDP, et al. Peritoneal cancer patients not suitable for cytoreductive surgery and hipec during explorative surgery: risk factors, treatment options, and prognosis. Ann Surg Oncol. 2015;22:1236–42.CrossRefPubMedGoogle Scholar
  36. 36.
    Passot G, Vaudoyer D, Cotte E, et al. Progression following neoadjuvant systemic chemotherapy may not be a contraindication to a curative approach for colorectal carcinomatosis. Ann Surg. 2012;256:125–29.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2015

Authors and Affiliations

  • Kayvan Mohkam
    • 1
    • 2
  • Guillaume Passot
    • 1
    • 2
  • Eddy Cotte
    • 1
    • 2
  • Naoual Bakrin
    • 1
    • 2
  • François-Noël Gilly
    • 1
    • 2
  • Stanislas Ledochowski
    • 3
  • Lorraine Bernard
    • 4
  • Pierre-Jean Valette
    • 2
    • 5
  • Olivier Glehen
    • 1
    • 2
  • Pascal Rousset
    • 2
    • 5
  1. 1.Department of Digestive and Oncologic Surgery, Hospices Civils de LyonCentre Hospitalier Universitaire Lyon-SudPierre-BéniteFrance
  2. 2.Equipe Mixte de Recherche 3738, Ecole Doctorale EDISS 205Université Claude Bernard Lyon 1LyonFrance
  3. 3.Intensive Care Unit, Hospices Civils de LyonCentre Hospitalier Universitaire Lyon-SudPierre-BéniteFrance
  4. 4.Clinical Research Unit, Hospices Civils de LyonPôle IMERLyonFrance
  5. 5.Department of Radiology, Hospices Civils de LyonCentre Hospitalier Universitaire Lyon-SudPierre-BéniteFrance

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