III Convegno Congiunto delle Società Lombarda e Triveneta di Chirurgia La carcinosi peritoneale da ca colorettale. Storia naturale, scenari clinici ed impatto prognostico D.Foschi Dipartimento di Scienze Cliniche L.Sacco Università di Milano Desenzano 12 maggio 2012

Pathogenesis of peritoneal minimal residual disease WP Ceelen, 2009 D

K.L. Sodek, 2012 Disease progression and metastatic spread

AuthorN. Patients P.C. Russell (1984)945 % Minsky (1988)2944 % Jayne (2002) % Lemmens (2010)* % Mulsow (2011) % Incidence of synchronous peritoneal carcinomatosis

W.E. Lemmens, Int J Cancer, 2011 Synchronous Peritoneal Carcinomatosis and Colorectal cancer Anni % 43.6%56.4%

W.E. Lemmens, Int J Cancer, 2011 General characteristics of patients with synchronous P.C. 0.1% 0.3% 21% 3.4%

Risk of P.C. : Multivariable logistic regression W.E. Lemmens, Int J Cancer, 2011

Meta-analysis of overall and local recurrence for – vs + preresection PFCC Rekhraj S,2008

Meta-analysis of overall and local recurrence for – vs + postresection PFCC Rekhraj S,2008

PROGNOSTIC FACTORS FOR SURVIVAL IN P.C. FROM C.R.C. Median (mos)Mean (mos)P value Synchronous P.C P = 0.78 Not synchronous P.C NS Initial pTNM staging T1,T2 (n = 4) T3 (n = 76)5.37.2P = 0.5 T4 (n = 38)3.44.7NS Lymph node involvement N P = 0.13 N+76.8NS PC staging Stage I Stage II Stage III4.46.0P = Stage IV Differentiation WD and MD3.25.3P = 0.9 PD and UD5.55.3NS Ascites Yes3.75.1P = 0.6 No5.16.5NS Liver metastases Yes4.46.1P = 0.4 No5.96.1NS B.Sadeghi, 2000 Cancer

Prognostic factors in metachronous ascites DZJ Chu, Cancer, 1989 M:6 mnt

Crude survival of synchronous peritoneal carcinomatosis V.E. Lemmens,2010

Incidence of metachronous peritoneal carcinomatosis AuthoryearN.PatientsMet.P.C. Cass % Malcom % Mendenhall % Gilbert % Tong % Gunderson % Jayne % ________________________________________________ Gilbert( autopsy ser.) % Russell ( autopsy ser. ) % ________________________________________________ Mulsow (CRC-PC) % Matsuda(CRC-PC) %

Logistic regression analysis for metachronous peritoneal carcinomatosis Odds ratioP Clinical Liver metastasis2.84 (1.7 – 4.6)<0.001 Histological Tumor stage2.74( )<0.001 Nodal stage2.47( )<0.001 Venous invasion2.07( )<0.012 Perineural invasion1.57(1-2.3)<0.032 Jayne DG, 2002

Risk factors for metachronous P.C. pT4 Positive peritoneal cytology Peritoneal seeding Ovarian Involvement Perforation of the tumor Rupture of a necrotic tumor mass Intraoperative tumor spill

Risk factors for metachronous P.C. N.PatientsSynchronous P.C. Ovarian Metastase Perforated tumor Tot n:41 n:25 n: 8 n:8 % + P.C. 15(60%) 5 (62%) 3 (37%) PCI 9±6 7±5 5±2 D. Elias, 2011

Risk of local recurrence after inadvertent rectal perforation M.T. Eriksen, 2004

Synchronous colorectal PC N:153 Complete resection N:31 Non complete resection N:122 All recurrences N:24 (77%) 1 ° site of recurrence Intra-peritoneal alone N. 8 (25.8%) P.C. – extraperitoneal N:1 (3.2%) Extra-peritoneal alone N:15 (48.4%) Matsuda, 2012 Risk of metachronous carcinomatosis after CRC-PC resection

ROS MIF TNF-α IL-1, -6, -8, -10 TGF-α bFGF TGF-β Pathophysiology of ascites accumulation K.L. Sodek, 2012

SurvivaL of P.C. after standard treatment or CRS-HIPEC