Peritoneal dissemination is a common route of cancer metastasis. The benefit of administering chemotherapy directly into the peritoneal cavity is supported by preclinical and pharmacokinetic data. In comparison to intravenous (IV) treatment, intraperitoneal (IP) administration results in a several-fold increase in drug concentration within the abdominal cavity. There is now growing evidence from clinical studies showing a survival advantage for IP chemotherapy in various tumor typies, including ovarian, gastric and colorectal cancer. However, while the use of IP chemotherapy is slowly gaining acceptance, it is not universal, largely due to the greater toxicity associated with this approach. Moreover, efficacy of IP chemotherapy is limited by poor distribution within the abdominal cavity and by poor tissue penetration. A new way of IP chemotherapy is the application of cytotoxics in form of a pressurized aerosol into the abdominal of thoracic cavity. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is applied through laparoscopic access using two balloon trocars in an operating room equipped with laminar air-flow. In a first step,a normothermic capnoperitoneum is established with a pressure of 12 mmHg. A cytotoxic solution (about 10% of a normal systemic dose) is nebulized with a micropump into the abdominal cavity, and maintained for 30 min. The aerosol is then removed through a closed suction system. Applying an aerosol in the peritoneal cavity allows a homogeneous distribution of the chemotherapeutic agent within the abdomen. Furthermore, an artificial pressure gradient is generated that overcomes tumoral interstitial fluid pressure, an obstacle in cancer therapy. This results in a higher local drug concentration compared to conventional IP or IV chemotherapy. At the same time the plasma concentration of the chemotherapeutic agent remains low. In first clinical studies with limited number of patients in ovarian, gastric and colorectal cancer, as well as peritoneal mesothelioma, PIPAC has obtained encouraging tumor response rates and survival, with a low-side effects profile. Larger clinical trials are currently ongoing to examine if these data can be reproduced and extrapolated to other situations.

This book is a state-of-the-art overview of cancer regional therapy (CRT) for the surgeons and interventional radiologists active in CRT development and research. The goals of this book are 1) to review the theory and practice of cancer regional therapies including pharmacology, devices, techniques, and workflow, 2) illustrate the most common procedures performed in the interventional and operating rooms, and 3) discuss data supporting use of CRT. This is meant to be a definitive text on the theory and practice of CRT. It begins with a summary of the history, technical principles that underlie regional therapy. The following parts discuss current data and practice in peritoneal, liver, limb, pleural and other sites. Included in the practice are considerations of workflow and financial issues revolving around CRT. Novel techniques and therapies under investigation are presented to inform the direction of the field. Cancer Regional Therapy summarizes the history, current technology, common procedures, and future prospects in this field and includes procedures from many surgical and interventional radiologic disciplines.

Peritoneal surface malignancies (PSM) include a heterogeneous group of primary tumors, like peritoneal mesothelioma, and peritoneal metastases from various origins such as ovarian, gastric, colorectal, or appendicular cancers. Their pathophysiology is complex and still not fully elucidated. Historically, due to their dismal prognosis, peritoneal surface malignancies were considered a terminal condition and treated as such in palliative intent.. Surgery has become pivotal in the treatment of PSM and the development of specific techniques of cytoreductive surgery (peritonectomies, “en-bloc” resection) open up a new era of curative intent treatments.

Peritoneal dissemination is a common route of cancer metastasis. The benefit of administering chemotherapy directly into the peritoneal cavity is supported by preclinical and pharmacokinetic data. In comparison to intravenous (IV) treatment, intraperitoneal (IP) administration results in a several-fold increase in drug concentration within the abdominal cavity. There is now growing evidence from clinical studies showing a survival advantage for IP chemotherapy in various tumor typies, including ovarian, gastric and colorectal cancer. However, while the use of IP chemotherapy is slowly gaining acceptance, it is not universal, largely due to the greater toxicity associated with this approach. Moreover, efficacy of IP chemotherapy is limited by poor distribution within the abdominal cavity and by poor tissue penetration. A new way of IP chemotherapy is the application of cytotoxics in form of a pressurized aerosol into the abdominal of thoracic cavity. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is applied through laparoscopic access using two balloon trocars in an operating room equipped with laminar air-flow. In a first step,a normothermic capnoperitoneum is established with a pressure of 12 mmHg. A cytotoxic solution (about 10% of a normal systemic dose) is nebulized with a micropump into the abdominal cavity, and maintained for 30 min. The aerosol is then removed through a closed suction system. Applying an aerosol in the peritoneal cavity allows a homogeneous distribution of the chemotherapeutic agent within the abdomen. Furthermore, an artificial pressure gradient is generated that overcomes tumoral interstitial fluid pressure, an obstacle in cancer therapy. This results in a higher local drug concentration compared to conventional IP or IV chemotherapy. At the same time the plasma concentration of the chemotherapeutic agent remains low. In first clinical studies with limited number of patients in ovarian, gastric and colorectal cancer, as well as peritoneal mesothelioma, PIPAC has obtained encouraging tumor response rates and survival, with a low-side effects profile. Larger clinical trials are currently ongoing to examine if these data can be reproduced and extrapolated to other situations.

Paul Sugarbaker and his colleagues have persevered in the study and treat ment of peritoneal carcinomatosis. The peritoneal cavity has many unique and incompletely appreciated properties. These properties, coupled with the biologic behavior of many cancers, results in the seeding and growth of these cancers on the peritoneum. Many of these cancers remain localized to the peritoneum only, never metastasizing to other sites. One possible reason for this may be the obstruction of the afferent lymphatics on the undersurface of the diaphragm. The mucopolysaccharides produced by many of these neoplasma are probably viscous enough to obstruct these lymphatics, leading to the syndrome of pseudomyxoma peritonei. Many of the neoplasms taking residence on the peritoneum have extremely long cell-cycle times and are resistant to radiotherapy and many chemotherapeutic agents. How ever, much can be done for these patients - resection of primary cancers, omentectomies to reduce ascites formation, management of recurrent ascites, management of intestinal obstruction, nutritional care, and, hopefully, intraperitoneal chemotherapy. We have reviewed many of these problems in the past [1-7]. Dr. Sugarbaker and his colleagues have organized the current state of knowledge and technology for continuing use. The book provides a basis for thoughtful, prospective research planning. John S. Spratt, M. D. , F. A. C. S. Professor of Surgery The James Graham Brown Cancer Center University of Louisville Louisville, Kentucky References 1. Long RTL, Spratt JS, Dowling E.

This book provides surgeons and oncologists with a well-founded and detailed overview of the available treatment options for peritoneal malignancy and differential selection of the appropriate forms of therapy. Systemic chemotherapy options are also considered, as are surgical cytoreduction (CRS) and all forms of intraperitoneal chemotherapy (IPC) especially hyperthermic IPC (HIPEC), and immunotherapy, including specific procedures such as PIPAC. Subsequent chapters address perioperative care, complications and recurrences, as well as psycho-oncological, palliative medical and nursing care. The process of parietal and visceral peritonectomy in the large and small intestine is additionally illustrated by three video clips accessible online. Covering a broad range of aspects, including peritoneal metastasis and intraperitoneal chemotherapy, the book offers a valuable tool for surgeons, oncologists and anesthesiologists alike.

"Gastric cancer is the fourth most common cancer in the world. Most gastric cancers are diagnosed in advanced stages, and the prognosis remains poor. The 5-year survival rate is 40-60% in eastern countries and around 25% in the west. Among advanced gastric cancer cases, peritoneal implantation is one of the most common forms of metastasis and around 14% of cases present peritoneal metastases at initial diagnosis, presenting a survival of 3-6 months. Until the early 1990s it was considered a terminal disease. But today these patients have some opportunities to be treated with curative intent or to prolong their life. Although the prognosis remains poor, there are some treatment options including cytoreductive surgery, neoadjuvant therapy, and some forms of intraperitoneal chemotherapy with or without hyperthermia. These are aggressive treatments, so we must be careful when selecting patients. Imaging and preoperative staging are also crucial in selecting patients for appropriate treatment. The surgical technique is described and a detailed demonstration video is available in the e-book version. New forms of treatment such as PIPAC and new scientific advances and future perspectives are discussed. This book is an update on this topic and attempts to provide an overview for all medical personnel involved in the treatment of these patients"--