Quantitative prognostic indices in peritoneal carcinomatosis

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Abstract

Five different descriptions quantitating peritoneal carcinomatosis are available: the Lyon staging system, the Peritoneal Cancer Index (PCI), the Japanese Research Society for Gastric Cancer carcinomatosis staging (JRSGS), the Dutch simplified peritoneal carcinomatosis assessment and the Completeness of Cytoreduction Score (CCR). These five staging systems are described and discussed. Combinations of these to achieve a complete description of peritoneal lesions prior to and following treatment assist in a correct prognostic assessment for these patients and in a selection of treatment options.

Introduction

Quantitative prognostic indicators have been successfully used in several surgical disciplines and served as guidelines in the selection of treatments to maximize benefits. Often, the major value of the quantitative prognostic indicators is to exclude patients who have no chance to benefit from high risk and costly management protocols. Major requirements of a quantitative prognostic indicator are reproducibility within a defined patient population and simplicity.

Concerning peritoneal carcinomatosis, five different staging systems are available: the Lyon staging system, the Peritoneal Cancer Index (PCI), the Japanese Research Society for Gastric Cancer carcinomatosis staging (JRSGS), the Dutch simplified peritoneal carcinomatosis index (SPCI) and the Completeness of Cytoreduction Score (CCR).

Section snippets

The Lyon staging system

This staging was first described in 1994 by Gilly and coworkers and takes into account the size of malignant implants (<5 mm, 5 mm to 2 cm, >2 cm) and their distribution (localized or diffuse).1 The details of this staging system are summarized in Table 1.

This staging system can be used as the abdominal exploration is performed as well as after cytoreduction is complete, allowing a downstaging index. For example, a stage 4 peritoneal carcinomatosis which has underwent a complete macroscopic

The Peritoneal Cancer Index

The Peritoneal Cancer Index (PCI) was reported by Jacquet and Sugarbaker: it is a quantitative assessment of both cancer distribution and cancer implant size throughout the abdomen and the pelvis.7 This scoring system has been used to quantitate carcinomatosis, sarcomatosis and peritoneal mesothelioma. Two components are involved in its calculation. One component is the distribution of tumor in the abdominopelvic regions and the other component is the lesion size score. Distribution of the

The Japanese Research Society for Gastric Cancer carcinomatosis staging (JRSGC)

In Japan, carcinomatosis from gastric cancer is classified by the JRSGC as follows: P0 means no implants to the peritoneum. P1 means cancerous implants directly adjacent to the stomach peritoneum, including the greater omentum. P2 means several scattered metastases to the distant peritoneum or ovarian metastasis alone. P3 means numerous metastases to the distant peritoneum. This classification has been used in Japanese studies as an accurate quantitative prognostic indicator for gastric cancer.

The Dutch simplified peritoneal carcinomatosis assessment

At the Netherlands Institute, the extent of tumor is recorded on standardized forms indicating large (>5 cm), moderate (1–5 cm), small (<1 cm) or no involvement. The tumor distribution was recorded according to the presence of tumor deposits in seven abdominal areas: left and right subdiaphragmatic, subhepatic, omentum/transverse colon, small intestine/mesenterium, ileocecal and pelvic. This assessment has been referred to as the “simplified PCI” or SPCI. The system is routinely used for

Completeness of Cytoreduction Score (CCR)

Using UICC score for surgical resections in carcinomatosis is possible. However, in patients with peritoneal carcinomatosis, it is difficult or impossible to confirm a real R0 resection and the UICC score is “R0–R1” for complete cytoreduction and R2 for incomplete cytoreduction. This UICC score has been used in evaluation of cytoreductive surgery combined with IPCH. In a series of 56 patients with carcinomatosis from colon and ovarian cancer treated by cytoreductive surgery and IPCH, Glehen et

Discussion

One may be surprised by the number of peritoneal carcinomatosis staging system available all over the world. In fact, at least three of them are complementary ones: the Lyon staging system, the PCI and the SPCI.

The Lyon staging system and the PCI contribute to the precise intraoperative description of carcinomatosis implants within the abdominopelvic cavity. Using both of them allows an accurate “map” of the lesions. For some diagnosis of peritoneal carcinomatosis, Lyon staging system is the

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