Management of peritoneal dissemination of recurrences granulosa cell tumor of the ovary.

Recurrences of granulosa cell tumor (GCT) of the ovary often occur as disseminated peritoneal metastasis or local mass in the pelvis. Although, various treatment options including surgery with/without systemic chemotherapy and/or radiotherapy have also been reported for treatment of recurrent GCT, there is no standardized management for recurrence of this disease. Here, we report our management strategies for the patients with peritoneal dissemination of GCT. Prior to admission to our unit, four patients were treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy with the diagnosis of primary adult type GCT of the ovary. They were not received adjuvant therapy because of the localized disease in the ovary and followed-up by their gynecologists until they referred to us with metastases. The median disease free survival after primary treatment was 4.7 (range, 1-9) years. All patients with peritoneal metastases from recurrent GCT were treated with cytoreductive surgery (CRS) using peritonectomy procedures and intraoperative hyperthermic intraperitoneal chemotherapy(HIPEC) using 100 mg cisplatin for 40 min at 43 °C in our unit. Postoperative complications were graded according to National Cancer Institute's Common Toxicity Criteria. No complication and no in-hospitalization mortality were experienced in all patients. The median length of operation was 3.55 (range, 2.50-5.50) hours. The median length of stay in hospital was 13(range, 12-21) days. After a median follow-up of 4(range, 1-6) years, 1 patient was died and other 3 patients were alive with no disease progression. Our study identified that recurrent adult type of GCT with peritoneal metastases could be managed with definitive CRS and HIPEC. Larger series and long term outcome data of CRS and HIPEC will be mandatory to develop standard management option in these patients.

Indication of peritonectomy for peritoneal dissemination.

A total of 521 patients with peritoneal carcinomatosis (PC) were treated by peritonectomy and perioperative chemotherapy. Each of the 95, 58, 316, 31, 10 and 11 patients were from gastric, colorectal, appendiceal, ovarian, small bowel cancer and mesothelioma, respectively. The distribution and volume of PC are recorded by the Sugarbaker peritoneal carcinomatosis index (PCI). Peritonectomy was performed with a radical resection of the primary tumor and all gross PC with involved organs, peritoneum, or tissue that was deemed technically feasible and safe for the patient. The postoperative major complication of grade 3 was found in 14%, and total 30-day mortality was 2.7%. The survival of gastric cancer patients with a PCI score ≤ 6 was significantly better than those with a PCI score ≥ 7. In appendiceal neoplasm, patients with PCI score less than 28 showed significantly better survival than those with PCI score greater than 29. The survival of colorectal cancer patients with a PCI score ≥ 11 was significantly poorer than those with a PCI score ≤ 10. Among the various prognostic factors in appendiceal neoplasm and gastric cancer patients, CC-0 complete cytoreduction was the most important independent prognostic factor. Peritonectomy is done to remove macroscopic disease and perioperative intraperitoneal chemotherapy to eradicate microscopic residual disease aiming to remove disease completely with a single procedure. Peritonectomy combined with perioperative chemotherapy may achieve long-term survival in a selected group of patients with PC. The higher mortality rate underlines this necessarily strict selection that should be reserved to experienced institutions.