The European contribution to "Sugarbaker's protocol" for the treatment of colorectal peritoneal carcinomatosis.

INTRODUCTION: In 1981, Dr. PH Sugarbaker, challenging oncological orthodoxy, considered carcinomatosis to be a locoregional stage of the disease that was still susceptible to treatment with curative intent. To this end he developed a new therapeutic alternative based on the combined treatment. The macroscopic disease treated by maximum radical oncological cytoreductive surgery (through the peritonectomies described by him), followed by treatment of the residual microscopic disease with the direct intra-abdominal application of intraoperative chemotherapy with locoregional intensification, modulated by hyperthermia and early normothermic postoperative intra-abdominal chemotherapy. Using this new therapeutic regimen, known as "Sugarbaker s Protocol", his group has reported 45% survival rates in carcinomatosis of colorectal origin at 5 years, and, in selected groups of patients, 50% survival rates at 5 years. The scientific community, however, has criticized these results considering that: it is a personal experience, with a not homogenous treatment protocol with developmental modifications over time, that it is a retrospective non-randomized study, and finally that the cytostatics used in his protocol are obsolete. Various European groups have replied to these main criticisms confirming the good results that this new therapeutic alternative offers for patients with carcinomatosis of colorectal origin. The purpose of this article is to present these contributions. MATERIAL AND METHODS: All the articles published in the English language by European groups in the world s medical literature have been reviewed using the Pubmed-MEDLINE database to identify the relevant articles related to the treatment of carcinomatosis of colorectal origin using cytoreduction and intraperitoneal chemotherapy from January 1980 to January 2008. RESULTS: The European contribution during these 25 years in favour of the "Sugarbaker s Protocol" has consisted fundamentally in: a) one multicenter retrospective study; b) two randomized prospective phase III studies; and c) the use of oxaliplatin and irinotecan as new cytostatic agents in the protocols for intraperitoneal chemotherapy. At the same time, two new transcendental European contributions have been made in which the possibility has been considered of combined simultaneous treatment for patients with hepatic metastases and carcinomatosis, and the introduction, as a selection factor, of patients responsive to intravenous induction chemotherapy within the regimen of sandwich treatment (with systemic neoadjuvant and adjuvant chemotherapy) complementary to intraperitoneal chemotherapy. CONCLUSIONS: The results obtained by European groups using "Sugarbaker s protocol" and "Elias protocol" with oxaliplatin compel us to request that these treatments be considered by all professionals involved in the treatment of patients with colorectal carcinomatosis as the best treatment currently available for this condition. Furthermore a randomized, prospective, multicenter study should be carried out to clarify its value and the degree of scientific evidence. A validation of this treatment will change, in the future, the dogmatic consideration of carcinomatosis as an incurable disease stage.

Aportación europea al “protocolo de Sugarbaker” en el tratamiento de la carcinomatosis peritoneal colorrectal / The European contribution to "Sugarbaker's protocol" for the treatment of colorectal peritoneal carcinomatosis

Introducción: el Dr. P. H. Sugarbaker en 1981, desafiando la ortodoxia oncológica, consideró la carcinomatosis como un estadio locorregional de la enfermedad susceptible todavía de tratamiento con intención curativa. Para ello desarrolló una nueva alternativa terapéutica basada en el tratamiento combinado. La enfermedad macroscópica mediante la máxima cirugía citorreductora radical oncológica (merced a las peritonectomías por él descritas), seguido del tratamiento de la enfermedad microscópica residual con la aplicación directa intraabdominal, de quimioterapia de intensificación locorregional, intraoperatoria modulada por hipertermia y de quimioterapia intraabdominal normotérmica postoperatoria precoz. Con este nuevo esquema terapéutico, conocido como "Protocolo de Sugarbaker", su grupo ha publicado supervivencias en carcinomatosis de origen colorrectal de 45% a 5 años y en grupos selectos de pacientes supervivencia de 50% a 5 años. La comunidad científica, sin embargo, ha criticado estos resultados al considerar que: se trata de una experiencia personal, con un protocolo de tratamiento no homogéneo con modificaciones evolutivas en el tiempo, tratarse de un estudio retrospectivo no randomizado, y finalmente considerar que los citostáticos empleados en su protocolo son obsoletos. Diversos grupos europeos han dado respuesta a las principales objeciones, confirmando los buenos resultados que esta nueva alternativa terapéutica ofrece en pacientes con carcinomatosis de origen colorrectal. El objetivo de este trabajo es presentar estas aportaciones. Material y métodos: se han revisado todos los artículos publicados en lengua inglesa por grupos europeos en la literatura médica mundial usando la base de datos Pubmed-MEDLINE para identificar los artículos relevantes relacionados con el tratamiento de la carcinomatosis de origen colorrectal mediante citorreducción y quimioterapia intraperitoneal desde enero de 1980 a enero de 2008...(AU)

Introduction: in 1981, Dr. PH Sugarbaker, challenging oncological orthodoxy, considered carcinomatosis to be a locoregional stage of the disease that was still susceptible to treatment with curative intent. To this end he developed a new therapeutic alternative based on the combined treatment. The macroscopic disease treated by maximum radical oncological cytoreductive surgery (through the peritonectomies described by him), followed by treatment of the residual microscopic disease with the direct intra-abdominal application of intraoperative chemotherapy with locoregional intensification, modulated by hyperthermia and early normothermic postoperative intra-abdominal chemotherapy. Using this new therapeutic regimen, known as "Sugarbaker's Protocol", his group has reported 45% survival rates in carcinomatosis of colorectal origin at 5 years, and, in selected groups of patients, 50% survival rates at 5 years. The scientific community, however, has criticized these results considering that: it is a personal experience, with a not homogenous treatment protocol with developmental modifications over time, that it is a retrospective non-randomized study, and finally that the cytostatics used in his protocol are obsolete. Various European groups have replied to these main criticisms confirming the good results that this new therapeutic alternative offers for patients with carcinomatosis of colorectal origin. The purpose of this article is to present these contributions. Material and methods: all the articles published in the English language by European groups in the world's medical literature have been reviewed using the Pubmed-MEDLINE database to identify the relevant articles related to the treatment of carcinomatosis of colorectal origin using cytoreduction and intraperitoneal chemotherapy from January 1980 to January 2008...(AU)