Peritoneal based Malignancies

Peritoneal based malignancies refer to cancers that either originate from the peritoneum or have spread to involve the peritoneal lining. 

Tumours that arise from the peritoneum: 

Tumours that may spread to the peritoneal lining: 

• Ovarian Cancer 
• Colorectal Cancer 
• Stomach Cancer 
• Pancreatic Cancer 
• Gallbladder Cancer 
• Appendiceal Cancer

Imaging tests

Ultrasound, MRI or CT scans may be used to produce detailed pictures that may indicate the presence of cancer. 

Blood tests

A blood test that measures levels of a chemical called CA-125, Ca19-9, CEA in the blood may indicate 

the presence of peritoneal based malignancies. However, these markers are not specific and high levels may be present for other reasons. If your health screen shows high levels of these markers, please head to your nearest clinic for a referral to a tertiary centre for further workup. 

Lower GI series or barium enema

During this procedure, the colon and rectum are filled with a white liquid called barium, that helps x-rays show details in the large intestines, making it possible to spot tumours or other abnormalities. 

Upper GI series

In this procedure, barium is swallowed so that the x-rays can show details of the oesophagus, stomach and duodenum (first part of the small intestine). 

Endoscopy

A scope is used to provide direct visualisation of the lining of both the stomach and large intestine. This procedure is usually done under sedation and is generally safe. Any suspicious lesions can be biopsied for histological diagnosis. 

Laparoscopy

A thin tube is passed through a small incision in the abdomen so that organs inside the abdomen can be examined. If necessary, a biopsy (a small sample of tissue) may be taken for examination and testing in the laboratory to confirm a cancer diagnosis. 

Paracentesis

In cases where a biopsy is not possible or if it is suspected that the fluid build-up (called ascites) that is characteristic of peritoneal based malignancies, is due to other causes, a doctor may remove fluid from the abdomen so that it can be examined under microscope to indicate which type of cancer is present.

In the case of peritoneal based malignancies, not all patients are suitable for surgery. Those who typically are suitable for surgery are: 

Treatment for peritoneal based malignancies includes cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). New treatment in the form of pressurized intraperitoneal aerosolized chemotherapy (PIPAC) has emerged as an option in patients with extensive peritoneal disease that is deemed not suitable for resection. 

Cytoreductive surgery (CRS) 

CRS aims is to remove all visible tumours in the abdomen. Intra-abdominal organs that have tumours which can be safely removed, will be resected to ensure no disease remains. In addition, surgery to remove the involved peritoneum will be performed. 

Hyperthermic intraperitoneal chemotherapy (HIPEC) 

Once CRS is completed, HIPEC is administered in the operating room to treat any microscopic tumours that may be present. During this process, the chemotherapy drug is heated and kept at a temperature of 42 degrees Celsius. The heat is used to help increase the penetration of chemotherapy drug into the tissues. The chemotherapy is circulated into the abdominal cavity and then out for a constant flow using a specialised pump that moves the heated chemotherapy solution. This is done over a period of time after which the abdominal cavity is washed and the procedure is completed. 

Patients with extensive peritoneal disease that cannot be completely removed may not be suitable for CRS and HIPEC. These patients may be identified pre-operatively after imaging scans or may only be identified during surgery. Disease on the peritoneum may be very small and can be difficult to detect on imaging prior to surgery. 

During surgery, the surgeon may decide not to proceed if tumour spread is too extensive or if too much of the bowel has to be removed. In these cases, surgery to remove as many tumours as possible to lessen symptoms, may be an option for some patients. 

Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) 

PIPAC is another way of introducing chemotherapy into the abdomen for patients with advanced peritoneal based malignancies. It is done with laparoscopy technique under general anaesthesia. No organs are resected during the procedure. Biopsies will be taken prior to infusion of chemotherapy. 

This procedure may be repeated multiple times with or without conventional chemotherapy given in between treatment.

Before surgery, the anaesthesia team will also assess your fitness for surgery and advise you on various aspects of general anaesthesia aspects and pain control after surgery. 

Specialist nurses will also provide pre-surgery counselling.

Stoma

Some patients who undergo CRS will need a temporary stoma (a surgically created opening on the surface of the abdomen to divert the flow of faeces into a disposable bag worn over the stoma). The stoma allows the bowel to heal after surgery. This will be reversed after 2 months’ post-surgery, after discussion with the surgeon and medical oncologist. All patients are seen by specialist stoma nurses before and after the operation, who provide information about stoma care. 

Recovery

After recovering from surgery, you will be given regular outpatient appointments to see your team of doctors. These visits may include blood tests and scans to monitor and check if the cancer recurs. It is important to follow your doctor's advice, keep to scheduled clinic visits and do the prescribed tests so that timely treatment can be administered if the cancer or other problems arise.

Early postoperative 

Late postoperative complications 

For more information, click here for the English publication on Peritoneal based Malignancies. 有关腹膜表面恶性肿瘤的中文册子，请点击此处。 Click here to watch our video on ​Peritoneal based Malignancies. For further enquiries on Peritoneal based Malignancies, please call the Cancer Helpline at (65) 6225 5655 or email to cancerhelpline@nccs.com.sg

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