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Good evening, everyone and welcome to our session on peritoneal metastasis, setting the scene for the colorectal surgeon. We have got excellent speakers here today who have kindly given up their evening to be with us to talk about this really interesting topic which is also incredibly popular for the FRCS exam. Um I will be just set the ground rules. So there's a chat box on the left on the right hand side, please ask your questions in there. We're hoping that this is going to be a very active session with lots of engagement. So please do not shy away from answering questions and as well as asking questions without further ado I'm handing over to Johanna Dr who is our Advanced Council and perit malignancy representative. Thank you. Thank you. Um It's a great pleasure to introduce our two speakers today. Doctor Dine, you who are um both from Birmingham. So Mr Y is a consultant coral surgeon, um and also he's the chair of the um peritoneal malignancy subcommittee of the ME CP and Doctor Dese is a consultant uh radiologist. So the layout for today's session will be um about half an hour of uh background knowledge of what we need to know um as colorectal surgeons and that will be followed by um about 4 to 5 cases um in kind of an MDT set up. So it would be great if everyone gets involved. So give your answers on the chat box and ask questions during that time as well. And that further, I do. Thank you. Thank you very much. Thanks Riana. Thanks uh for inviting us to talk. It's a great privilege. So, um I'm just going to talk to you a bit about colorectal peritoneal metastases mainly. Um And let me know if you can hear me or if you can't hear me and if you can see the slides, OK? Yeah, we can see the slide and hear you. Thank you. So, so the background to this is that about somewhere between 5 to 15% of bowel cancer patients present with colorectal peritoneal metastases. Some of this occurs synchronous with the primary. That's about a third and in two thirds of cases, uh it's metachronous. So it comes later once the primary has been removed and it occurs within the peritoneum. And in 3% of all bowel cancer cases, we think it's peritoneal only metastases. So, in the absence of systemic meds such as bone brain, lung, liver, and so on. So if you look at, if you look at uh the population of 35,000 or so new cancers per year in England, you'd be looking at just over 1000 cases that would have peritoneal only metastasis in England. And, um, it was Paul Sugar Baker. I've shown this photo here. Look, this is what happens if you go for a fellowship, you get a free trip to Washington DC. Um, and that was me back in 2009. I was happy and young and, uh, this is Paul Sugar Baker from the Wa Washington Cancer Institute. Um And um it was Paul Sugar Baker first described um combining cytoreductive surgery which er is complete macroscopic tumor removal um or combined with heated intraperitoneal chemotherapy. And we'll, we'll go through the rationale for that. So basically, macroscopic tumor removal gets rid of all visible signs of tumor and the HIPEC as we call it, um will aim to destroy up to 2 to 3 millimeters of disease. So, hopefully, uh destroy the microscopic evidence of cancer. And in a, in a complete cyto reduction there, there's a whole host of peritonectomy and visceral resections that it can involve very few operations involve all of these, maybe some pseudomyxoma which we can touch on towards the end. But um the majority of colorectal peritoneal metastases will just involve a few of these because if it, if you had cancer involving all of these and the patient would not be suitable for, for a colorectal peritoneal metastasis side reduction. But it's sort of things like the parietal or paracolic peritoneum that we can strip out the pelvis, the diaphragmatic, the liver capsule, porto hepatis, the aorto caval groove, which is just under the cald lobe. When you slide your hand up, uh subhepatic groove, overlying the pancreas, you've got peritoneum absolutely everywhere. Um And obviously, visceral resections, bowel spleen, pancreas, gallbladder, often tailor pancreas. Um, a small proportion need gastrectomy, greater and lesser omentectomy. We, we take greater omentum routinely and, and we often take ovaries routinely when we can, uh, hysterectomy if involved. And a, as a general rule, with the exception of the ovaries and the omentum, we only remove, um, organs or peritoneum that is involved with tumor. We don't just remove all the peritoneum for the sake of it because as you remember, the peritoneum is the first defense, mechanical defense, uh, to keep cancer out. And once you remove that peri peritoneum and, and create a raw surface, um, it's a, it's a real breeding ground for cancer cells to latch onto. Um, so we always do that with the HIPEC. So this is an example of a parietal peritonectomy. You can see we're holding up there, the abdominal wall, the rectus and rectus muscle with, uh, some little woods forceps. I'm holding the peritoneum there, which we've stripped off and you can just about appreciate, um, a peritoneal metastasis there, there might be another one there and, and possibly some that you can't see lower down here is a typical, um, sort of recto sigmoid T four tumor you can see how it's puckered, the cancer and that you can see a white peritoneal match. You might notice the peritoneum is a bit discolored here. And that's because we'd actually stripped it. So it was devascularized. And then we put it back for the photograph when the, when the, when the photographer arrived. So the peritoneum doesn't normally look so, so colored, but more glistening and pink and healthy like this. And we removed that fat specimen with a tumor. Is it somewhere there? There's the rectum and sigmoides, there's the high ligation and here's the peritoneum um en block, pelvic peritoneum, en block with the um with the bowel. This is a different. So this is more of a uh metachronous one. Now, the last one we looked at was a synchronous one where the primary was intact. This is a metachronous one where you have, for example, uh here, a Kruckenberg tumor, an ovarian metastasis with small bowel stuck to it and omentum stuck to it and there was a uterus and a bit of sigmoid stuck to it as well. So, here is a resection which shows the KRG with the uterus and the, the bowel and the pelvic peritoneum. All, all take and unblock. And that's often the easiest way. Once we've done the resections, we then put in uh usually for, for um gi malignancies, we use mitoMYcin C. Uh We use it for 60 minutes, heat it to approximately 4142 °C. The heat is interesting. It works synergistically with the cytotoxic agent. There's various theories as to why this may be. Um we used to think it was just because it it destroyed the cell membrane. So the cancer cell membrane, so the chemotherapy could penetrate more deeply into the um cancer cell. But there may be more cleverer immunological things going on with heat. And this is the more recent machine we use. You can see here on the right, a a nice touch screen machine now. So this all was all based on evidence back in 2003 with a multicentre Dutch trial which compared site reduction and HIPEC with s with systemic chemotherapy, which was then the standard of care for patients with colorectal peritoneal metastases. And they showed a uh 44% versus 24% survival at two years. Uh advantage with the site reduction, high group versus systemic chemo alone. However, it was a small study and um the, it the study was contaminated with append a few appendix tumors making it slightly um inaccurate. Nevertheless, the survival advantage did come out to eight years in, in in medium term follow up. Um disease free survival was better with a CRS and IPC group uh versus standard chemotherapy and median survival was very impressive at 48 months with five year survival of 45% in this randomized controlled trial. And remember these are using chemotherapy agents back in 2003. And, and before we do have better agents nowadays, so I'm gonna talk to you now about how we um some of the terminology we use in this surgery and how we select patients. Um So this is the uh Sugar Baker's peritoneal carcinomatosis index and it, what it does, it divides the abdomen into nine parts and the small intestine and four, the first quarter, second quarter, third quarter and fourth quarter. So that gives you a total of 13 regions in each region. You can score between 0 to 3, depending on the size of the tumor, biggest tumor nodule seen in that region or in, in, in cases of confluence, the size of the confluence of the tumor. So the maximum score you can get here is 39 and the minimum score you can get is zero. Um And if you look here, this is um sugar bakers and also the, the French data that was published back in uh quite a few years ago now, but still holds true today. That shows you the lower the PC score, the better the survival. So this is PC lesson 10. Um And you've got 10 to 20 then less than 20 you've got the similar thing here and what we've discovered if you look at the um 20 or more um the survival is not very good and is probably similar to systemic chemotherapy alone. So, in often when we we look at patients with colorectal peritoneal metasis if they have a PC score of 20 or more, when we get into theater, this is an intraoperative scoring system, we will often pull out just because of the uh reduced survival advantage. These things are never absolute. Um And you have to take it in conjunction with the patient's wishes and quality of life and age and, and what have you. But, but as a general rule, you're not gonna do a lot of good. If you um take people on with PC 20 or more, we also measure at the end of surgery, the completeness of sight reduction with CC zero indicating no disease. CC one less than 2.5 millimeters. Uh and CC two and CC three mo more we consider CC zero and CC one as complete site reduction. Although there, there is a difference between the two. Um just because we think the HIPEC destroys some of these um small nodules. And again, if you look at the er completeness of site reduction score, uh if you get a complete site reduction like CC zero or CC one, then your survival is better than if you can only debulk a patient. But you can see here in the French data that there is a difference between CC zero and CC one. So CC zero is absolutely what we're aiming for. Oh, on the back of a lot of this data came, the nice guidance in 2010, which then told us that uh we could do c reduction high pec for peritoneal mets from colorectal origin, but only under with careful data and in, in recognized centers. And off the back of that, we got uh commissioning in NHS England. Uh a commissioning document that said uh we could operate on peritoneal neoplasms, benign and malignant and appendiceal or colorectal origin. But this excluded pseudomyxoma peritonei which has a separate commissioning document. So, the current commissioning um situation in England and apologies if you've joined us from Scotland or, or Wales or um Ireland, I can, I can touch on those. Um is that um we have three commission centers for colorectal peritoneal metastases and they're the Manchester Christie Birmingham at Scut Hope Hospital and Basingstoke in Wales, there is a center starting up um Swansea, I think. Um and in Scotland there is a center in Dundee. Um and in um Ireland, you have Dublin in the Mater hospital. So there are some elsewhere but they're not, they're not formally commissioned, although the Welsh one is, is coming on board soon. I hope so. Looking at the one in University Hospital Birmingham, what do you need to have a peritoneal service? Well, you need a specialist MDT, you need good colleagues. So surgical colleagues and radiologists and anesthetists and theater staff. Er you need a fully trained team, itu ward team and so on specialist nurses. Um We do uh colorectal and appendix cancer. We don't do pseudomyxoma peritonei just, just, uh, because we're not commissioned for it and we do some, some selected cases of peritoneal mesothelioma, which is probably not within this talk at the moment. Um, we, we do things like hold patient support group meetings yearly and if anyone wants to see the, some of the information we give to our patients, you can visit this website, er, which is, er, peritoneal surgery.co.uk. Um We hold a lot of educational meetings. It's very important to keep your data, which we do religiously using a data manager. So anyone who wants to come as a, we have a peritoneal Clinical fellowship, which we've just recently appointed to. So it will be occupied for a year but um will be probably available in a year's time. And uh for anyone who wants to, there is a, a prospectively collated uh database with a data manager. So all you have to do is extract the data and analyze the questions you want to ask. Um, we also have a phd or MD uh fellow program along with Professor Beggs Andrew Beggs at the University of Birmingham. That's a lab based um research post. So, looking at what we've learned over the last few years while our referral numbers have gone up, this, this was half, mid, mid year and we operate on just around half of the number of referrals that we and we've just er surpassed 600 cases um, most of these patients are, um, well, there, there's a female male mixer, slight, slight preponderance towards female at 54%. And most are in the fifties and sixties. Um, age group. Um, the complications are significant, um, but, um, get less with time. So most units when they start have a grade 34 Clavian DDO or CTCA e complication rate of 35%. And I've, over the years seen I dropped to 25 and 15%. And now most of us, er, er, Christie and Basingstoke and Birmingham all sit around 9%. The death rate is around 1% for a very, uh 1 to 2% for established high volume units. Um, these are the sort of complications you can get like, like any bowel operation, really, bleeding infections, collections. VT E is particularly high in patients with high tumor burden, anastomotic pancreatic le enterocutaneous fistula and COVID. Hopefully not so much now. And this is the sort of survival data we've been getting in Birmingham, which is very similar to what we're seeing in, in, in trials. But if you get acc zero, we're seeing uh five year survivals around 32% but median survival of, of four years, which is bang on what the Dutch trial found also much less if you get CC two with a five year survival of zero. Uh, disease free survival is interesting. So people often say, do you ever cure these patients? Well, in about 20% of cases. Yes, we do. Um, here it says 31% but we've since looked at our date again and it's looking closer to 20% disease free survival at, at five years having said that that doesn't necessarily mean we cure them. I just saw a nine year recurrence which was very disappointing. So it's, um, although we often call disease 3 to 5 L5 years as a cure, I can tell you it isn't. Um, and we also found that if your PC was less than 12, you did much better than if it was greater than 12. Um, with five year survivor, 48%. Um, and er, zero, if it was greater than 12, this is a really interesting one. If you compare rectum with colon, these are all peritoneal mets, of course, um uh with the rectal primary, your five year survival is zero. And I don't think there's any series in the world to, to find otherwise. Whereas colon has a higher five year survival. So, optimal selection for these patients are people with PC lesson 12 ones where you think you can achieve a complete site reduction. And we judge that based on radiology, plus minus laparoscopy and those with colon cancer rather than uh rectal cancer. We are achieving median survivals of 44 months for these patients. So, um, we've, uh, so we've talked about obviously patients with limited peritoneal metastases will do better, lower PCI, we we see small bowel cirrhosal disease as a relative contraindication, but not absolute. You will often get peritoneal disease in the term lilium at areas which are fixed. So TI and DJ flexure, but if you've got widespread small bowel cirrhosal disease or diffuse miry deposits, then that is an A no go area really. Um And if you're not sure, then a laparoscopy can help. We also looked at a small subgroup of our data. And if you look at the time it takes to recur from removal of the primary. So this is for patients with metachronous recurrence, which is the majority if the disease free um interval is less than 12 months, that's probably an indicator of uh more aggressive tumor biology. And so the one and three year survival is lower at 54 and 0%. Whereas if your disease free interval is greater than 12 months, you can have much higher one and three year survival of 92 65%. And if this is a surrogate marker for tumor biology, probably we look at fitness not age. So we've operated on patients from age uh 19 through to 87. Um If you've had a lot of previous surgery, patients do worse, it's called the prior surgical score. Um And obviously, if you've had recent surgery, so within the last six months, you might want to delay surgery because things are a bit sticky. You want to wait at least six months before going back in um the, the response to systemic chemotherapy is, is contentious. We don't have strong evidence that if you respond to systemic chemo, you do better. But um it's what we all do because if you're not responding to chemotherapy, you've probably got horrendous um biology and we will do synchronous resections with uh liver metastases. We've done up to five liver metastases, but normally one or two would seem sensible lung mets aren't an absolute contraindication. They used to be. But actually, we've all seen people live with lung metastases for many years or if they have very limited lung mets, they can be treated also. So, other considerations just to finish up with then is that um some of you may have heard of the Pro seven trial, which was a Multicenter French trial, um which reported a small number of years ago. Um looking at the role of high pe in this. So, er, they compared site reduction and high PC versus site reduction alone and found no difference in overall survival in using the HIPEC. Oh, no, high, there was a reason expected um over a median survival with the site reduction alone and they did use oxaliplatin, um which isn't what most of us use in, in the UK. Um So, um and they did find also in the mid range that there was an improved disease free interval in the mid range PCI, there was an improved disease free interval for the high PC group. So it wasn't a, a complete disaster for HIPEC but it didn't, certainly didn't show the, the um benefit of hype C in that trial. We are looking at maybe doing a mi a similar trial for mitoMYcin C in the UK. Uh but, but we just need to watch your space. Uh, the role of systemic chemotherapy needs more work. We've looked at, er, we've published a Catherine white. One of our previous research fellows published a systematic review um on the er role of neoadjuvant and adjuvant chemotherapy. And we found that there wasn't as much of a benefit as you might expect with neoadjuvant chemotherapy before site reduction I PC. And in fact, it probably worked better if you gave it afterwards. Nevertheless, there is still very much a feeling that you should try to get control of the disease by giving systemic chemotherapy. Interesting how the trials don't always change clinical practice. Um the role of CRS and IPC with liver and lung meds needs a little bit more evaluation and, and probably uh it's time that we started developing metastatic colorectal cancer MDT S. And of course, we mustn't forget about quality of life. And this is a Harry sero one of our previous research fellows published this review of Quality of Life in the European Journal of Surgical Oncology, which showed that um depending on whether you were symptomatic before the surgery or not, you would return to baseline or better quality of life at somewhere between 3 to 6 months, postoperatively. So, if you think someone doesn't have um much prognosis beyond six months is not an awful lot of point doing it. And I would argue if you didn't think they were gonna live 18 months or more, then you should think very carefully about doing um, this big surgery. So that's an introduction um, to uh side reduction hype for colorectal peritoneal metastases. Uh Thank you for listening. I'm now gonna hand over to um my colleague, Bally, er, Doctor Dese, who's going to talk to you about CT scans. I don't know. Uh Yeah, I don't know if you, if you want me to take questions at this point or leave more till the end, I think um they can all type questions and then we can answer them at the end if that's OK. So we'll, we'll hand you over to Doctor Dese. We'll talk to you about CT and peritoneal malignancy and then we'll meet again to do some cases. Thanks, honey. Um Hope you can see um act which I've um anonymized and uploaded um for you to review. Essentially, we're gonna discuss this case shortly as part of the kind of the, the MDT. But I thought it's a good example just to kind of explain what we do and what we go through. Um So Hay's mentioned that we look at the um PCI PCR is a really important um s um significance on survival and how successful the operation is. Unfortunately, radiologically, we always underestimate the PCI. Um If there's a big macroscopic nodule, we're more likely to see those but very small implants sheet like implants. We're very unlikely to see radiologically, unfortunately. Um, but we do, um, I try and do certain things to try and maximize um our chance of finding di disease. Um That was the most important thing is thinking of the um peritoneum physiologically. So, obviously, you, you tend to have peritoneal fluid um kind of in the pelvis as you breathe and expire, you have a negative pressure, peritoneal fluid comes up um in the paracolic gutters um bilaterally but much more on the right. So the right paraconic gut is much wider, the left is smaller and you have the left from colic ligament which prevents fluid coming up that side. So, peritoneal disease on the right is much more common. Um You also get disease over the liver and spleen. So there are areas we look at. Um and also where essentially you get stasis of peroneal fluid. So anywhere where these malignant cells which are floating around in the fluid, wherever they um are more likely to kind of slow down is where you're more likely to get implants. So they tend to be in gravity dependent position. So, um hopefully you can see the CT scroll, but so are you more likely to get the disease in the pelvis, so particularly pouch of Douglas or the rectal vy pouch in um in men. Um and also o over the sigmoid colon typically as well. And then you also get disease where um peritoneal fluid resorbs. So that's also at the diaphragms. Hence, you're more likely to get disease of the liver um of the spleen and also in the omentum, which is the white suture. Um it comes, pays for implants as well. Um I suppose I II, the other thing I should mention is that CT scanning is what we do most of the time. So when a patient is diagnosed with a colorectal cancer, they have to have a CT scan. Um first off. So actually, we, we, we, we were just discussing this before the meeting that and often the radiology registrar and report um CT S out of hours. But actually, the surgeons do look at images a lot themselves. So it's worth um obviously having a look for if you can bef before you do an operation to review CT scans, cos if there are any obviously peritoneal deposits that you're suspicious of um having um CRS and high PC as an initial operation rather than coming back once um you, you've gone through a resection is probably more beneficial for the patient. Um And yeah, and finally, so there are other imaging techniques we do. So obviously, you can use CT imaging um MRI we, we can use as well, but it's much more resource. Um um use much more of our resources. MRI is probably the one modality which is in the most demand in the radiology department and that's slightly better at picking up diseases over the liver. Um And in the Pelvis, pet CT is also useful um not so much for mucinous disease. Um but and pet CT is very good at finding big implants excluding kind of extra peritoneal disease um which may change how the patient's being managed. Um I suppose we can start with the MD. OK. So, um I'm very happy for this to be interactive. Um If you want to um put your ideas down in the chat, that would probably be the best, best bet. Don't be shy, you won't be marked. Um So not yet. Um So first case I'd like to present is a 66 year old lady from Redditch who um had a right hemicolectomy, December 23. So just uh seven weeks ago, eight weeks ago, for what was it T four BN 11 out of 15 nodes perforated tumor. And um this is the scan that er Doctor Dey will show us now. Yeah. So when, when we discuss these patients on the MDT, it's really important we have all the imaging because the story is kind of what um helps also make the decision. So this is actually her index scan um and preoperatively and she's got a um she had a sequel tumor. And actually, if you look at the sequel tumor, they tend to normally um typical kind of adenocarcinoma, they tend to be quite solid, quite enhancing. Um but this is quite a low um density component. And when we find a um a tumor, we look at follow the ileocolic um mesentery up and they do, they did have some nodes and actually, these nodes once again are quite rounded and quite low density. That so gi given the talk is peritoneal disease, obviously, you need to make sure there's um where else is the peritoneal disease? Did they see the disease at the time of the operation? Was it picked up before that? So this was um this was I think picked up at the time of surgery. Yeah. Yeah. So, so um yeah. So on this patient, if you look at those certain areas, you look at the right paracolic gutter, the di the tumors on the right, you're more likely to get disease on the right. You can look down in the pelvis, make sure there's nothing in the um pouch do that or at the peritoneal reflection. And actually the the intra of fatty is quite clean, but where the patient does have some apparent disease, it's just over the liver. So you can see some resettle um kind of thin almost plaque like disease capsa deposits over the liver. Um And the patient had an MRI to try and characterize this slightly slightly better and on the Mr you can see the disease slightly better. So this is, you can't see the imaging. It's just sort of, um, frozen on one ct slice. Ok. Um That's a shame thing. It's moving now. It's moving. Yeah. Yeah, it's moving. It's moving. Can you see an MRI scan now? Yes. Oh, fine. Oh, ok. Um, yeah, so I, I'll, I'll, I'll just, in case there's a bit of a bandwidth lag. I won't scroll so quickly. So I'll just stop at. Um So it's so this is um yeah, a capsid deposit of segment seven second six and it shows that there's significant capsid disease but the rest of the CT um scan looked OK, brilliant. So my question to the panel and you are on the panel um is put, please put in the chat box, what you would do with this patient. So the patient has actually had the primary out because it was perforated. Um And is sent to us knowing that there is some capsular deposits, subcapsular deposit and some peritoneal disease around the right iliac fossa. Um So who, what I need to know from you is what, what we do next in two or three words or less? I'll give you 2030 seconds just to type in your ideas into the chat. Shall we give them some options and I can create the poll. Do you want? Should we do, should we do a poll then go on? Ok. Who we want, we want to know who would operate. Yes. Um, ok, we're, we're, we're creating a PIC side. Ok. What to do? Operate chemo, palliative care. Yeah, I think that's, that's, uh, they're the three options, aren't they submit? We have some answers already just to. Ok. But I'm just wondering if we should give them a couple of minutes to do the poll and then we can discuss their answers as well just in case. Yeah. Excellent. Ok. Any more answers? Oh, it's swinging around the other eye. Fantastic. So we've got 15 responses. How many, how many respondents do we have? 4040. Ok. We'll give it just a few more, a few more seconds for the remaining 23. Oh, someone is asking if we know the MSI status, uh MSI um low. Ok. Don't be shy because we don't know who's answering what I think on the poll. It's all anonymous. So. Ok. So che, so if er the operate, so definitely I would be looking at some point to operate on this patient. However, they have just had an operation in December 23. You may have missed that. Um And as I mentioned in my talk that you want to wait at least six months before you go diving back in because it's gonna be really sticky in there. The patient's gonna be a little bit ropey. So, um we would favor uh chemotherapy in the first instance, we would normally recommend three months of chemotherapy. So about uh anything between 4 to 6 cycles followed by a restage at that point, if the patient remained stable or um in fact, had a response, we would offers reduction hy pec. So I suspect the, the um you're both right, both groups. But the timing is chemo first and operation. And if A PC is, is accurate, you've probably got a PC of a radiological PC of about two in your right hip quadrant would say belly and about two or also in the right eye fossa. So a PC of about four. Um So if you've got a PC of less than seven, you're actually looking at potential 50% 5 year survival for this patient, which is pretty good odds for stage four bowel cancer. Really? Ok. Let's move on to the next case then. So I'll tell you about the next case just as er Doctor Desi's getting the scans on. So this next guy is a 40 year old man. These are all real cases actually um in our MDT within the last two months, OK. Um Some of the, some of them within the last uh couple of weeks. So Joe's uh so this, this 40 year old man had a from the neon, am I allowed to say that we're a confidence, I think we are, are we, there's a lot of quite big. So we had a right hemicolectomy in May 23. OK. So, um we're looking at what, 78 months ago? Um and that was done for large bowel obstruction with colonic perforation. So, it was an ascending colon tumor caused a cecal perforation. And histology came back as a PT four B N two BR one tumor with signet ring. Um And then the MDT decided after that quite rightly to give um some adjuvant chemotherapy. So he went on to have eight cycles of adjuvant capox. He's now been sent to us with a um post chemotherapy CT scan, uh which doctor will show you now. Um Yeah, so I'm just going to very briefly discuss the index scan. The reason why this is important is because the patient's perforated and you can see where the fluid's gone. So when I see where the fluid's gone, that's where the peritoneal disease is most likely likely to track. So this is his perforated ascending colon tumor. You have fluid over the liver, you have fluid tracking down the right paracolic gutter into the pelvis. Um So this is his restaging scan. Um He has um disease over the liver. So he's got some small um kind of implants just over the liver. He has got kind of a thick rind of tissue um in the right para colic gutter which kind of tracks down into the pelvis um within the pelvis itself. He's got this kind of matted to get his bladder sigmoid and small bowel loops in the right leg across are all matted together with this plaque of disease which extends into the pelvis to the sigmoid. And he's also got implant down in his p, the peritoneal inflection um, in the pelvis as well. So you can see how many sites there, there's the liver, the right side, there's two as the, uh, pelvi pelvis right down and then deep in the pelvis. Four. So at least four sites of disease. Yeah. Ok. So it's back on your er buzzers. Um Let's create a pole for you. Do we operate chemo or palliative care? I don't have any other options. Can anyone think of any other options? Uh radiotherapy? No, if you want to write other, just write other in the chat saber, I'll just give you a minute or two just to, don't we shine? Now, click your buttons and feel free to type anything different or if you have any questions or if you have different suggestions I should add at this point that the decision making for, for this is not, it's not uh black and white. It is very uh based on experience and it is uh it, there is an art to it. As much of what we do as surgeons. There is an art to what we do. You know, it's like deciding whether you treat someone conservatively or surgically with a local perforation of diverticula or whatever. You just look at the whole picture. You don't just look at the scan. Remember the surgery was in May. He's had chemotherapy. Um, he's 40 and um, he's had, um, he's got those four sites of disease. We have a comment whether the ring, um, histology is a bad prognostic. Yes, factor, signet ring tumor is a poor prognostic factor very much. So, it's often hand in hand with poorly differentiated disease and someone mentioned to discussing the MDT. Well, I presume this is the RM DTI guess the, this is our MDT. We are the MDT. You can't get out of that discuss with senior colleague. You're not gonna get away with that. Ok. I'll give you 10 more seconds. Oh, we got more responses this time. That's excellent. Ok. So, um it looks like uh most are in favor of surgery. Well, we as an MDT decided not to operate at this stage and the reason is we have, do you remember I said if your disease free interval is less than 12 months? Um And there was no disease, no peritoneal disease seen at the time of surgery, it was just perforation. And um you also have someone who has progressed quite rapidly through chemotherapy, through adjuvant chemotherapy. So we're not in control of this disease. This will continue to go pretty rampant while we're operating and while the patients recovering. So, what we suggested is that again, he goes for chemotherapy in the first instance, for three months. Um and depending on response, either go for six months or you know if he's had a slight response come back to us and we could then have a look and decide whether he's responded, stayed stable and whether we're gonna go ahead and, and give him a go. The other thing to bear in mind here is as doctor does, he said, the radiological PC vastly under stages compared to the operative PC. And my feeling is where you have multifocal disease. That's more so the case. So here you've got four sites of disease. In reality, you'll probably have 678 sites of disease. And there have been various papers published that estimate the difference between radiological and intraoperative PCI. Some saying that the RA the, the actual PC is 3 to 4 times the amount of um uh a radiological PC. My experience is, it's not quite that bad most of the time, but it can be double in these, in these sites. So for this reason, we decided to go with um chemo and then reassess not much to lose by giving chemo upfront. Um because if the disease progresses through chemo, you're dealing with bad biology. So it does give you that trial of time that you sometimes need when you're not sure. Ok, thank you. We'll move on to the third case. What's that? Say? It, it's unlock to get benefits from CRS and IPC. Uh What does that mean? Naveed? Sorry. Just uh just uh explain, explain that. So you understand, I'm not sure I think it's a typo. If you can retype it, please read. Ok. Um third case then is a 61 year old lady who had a colonic uh a sigmoid cancer stented with a colonic stent in February 22. Ok. Um She then had um five cycles of folfox uh as a neoadjuvant to her resection, she went on to have a sigmoid resection. A Hartman's resection with a left iliac fossa colostomy done in May 22. She um has now come back in surveillance scan um with the CT scan. Yeah. So this um lady's had a heart's, you can see her left um electro uh colostomy rectal stumps in the pelvis. So when you look at those areas again, um down in the pelvis, there's no disease you're concentrating on the, on the left hand side given that's where her primary tumor was. Um And within her left omentum, she's got this implant here. So um I don't know if I can measure um but you've got a yeah, 1.8 centimeter left a mental implant and actually on um CT that's the only disease we can see. I think this lady also had a pet scan um at her um where, where she had uh CT imaging and this was the only cyto disease in the in the left omentum, right. So, uh surgery, chemo palliative or saber. Do you know much about saber, stereotactic l radiotherapy? Very highly focused high dose radiotherapy to a small area with minimum. Yeah, I've got a comment there from Naveed saying the patient is unlikely to get benefit from CRS. And I beg for the last case. And I think, I think you're right, but he is pushing quite hard cos he's 40. But anyway, we send him for chemo and we'll see if he gets a response or it'll probably self select whether he, he, it becomes inoperable or not. Ok. What have we got here? So we've got 14 responses. I'll give it a few more seconds. You can tell it's an audience of surgeons, can't you? They just want to operate. It's cos you guys wanna get your hands dirty. I get it. Ok. Five more seconds. Oh, no, it's still going up. That's great. One for Saber James will be pleased dear. You. It's not private. 54321. Ok. Surgery. 76%. And that's exactly what we would suggest. In fact, I saw this lady today in the clinic and I've offered her psych reduction I PC. So, um, yes, indeed. And actually what I didn't tell you on purpose is that she's already had three months of chemo, which the center had already done, but we would, we would operate on this patient if they came straight to us just because it's such limited disease. Let's clear it. Um Chemo at best is going to shrink it down a bit. Maybe get rid of it. But you you'll still be left with something there and you'll go back in. So, we, we would, um, we would operate just out of interest, what happened to the tumor to the mass during the chemotherapy that she had that one. Yeah, it shrunk a little bit. It shrunk a little bit. Yes, it did. So, does that give you a bit more confidence in order to go in and operate? Absolutely. The, the, the issue occurs, of course, when it shrinks so much that it's no longer pet habit and we don't always do pet scans, but referring teams often do, but you still see a little bit of a scar there and things and we have no idea whether that is diseased or not. And, and we discuss this with patients and we decide together with them, whether, how, how sure they wanna be or whether they're happy to keep it under surveillance. Cos there are times where we'll go in, remove that hard lump, which feels cancer still and it comes back as fat necrosis and that is probably a complete response to chemotherapy. So, um it is interesting in anything or could we have waited? But nevertheless, uh it's, it is the nature of the game. Some in some patients you get in and you, you remove abnor abnormalities, pet avid abnormalities, which come back as benign sometimes. But we try to keep that to a minimum. Ok. All right. Uh Case number four then um from Doncaster. Uh, II, haven't the lady's age but I think she was in her forties and, uh, she s had a left colonic tumor stented, a descending colon tumor stented. And then she, um, went off for chemotherapy cos it, it would have been causing large bowel obstruction. It's quite, quite l locally advanced. Did you want to show the first scan the stented a stented tumor or should we, should I tell her a bit more first? Ok. So, and then she uh was referred to us, but in the interim, she got obstructed again and I told them to resent her. Um And so we will show you the scans now. Yeah. So this is um, the patient. So typically a surgeon's done the scope. So there's a descending colon tumor and it's actually in the sigmoid. Um But so the patient's got a very reasonably locally advanced tumor. So they've got a large soft tissue component extending into the sigmoid mesentery. Um This is the im just there and this tethers this small bowel loop. So there's a small bowel loop just, just, just tethered to it, um, as well. And actually, as well as this, she has got some protein deposits. So she's got a, um deposit down the protein reflection. She's got this focus in her, um, that's probably going to be her VTA and she's got this on the, on the left as well. So she's got, um, quite a nasty looking sigmoid tumor. Touching the small bowel loop, um, deposit on the right omentum on the left and in, in the peritoneal refraction just the there as well. Great. So, anyway, as I say, the, um, patient came with a large bowel obstruction. A and those, uh, peritoneal Mets was stented and then was sent for chemotherapy. So I'm gonna give you that one. Um, and then in the interim while waiting for s er, for, to see us got, got obstructed, started vomiting. Um and I suggested that they er re they thought it was large bowel obstruction and they resented the patient. Um So uh have we got a post chemo or is that the post chemo? Uh that is, I think I'll turn it in the No, I I've showed them the wrong way round. Ok. So yeah, so this was the initial one with a slightly large extra bigger mental deposit. Um and the disease on there. So, so this, sorry, I apologies a long way around. So this is so there has been some response to a treatment where the deposits have all decreased in size as is the large extra components. So this was the index scan that this was the post treatment actually. Ok. So at this stage, do we operate now to take the sigmoid cancer out along with everything else? Do we? So, so I'm gonna say do we operate with a CRS and a high pe uh do we just take the primary out or do we give more chemotherapy or do we just monitor? Ok. So we've got 10 responses so far. Bit of a mixer. And we've got a question here from Liam for the non perforated a Intex presentation cases. Any thoughts on how the results from HIPEC T four for MSI lo locally advanced tumors may influence practice plus minus the adjuvant chemotherapy approach such as that described in Foxtrot. So what um Liam is asking is, uh, you're referring to the Spanish trial, the hype CT four trial, which recently showed an improvement in um local, local regional control, giving a high pe um, at the time of the T four cancer surgery, it improved, a reduced local recurrence. Um I think this is gonna catch on, um, but uh, I suspect we're waiting for one or two more trials before it does and I absolutely think that the er, combination of Foxtrot, er neoadjuvant chemo along with high P ET four is, is probably the way to go for T four cancers. The only problem with systemic chemotherapy neoadjuvant is um, is resource in our country. I don't know about your trust, but our trust has a, a big waiting list for people waiting for chemotherapy. Um, and people are waiting sometimes two months to see a, an oncologist. So that will scupper somewhat. Um Foxtrot if, er, oncologists haven't got the resource to see them in time and they progress on that. But I think as a, as a theory, it's a, it's the right thing to do. Ok. So the results are in, it looks like there is a preponderance for CRS and IPC. And, uh, that's what we did. So, but before we move on from this case, I'm gonna tell you the operative findings. So we found the sigmoid tumor was stuck to the ideal mesentery such that we'd have to remove 100 and 20 centimeters of distal small bowel, which would leave only 100 and 80 centimeters of small bowel. We would have to do a right hemicolectomy, of course, to remove the, um, sorry. Uh, yeah, this was a, oh no, this was a, sorry, a sigmoid tumor. We'd have to do a, a uh sigmoid resection. Um, and we would have to do a, um, periton. We found also that the right ureter was very closely related to the tumor. Uh, the omentum was involved in a tumor. And, um, and yes, you saw Doctor de Desi showed that the small bowel was pinched into the tumor as well. So, actually the, and the patient had chronic small bowel obstruction very soon. So, what would you do? Would you proceed the surgery, proceed, bail out? It's a bit, you know, should we do a, um, pole? Sorry. Can you repeat her age? Was it 40? Um, her age was mid fifties about 56 and she's from Doncaster. If that makes any difference to your response. All, all the Southerners are saying bail out, bail out. I think they've all got home. Ok. Have we got anyone left on the court? Oh, no going, going proceed bail. Give you 10 more seconds. How do you consent these patients? Er, we just say we're gonna remove whatever we have to, to get it out and that can involve the bowel, the peritoneum, the gallbladder, the spleen, the liver surface, um, the uterus, the ovaries, the omentum and anything else that you can do without. And I tell them, um, if in doubt, we take it out and that usually makes them sign up to most things. So, um, but I say if you can do without it, we'll, we'll take it out if it's got cancer on it and if we can join the bowel together, we will, but you might end up with a stoma and we run through the risks which are same as bowel surgery. Plus, I quote them at 1 to 2% risk of dying based on our data. Ok. Proceed. And that's what we did. And luckily we were able to dissect the right ureter off. We did take out the 120 centimeter small valve. We gave her a low Hartman's but we, um, had to do a, an anastomosis five centimeters from the Ileocecal valve. Um, some would have taken the cecum, but because I was only leaving 100 and 80 centimeters of small bowel, I thought it would be worth keeping the Ileocecal valve, which is worth about 30 centimeters of small bowel in itself, isn't it? And, uh, keeping the right colon. So we proceed and did BSO omentectomy and it was AAA, nice, technical, technically challenging, um, er, operation which you would all enjoy, I'm sure. Ok. And then finally we're going to do a last case and this gentleman was in his sixties, 68 I believe. Um, this one goes back a few years now. Um, and I actually walked into the handover room while uh seeing a few surgical juniors looking at the scan. Um, and they told me that they had been called by the medics uh because the patient had some belly ache, uh, he was known to have metastatic bowel cancer and they had told him that it was palliative and that, um, that there was no further surgical input required. So probably if you could show us the scan. Yeah. Sure. So, yeah. So he had a CT abdomen and pelvis. He's had a history of a, um less side of colon cancer which was removed. As you can see, he's got this kind of low density. So this um material within the upper abdomen which is scalloping the liver. So this is typical of um, kind of pseudomyxoma or, well, I should call it a um, mucinous implants all over the liver. Um, he's got a gastric band in situ and actually where that gastric band goes through his anterior abdominal wall. He's got um disease tracking through there around his port um and um um the port connector and he see as disease all the way around. Um And he's had on his previous laparotomy involvement of the anterior abdominal wall and within the pelvis. So he's got large volume mucinous. Um It should have been so the type of metastatic disease throughout the abdomen and pelvis essentially. Ok. So back on your pole, operate chemo palliate. It's hard to, it's hard to say uh which because uh you don't am as told you, but I'm gonna ask you anyway. Oh, so operation. Can you imagine? I, I'm, I'm influencing the vote now, palliative care. Yeah. Yeah. Give you a few more seconds. Really chunky subcutaneous disease, tracking under the skin there. You could, you could feel this disease, of course. Ok. So, um this is as doctor does. He says it's typical of pseudomyxoma peritonei. It's a different beast and biopsies of it showed low grade mucinous tumor and it most of the time it arises from the appendix. Um And it gives rise to his typical Pseudomyxoma Peritonei syndrome or jelly belly. This one in fact arose from the colon from the sigmoid colon and we decided to, to do a debulking operation. We couldn't get a complete site reduction on this guy cos the all the upper abdominal contents were caked, but we could remove the disease from his subcutaneous tissue and all the disease around his bowel and lower half of the abdomen below the liver edge, which meant we could get him eating and drinking again. Um And it involved a what, what, what it often involves is a, a bilateral parietal peritonectomy with a total colectomy omentectomy, sometimes with splenectomy down to the rectal stump and then end ileostomy. And that bought him a couple of years of um reasonable quality life before it uh progressed in his upper abdomen and he got early satiety and, and obstructive, couldn't eat then and then, and then died. So when you're going about your business, if you see this cla classical indenting of the liver, the scalloping of the liver and spleen. Um This is different from ascites where you get a, a sharp rim of fluid around it. This is mucinous ascites and, and tumor invading the liver capsule. This is more typical of a low grade mucinous tumor and even if it looks advanced, you should think. Um but it, it could still be suitable for treatment and, and referred to to one of the peritoneal centers. So that's um thank you very much for listening. We've run over by 10 minutes, I believe. But that's all we've got for now. And I'm very happy, we're both happy to take questions if there are any final questions there. Thank you both. Shall we give them a couple of minutes so that they can um have a chance to type if they have any burning questions. I think it's been a very exciting session, especially being engaged with all the answers and kind of, some of them were pushing themselves. I think on what to answer you could see going through all the different options. Um, yeah, let's give them a couple of seconds. Can I just ask about? You? Said that some of them will have neoadjuvant chemotherapy. Is there like a washout period between that and surgery? Four weeks, we like to wait. Um, um, and, but, but if people are really battered and, and we don't like too much chemo, I think once you get more than six months, they do come very battered and they struggle with surgery, but it's some are very fit. You know, I've seen people come after 56 cycles of chemo and they still still have surgery but, um, have chemo as have a four week break and then we can operate and that will reduce things like neutropenia and uh, infective complications and bleeding, particularly if they're on immuno. The therapies. Latest case is very thought broken because I don't think a lot of us are automatically referring that. Yes, absolutely. So they're, they're the ones that need to go probably to basing stone called Christie for the moment unless we get commissioned also for Pseudomys. But if you get those classical and often you will find a small calcified mass in the right eye fossa, just a little bit of calcification right fossa, that's probably a very tiny primary appendix tumor or it'll be picked up incidentally at hernia repair. Um You open a sack and you'll get some jelly come out, particularly an umbilical hernia or uh a young woman will be having an ultrasound scan of the pelvis and pick up mucinous tumor of an ovary. Um and often with a mucocele of the appendix and that's typical of a low grade mucinous t of the appendix. So these are the typical presentations. All like this gentleman will present with abdominal distension. Often they come with a long history of misdiagnosis as IBS which is unfortunate, unfortunate cos the majority of people do have IBS but, but this two per million per year in the UK will have pseudomya peritoneal. So if you do have a distended abdomen after your dinner tonight, you're probably OK. Ok. I think we'll draw that session to an end here. No, sorry. Um Thought. Thank you. Good question, Liam. Um So, absolutely. So we consider Kruckenberg as peritoneal metastases. Um We think that because if you remove Kruckenberg and and don't do a proper site reduction with high PC, there is a 60% recurrence rate of peritoneal disease within a year. So we would very much um recommend referral of Kruckenberg tumors to a peritoneal unit um for excision of the ovaries, the omentum. Um And also w what we do differently is we look very carefully in all the places we know where peritoneal Mets happen. And I think sometimes it's just, it's just gone unrecognized. Great. Any other questions that anyone would like to talk on the chat? Ok. I think we've exhausted them. So I think we'll do all this twin and thank you both very, very much for your time today. For all the cases for your expertise. Thank you to the audience for participating and making the question a bit more interesting in terms of seeing how they think and how as surgeons they want to operate. Always. Um Thank you to everyone and uh hope to see you soon. Thank you, Lillian. Thank you. Thank you. Fantastic presentations. We would love to have you back again, mister Ysf and doctors feel free. Um uh We, I think this, this has been one of the most helpful webinars so far in this, in this uh in this uh chapter. Definitely. And it's uh lovely to end February with that. Um So, uh we'll, we're coming back in March 4th of March. We're coming back with a robotic series again and colorectal surgery. So stay tuned to everyone and make sure you keep in touch on me. Thank you. Have a great evening. Thanks very much guys. Have a good night.