Figure 18

Assessment of cancer distribution using abdominopelvic regions zero through twelve. A clinical tool to allow statistically evaluable recording of the sites of peritoneal carcinomatosis has been proposed. Anatomic landmarks that surround the abdominal and pelvic cavity define the anatomic boundaries of these regions. Two transverse planes and two sagittal planes are used to divide the abdomen into nine abdominopelvic regions (AR zero through eight). The upper transverse plane is through the lowest aspect of the coastal margin. The lower transverse plane is through the anterior superior iliac spine. The sagittal planes divide the abdomen into three equal sectors. The regions are numbered from zero to eight, starting at the umbilical region and proceeding in a clockwise manner. The different anatomic structures found in the nine abdomino-pelvic regions have been defined. The small bowel is assessed as a separate entity and is designated abdominal regions nine through twelve. AR 9 includes the upper jejunum and is located in the left upper quadrant. AR 10 includes the lower jejunum and is located in the left lower quadrant. AR 11 includes the upper ileum and is located in the right upper quadrant just beneath the liver. AR 12 includes the lower ileum and is located in the right lower quadrant. It should be noted that the large bowel is scored along with the abdominal region, but the small bowel is scored separately. From Jacquet P, Sugarbaker PH: Clinical research methodologies in the diagnosis and staging of patients with peritoneal carcinomatosis (In) Sugarbaker PH (Ed): Peritoneal Carcinomatosis: Principles of Management. Kluwer: Boston p 361, 1996.

Figure 19

Assessment of lesion size by CT scan or surgery. (Lesion Size score). LS = lesion size. Zero indicates the absence of cancer within a particular abdominopelvic region. LS-1 indicates tumor nodules less than 5 cm in diameter. LS-2 indicates tumor 0.5 to 5 cm in diameter. LS-3 indicates tumor nodules greater than 5 cm in diameter. If an organ is coated by a mat of tumor (confluent disease), this region or site is scored as lesion size 3. From Jacquet P, Sugarbaker PH: Clinical research methodologies in the diagnosis and staging of patients with peritoneal carcinomatosis (In) Sugarbaker PH (Ed): Peritoneal Carcinomatosis: Principles of Management. Kluwer: Boston p363, 1996.

Figure 20

Completeness of cytoreduction following surgery. (CC score). A scoring system is used to indicate the quantity of malignancy that remains following surgery. A CC-0 resection indicates patients in whom no tumor was visualized during the course of the complete resection. These are patients with walled off tumor nodules, tumor encased with in scar tissue, or patients with a localized recurrence. CC-1 resections leave behind tumor nodules less than 2.5 mm in diameter. A CC-2 resection are those that have residual tumor nodules between 2.5 mm and 2.5 cm in diameter. The CC-3 resections are done in patients in whom tumors greater than 2.5 cm in diameter is left behind, or there is a layering of disease that is not completely peritonectomized. A CC-0 or CC-1 cytoreduction is usually scored as a complete resection. Theoretically, intraperitoneal chemotherapy can penetrate through a 2.5 mm tumor nodule, and thereby prevent its recurrence. Patients who have a tumor 2.5 mm or greater left behind within the abdomen or pelvis after the completion of cytoreductive surgery are scored as incomplete cytoreductions. From Jacquet P, Sugarbaker PH: Clinical research methodologies in the diagnosis and staging of patients with peritoneal carcinomatosis (In) Sugarbaker PH (Ed): Peritoneal Carcinomatosis: Principles of Management. Kluwer: Boston p368, 1996.

Abdominal incision
Abdominal peritoneum
Greater omentum
Lesser omentum
Right hemidiaphragm
Left hemidiaphragm
Liver surface
Spleen
Pancreas surface
Stomach
Small bowel
Large bowel
Right paracolic gutter
Left paracolic gutter
Right pelvic sidewall
Left pelvic sidewall
Bladder
Vagina & internal genitalia
Cul-de-sac of Douglas
Retroperitoneum
Kidneys

Table 8

Anatomic sites within the abdomen and pelvis. As an alternative to scoring of peritoneal carcinomatosis according to abdominopelvic regions, a catalogue of tumor within anatomic sites can also be used to record data in a statistically acceptable fashion. The anatomic sites, which are encountered in dissecting tumor, are listed. From Jacquet P, Sugarbaker PH: Clinical research methodologies in the diagnosis and staging of patients with peritoneal carcinomatosis (In) Sugarbaker PH (Ed): Peritoneal Carcinomatosis: Principles of Management. Kluwer: Boston p360, 1996.

Figure 21

Use of peritoneal cancer index in a clinical pathway for management of peritoneal carcinomatosis of appendiceal origin. The peritoneal cancer index (PCI) combines the distribution assessment and the lesion size assessment to come up with a composite score. The tumor in each abdominopelvic region is scored by CT scan, and then later at the time of surgery. According to the lesion size of nodules present, these scores are summated. The minimum score would be zero. The maximum score would be 39. Patients who have a PCI determination greater than 12 are not recommended for elective cytoreductive surgery with perioperative intraperitoneal chemotherapy. In patients who have been treated with prior intravenous 5-fluorouracil and leucovorin, irinotecan may be recommended as palliative chemotherapy.

Table 9

Assessment of response following cytoreductive surgery and perioperative chemotherapy. A problem in scoring the treatment using cytoreduction occurs because cytoreductive surgery should eliminate all disease that can be appreciated by radiologic criteria. An assessment of a response demands a 6-month time interval. From Jacquet P, Sugarbaker PH: Clinical research methodologies in the diagnosis and staging of patients with peritoneal carcinomatosis (In) Sugarbaker PH (Ed): Peritoneal Carcinomatosis: Principles of Management. Kluwer: Boston p370, 1996.