Peritoneal metastases from extra-abdominal cancer – A population-based study
Introduction
Peritoneal metastases (PM) predominantly arise in patients with colorectal, appendiceal, gastric or ovarian cancer. Approximately 5% of patients with colorectal cancer, 9% of patients with pancreatic cancer and 46% of women with ovarian cancer are diagnosed with PM at initial presentation (synchronous PM) [1], [2], [3]. While PM can arise from extra-abdominal primary cancers, such cases are uncommon and the true incidence is unknown. To date, primary breast and lung cancers are the most commonly reported extra-abdominal malignancies resulting in PM [4], [5], [6].
Peritoneal metastases from intra-abdominal primary tumours are thought to result predominantly from loco-regional rather than systemic spread [7]. A commonly accepted theory is the ‘coelomic theory’ in which serosal invasion leads to gravitational pooling of tumour cells and pelvic implants, subphrenic implants from clockwise directional flow of the peritoneal fluid, and eventually omental caking from phagocytic activity of the omentum [8]. To date, the pathophysiology of peritoneal metastases from extra abdominal primary tumours are less well understood.
PM is generally a terminal development, with an average overall survival of less than 6 months [9], [10], [11]. The true incidence and prevalence of extra-abdominal primary malignancies metastasising to the peritoneal cavity has not yet been well described in the literature. Despite recent advances in surgical techniques and chemotherapeutics in a subset of patients with PM, mainly from primary colorectal, appendiceal or ovarian cancers [9], [12], [13], [14], [15], [16], [17], [18], the paucity of clinical trials specifically focusing on PM demonstrates the need for further research to advance the development of novel targeted therapeutic strategies. A pivotal initial step in this process is the need for population based data to document the incidence, and outcomes, of patients with PM.
The aim of this study is to assess the pattern of disease and survival in Irish patients with PM from extra-abdominal malignancies.
Section snippets
Methods
The National Cancer Registry Ireland (NCRI) is a statutory body responsible for the registration of all cancers within the Republic of Ireland since 1994, encompassing a population of over 4 million inhabitants. Although the reporting of cancer is not yet mandatory in Ireland, the NCRI, through hospital-based tumour registration officers, makes considerable efforts to ensure the completeness of recording of all invasive and in situ cancers and completeness of registration is estimated at 97%
Statistical analysis
Statistical analysis was performed using SPSS 18.0 software (Chicago, Il). Survival outcome were analysed using Kaplan-Meier estimates. Differences in survival were compared using the logrank test. A p value of <0.05 was considered statistically significant.
Patients
Five thousand seven hundred and ninety one patients were diagnosed with PM between 1994 and 2012 inclusive. The annual incidence of PM diagnosis increased from 228 in 1994 to 401 in 2012. Of the 5791 patients, 543 (9.4%) had an extra-abdominal primary malignancy.
The extra-abdominal primary cancers which most commonly spread to the peritoneum were breast cancer (n = 222/543, 40.8%), lung cancer (n = 139/543, 25.6%) and malignant melanoma (n = 51/543, 9.3%). These cancers accounted over three
Discussion
This study is the first to provide detailed national population-based data on the incidence and survival of patients with peritoneal metastases (PM) from extra-abdominal primary tumours. Breast cancer, lung cancer and malignant melanoma are the most common extra-abdominal causes of PM. PM was diagnosed in 0.5% of the total population (n = 41,789) of patients diagnosed with breast cancer during the study period. This finding is slightly lower than previously published rates of 0.7%–2.7% [21],
Conclusion
The current study has shown that extra-abdominal cancers account for approximately 10% of diagnosed cases of peritoneal metastases. Breast cancer, lung cancer, and malignant melanoma are the most common cancers to spread to the peritoneum. There may be a significant latency between initial cancer diagnosis and the development of PM, particularly for breast cancer. Once established PM is however invariably and rapidly fatal. PM from extra abdominal malignancy presents an increasing challenge for
Disclaimer
The authors received no funding or financial assistance.
Declaration of interest
The authors have no disclosures or conflicts of interest to declare.
Novelty and impact
This is the first population-based study to report the incidence and outcomes for peritoneal metastases of extra abdominal origin. Peritoneal metastases of extra abdominal origin account for a significant proportion of the total number of patients diagnosed with PM, and survival is poor. These findings highlight the need for greater clinician awareness and the need to focus on new therapeutic approaches to improve patient outcomes.
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