Extent of Peritoneal Resection for Peritoneal Metastases: Looking Beyond a Complete Cytoreduction

Completeness of cytoreduction is one of the most important prognostic factors impacting outcomes of cytoreductive surgery (CRS). To what extent the surrounding normal peritoneum needs to be removed is not known. We hypothesized that the extent of peritoneal resection should be different for different tumors and performed this study to find evidence to support this rationale. To determine the extent of resection of surrounding tissue for any tumor, the mechanisms of tumor development and spread, tumor morphology, the possibility of finding disease in the surrounding normal tissue, and the pattern of lymph node metastases should be known. Surgical resections also depend on patterns of recurrence and the impact of varying extent of resection on survival. We performed a review of literature pertaining to pathways and patterns of peritoneal cancer spread to determine the scientific basis for the extent of peritonectomy. We also reviewed studies comparing less and more extensive peritoneal resection. There is no consensus on the extent of lymphadenectomy required for most PM. Based on this review, we provide recommendations for the extent of peritoneal resection and the extent of lymph node dissection that should be performed for some common peritoneal tumors and identify areas that require further research. We propose that a systematic method of synoptic reporting of pathological specimens of CRS should be developed to capture information regarding the disease distribution within the peritoneal cavity and morphology of PM from different tumors. This can in future be used to establish standard guidelines for such resections.