Pseudomyxoma peritonei (PMP) is a rare malignant disease characterized by the progressive and multifocal accumulation of abundant mucinous tumour tissue in the peritoneal cavity. It is generally associated with a perforated epithelial neoplasm of the appendix. The Peritoneal Surface Oncology Group International (PSOGI) has recently published a consensus statement about the diagnosis and treatment of mucinous appendiceal tumours and PMP. It recommends, whenever possible, cytoreductive surgery* plus hyperthermic intraperitoneal chemotherapy* (CRS + HIPEC) in reference centres, as the most effective treatment for these patients.
After this treatment, some patients may have a reocurrence. In some cases, this reocurrence could be managed by another surgical procedure in experienced units but sometimes this is not possible. In the cases considered as unresectable, currently palliative systemic chemotherapy becomes the only possible treatment with no satisfactory results.
Bromelin is a drug obtained from pineapple which it has mucolytic properties, making the mucin associated with PMP less thick and sticky. Bromelain has been associated to N-acetyl-cysteine, another mucolytic, in a composed drug called BromAc®. This was developed by Professor David Morris and it has had promising results to reduce the pseudomyxoma peritonei reocurrences in previous studies.
Our Unit of Surgical Oncology from Hospital University Reina Sofia, Cordoba in Spain is going to start a phase I/II trial to assess the clinical effectiveness and safety of the locoregional treatment with Bromelain +N-Acetylcysteine to decrease tumour burden in patients with abdominal reocurrence of mucinous tumours, who are not candidates for repetitive resection surgery. We have got a public grant to do it in a cohort of ten selected patients. This treatment could improve the outcome and the quality of life for our patients.
Study coordinators: Dr. Arjona-Sanchez A. And Dra. Rodriguez-Ortiz L.
Unit of Surgical Oncology and Pancreatic Surgery. Liver and Pancreas Transplantation. Research in Peritoneal Oncologic Surgery Group, Institute of Biomedical Research IMIBIC. University Hospital Reina Sofia, Cordoba, Spain
Complete cytoreduction is the complete surgical tumour removal. This is a long operation which takes about 10 hours to complete and includes:
- removal of the right hemicolon
- gall bladder
- greater omentum and lesser omentum
- stripping of the peritoneum from the pelvis and diaphragms
- tripping of tumour from the surface of the liver
- removal of the uterus and ovaries in women
- removal of the rectum in some cases
This is also referred to as a full peritonectomy. The goal is to remove tumour nodules down to 2.5mm.
Hyperthermic Intraperitoneal Chemotherapy
Heated chemotherapy, delivered directly into the abdomen, after complete cytoreduction. If the surgeons are able to remove the all the tumours, you may be given HIPEC.
Hyperthermic means that the chemotherapy solution used during the procedure is heated to a higher-than-normal temperature, typically around 41-43°C (105.8-109.4°F). This is usually Mitomycin C. This is put directly in your abdomen while you are in theatre. This elevated temperature is maintained throughout the duration of the procedure, usually around 90 minutes, to enhance the effectiveness of the chemotherapy drugs and to target cancer cells in the abdominal cavity. HIPEC will penetrate tumour nodules up to 2.5mm in size. The combination of chemotherapy drugs and hyperthermia can help to destroy cancer cells (increased cytotoxicity) while minimizing damage to healthy tissue.
Chemotherapy given into the abdomen during surgery is called intraoperative chemotherapy.
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This is very encouraging particularly for people like me who are told we are not good candidates for surgery in Canada.