Inguinal canal as an anatomic sanctuary site of relapse in peritoneal carcinomatosis previously treated with intraperitoneal chemotherapy

Pseudomyxoma peritonei involving the canal of Nuck: The added value of magnetic resonance imaging for detection and presurgical planning

The canal of Nuck is an abnormal patent pouch of the parietal peritoneum caused by the incomplete obliteration of the processus vaginalis in females. The most common disorders of the canal of Nuck are: hernia, hydrocele and endometriosis. Pseudomyxoma Peritonei (PMP) is a clinical condition characterized by the accumulation of mucinous material on the surfaces and in the recesses of the peritoneal cavity, resulting from the perforation of an appendiceal mucinous neoplasm. We report the case of a young woman with a clinical history of chronic pelvic pain and infertility who was referred to our center after being diagnosed with appendiceal mucinous neoplasm and PMP. MRI staging examination revealed the right canal of Nuck filled with mucinous material, which was confirmed at surgery. The involvement of canal of Nuck is extremely rare in PMP. MRI provides a sensitive imaging modality for appropriate preoperative planning of PMP and helps surgeons identify uncommon disease sites such such as the canal of Nuck in women, which, if missed, may prevent complete cytoreductive surgery.

Management of Inguinal Involvement of Peritoneal Surface Malignancies by Cytoreduction and HIPEC with Inguinal Perfusion

Background: Achieving complete cytoreduction of peritoneal surface malignancies (PSM) can be challenging. In most cases, delivery of heated intra-peritoneal chemotherapy (HIPEC) is straightforward. However, using the closed technique in some cases may be technically challenging; for example, in patients requiring abdominal closure using a large synthetic mesh. In cases where groin hernias are present, it is imperative to resect the hernia sac, since it may contain tumor deposits. In cases with major inguinal involvement where disease may spread out of the hernia sac or in cases where a hernia repair was performed while disease is present, inguinal perfusion should be considered.

Aim: To describe our experience with combined intra-peritoneal and inguinal perfusion of HIPEC following cytoreductive surgery.

Patients and Methods: This is a retrospective review of all patients who underwent cytoreductive surgery (CRS) and HIPEC at our institution. A prospectively maintained database containing data of patients treated by CRS and HIPEC (n=122) was reviewed. All patients with macroscopic inguinal involvement by PSM with complete cytoreduction perfused by HIPEC were included.

Results: We identified five cases who underwent CRS and combined intraperitoneal and inguinal perfusion after resection of large inguinal tumor deposits (n=4) or after a recent hernia repair with hernial sac involvement by mucinous adenocarcinoma (n=1). All five patients were successfully perfused using an additional outflow catheter placed in the groin.

Discussion: In cases of inguinal involvement by PSM, complete cytoreduction should be achieved and perfusion of the involved groin considered as it is feasible and safe.

The porta hepatis as a site of recurrence of mucinous appendiceal neoplasms treated by cytoreductive surgery and perioperative intraperitoneal chemotherapy

BACKGROUND

A successful new treatment for a particular disease may change the natural history of that disease as patients go on to longer survival. The goal of this study was to investigate the porta hepatis as a site of recurrence of appendiceal mucinous neoplasms.

METHODS

A prospective database on patients with peritoneal dissemination of mucinous appendiceal neoplasms has been maintained for 21 years. In patients with complete cytoreduction, disease progression/recurrence in and around the porta hepatis has been noted as a new manifestation of this disease.

RESULTS

In 710 patients treated for mucinous appendiceal cancer with a complete cytoreduction, 140 developed recurrent disease. Seven patients (5%) had disease recurrence in and around the porta hepatis. Four of the seven had biliary obstruction and three had masses within the liver hilum not causing bile duct obstruction. Four of the seven patients were successfully palliated by surgical procedures within the liver and biliary tree. Two patients were successfully palliated using a biliary stent and one patient was not treated.

CONCLUSIONS

Progression of mucinous neoplasms within the porta hepatis may be related to imperfect cytoreduction technique. Reoperative surgical treatment and biliary stents were beneficial in some of these patients.