UGIC P73 Role of peritoneal cytology as part of multi-modal staging in oesophago-gastric cancers: A single centre experience
Published Date: 01st November 2019
Publication Authors: Kaul A
Background
Over 16,000 cases of oesophago-gastric cancer are diagnosed in the UK annually. Multi-modality staging of these cancers include computer tomography, endoscopic ultrasound and positron emission topography. Laparoscopy and peritoneal lavage are recommended as an additional staging modality due to the propensity of these cancers to rapidly metastasise to lymph nodes and peritoneal cavity. Peritoneal lavage can identify free malignant cells that have been shown to be associated with poor outcome and exclude resectability. However, considerable debate remains regarding its role in routine staging of oesophago-gastric malignancies. We undertook a prospective study to assess the benefits of routine peritoneal washings in oesopha-gogastric cancers with radiologically staged resectable disease.
Methods
The study cohort was formed by patients diagnosed with radiologically deemed resectable gastric, junctional or lower oesophageal cancers at a supra-regional MDT between July 2015 and December 2016. All patients underwent staging laparoscopy and peritoneal washings as a part of multi-modality staging process. Patients with squamous cell carcinomas were excluded from this study. Staging laparoscopy was performed using a standard 3 port technique, with subsequent systematic assessment of the abdominal viscera and peritoneal cavity. Peritoneal washings were undertaken utilising 500mls of warm 0.9% sodium chloride irrigated into the peritoneal cavity and stimulated externally, prior to being aspirated and submitted for cytological analysis.
Results
Some 158 patients with gastric, junctional and lower oesophagealadenocarcinomas were included. Majority of the patients in the cohort were male(male 113, female 45) and the mean age of patients undergoing laparoscopy was68 years (male 67.5 years, female 69 years). All procedures were undertaken asa day case procedure with no reported major complications or mortality. Mostof the patients were noted to have advanced disease (T3 or T4) at preopera-tive staging (131/18) as well as having node positive disease (60%). Laparoscopyrevealed 15 patients who were noted to have locally advanced disease or histolog-ically conrmed peritoneal disease who were excluded. Further 9 of 143 patientswho had no evidence of peritoneal metastasis at laparoscopy returned a positivecytology result from peritoneal lavage and deemed unsuitable for curative ther-apy. Radiological staging for these 9 patients varied from T3N2 to T4aN1(Stage3) disease in patients with positive cytology results with majority of the patientshaving T4aN1 disease. No positive cytology was returned in stages T3N0 or T2disease (Stage 2).
Conclusions
Our study has confirmed the role of laparoscopy in identifying low volume disease which proves a challenge for characterisation by cross sectional imaging currently. Peritoneal cytology altered the management of 6.3% of patients in our cohort who were deemed to have resectable disease based on radiological staging and staging laparoscopy. Of the 9 patients with peritoneal micro metastases, they were noted to have at least stage 3 disease (T3N2 or above) with no positive cases noted in stage 2 disease. This suggests the incidence of occult peritoneal metastasis is very low in early stage diseases, hence peritoneal washings can be utilized selectively as a staging adjunct.
Rao, R; Kaul, A et al. (2019). UGIC P73 Role of peritoneal cytology as part of multi-modal staging in oesophago-gastric cancers: A single centre experience. British Journal of Surgery. 106 (S7), 86.