About the Peritoneal Malignancy Institute

Peritoneal Malignancy Institute

Specialised services are commissioned by the Wessex Local Area Team on behalf of NHS England for English and eligible overseas patients. Highly specialised services (Pseudomyxoma Peritonei) are commissioned through the Highly Specialised Commissioners on behalf of NHS England for English, Scottish and eligible overseas patients. For Welsh and Northern Irish patients, services are funded through individual funding requests which are made by the patients local hospital team.

Pseudomyxoma Peritonei

The assessment and management of patients with Pseudomyxoma Peritonei (PMP) has been commissioned from Basingstoke and North Hampshire Hospital, part of Hampshire Hospitals NHS Foundation Trust, since April 2000 and from the Christie Hospital NHS Foundation Trust in Manchester in 2002.

Pseudomyxoma peritonei is a rare malignancy, generally thought to have an incidence of two cases per million per year based on the clinical experience of the Basingstoke and Manchester services, combined with recent epidemiological evidence from Holland.

It is a slowly progressive tumour arising mainly from the appendix (though can originate from the colon, ovaries in women or even more rarely from other intra-abdominal organs) which spreads throughout the peritoneal cavity producing a large amount of mucus. The condition is, at best, borderline malignant but can vary in its aggressiveness and clinical course.

Colorectal Peritoneal Metastases

Patients with peritoneal metastases from colorectal cancer have traditionally been treated with palliative intent. Recent evidence has shown that the use of Cytoreductive Surgery (CRS) and Hyperthermic Intra-peritoneal Chemotherapy (HIPEC) can result in improved survival rates. The needs assessment as set out in the Clinical Commissioning Policy: Cytoreductive Surgery for Peritoneal Carcinomatosis (2013) suggests that the incidence of Peritoneal Carcinomatosis secondary to colorectal cancer in England is 2325-3322; and 178-266 of these patients will be fit for and consent to surgery.

Table 1 - epidemiology and needs assessment for Peritoneal Carcinomatosis.

This needs assessment suggests that demand for CRS and HIPEC will be 178-266per year in England, however recent activity data and case selection suggests the demand is more likely to be in line with the number of patients with ‘no significant morbidity and suitable for referral’ ranging from 714-797 cases per year.

Therefore there is national recognition that capacity within the two current national centres providing this service will need to grow and potentially the number of centres providing this service in England will need to grow.

Colorectal Peritoneal Metastases as a specialised service has been commissioned by NHS England Specialised Commissioning from Hampshire Hospitals NHS Foundation Trust without the need to involve the Individual Funding Request (IFR) process since 2013.

Mesothelioma

In July 2015, NHS England announced their investment decisions for certain specialised services as part of the annual commissioning round. This included the decision not to routinely commission Cytoreductive Surgery + HIPEC for peritoneal mesothelioma. There were a number of patients already referred to the service and progressing along their care pathway and Hampshire Hospitals NHS Foundation Trust made the decision to honour these care pathways to completion.

Following further discussion, HHFT made the decision to continue to offer this service, with a view to establishing a national peritoneal mesothelioma multi-disciplinary meeting to review all referred cases, gain consensus on treatment advice collating evidence required to demonstrate effectiveness.

Historically the standard surgical approach to the management of PMP has involved what has been termed “debulking” where as much as possible of the mucinous ascites is removed together with easily removable structures such as ovarian masses and parts of the omentum.

Debulking was usually repeated at diminishing intervals, becoming increasingly ineffective with escalating complications often culminating in death from a post-operative complication such as a small bowel fistula or pneumonia.

Thus debulking is no longer recommended as the standard of care if complete tumour removal is possible. It is expensive, fraught with long-term risks and results in very poor quality of life for most patients treated in this manner. For these reasons the technique of complete cytoreduction was developed and evolved.

The management of pseudomyxoma peritonei at HHFT can include complete cytoreduction, debulking and/or active monitoring and is in accordance with the NICE guidance on Complete cytoreduction for pseudomyxoma peritonei (Sugarbaker technique) issued in January 2004, to the NHS in England, Wales, Scotland and Northern Ireland

The Sugarbaker Technique (Complete Cytoreduction)

The Sugarbaker technique was developed by Paul Sugarbaker at the Washington Cancer Institute. It involves complete surgical tumour removal (also known as complete cytoreduction) combined with heated intra-operative, intraperitoneal, chemotherapy, followed by postoperative intraperitoneal chemotherapy for 3-4 days in selected cases. The surgery takes about 9 hours to complete and includes:

• removal of the right hemicolon, spleen, gall bladder, greater omentum and lesser omentum
• stripping of the peritoneum from the pelvis and diaphragm
• stripping of tumour from the surface of the liver
• removal of the uterus and ovaries in women
• removal of the rectum in some cases

Maximal tumour debulking

In some patients extensive involvement of the small bowel, in particular, makes it impossible to perform complete tumour removal. The previously described techniques of debulking have been extended to include a much more radical, more effective and more durable technique entitled maximal tumour debulking. This usually involves an extended right hemicolectomy (in some cases a total colectomy with an ileostomy), a greater omentectomy often with a splenectomy and removal of the uterus and ovaries in women.

Disease progression of the residual disease is almost inevitable but few patients require any further surgery and a quality of life study from the Basingstoke unit has shown excellent early results in these patients.

Active Monitoring

People with newly diagnosed and early PMP may also be monitored using a 'watch and wait' policy. This is applicable to patients who have had a perforated appendix tumour where there is some mucinous peritoneal involvement but uncertainty as to whether PMP will develop. Surgery may be required some months to years later, though some avoid the need for further treatment.

A further group who are actively monitored are those unfit or unwilling to undergo surgery and patients where investigations have suggested that complete tumour removal is unlikely.  Some require subsequent surgery but only when unacceptable symptoms or life-threatening complications such as intestinal obstruction develop.

PMI annual review 2018-19

PMI annual review 2019-20