Surgical procedures and chemotherapy are standard treatments for patients with PMP cancer but involves the removal of the fallopian tube and ovaries. Young women wishing to maintain fertility may be reluctant to pursue this. An alternative treatment strategy for women with low-grade PMP has now been explored.
Pseudomyxoma peritonei (PMP), commonly known as “jelly belly” is a rare tumour of the appendix where mucin and mucin-producing cells, (glycoprotein constituents of mucus that lubricate and protect the body) can spread extensively inside the abdominal cavity.
In women with PMP, the ovaries are commonly involved. Moreover, infertility seems to be a symptom of PMP. The current gold standard for treatment of PMP is cytoreductive surgery (CRS), where all affected organs and tissues are removed, followed by hyperthermic intraperitoneal chemotherapy (HIPEC), where the abdominal cavity is washed out with a heated chemotherapy solution.
An alternative strategy is explored
In their research paper published in the journal Pleura and Peritoneum, scientists explored an alternative strategy in women with low-grade PMP in the form of laparoscopic evacuation of pelvic and ovarian mucin with resection of the appendiceal tumour.
Removal of the ovaries is a standard and routine component of this surgery. However, young women wishing to maintain fertility will understandably be reluctant to pursue this, not just due to the distressing outlook of permanent infertility but also the relatively serious consequences of early menopause.
Striking a fine balance
Alternative strategies to CRS and HIPEC aimed at maintaining or improving fertility would have to strike a fine balance between preserving the ovaries and controlling the PMP.
One such strategy has been developed at the Peritoneal Malignancy Institute Basingstoke and involves a laparoscopic washout procedure (keyhole surgery), where all mucin is removed from the pelvis and from the surface of the ovaries, combined with removal of the appendix.
Among all women who were offered CRS and HIPEC for PMP between 2012 and 2015, four premenopausal women with limited PMP and fertility issues were additionally offered this laparoscopic washout as an alternative treatment.
All patients were made aware that this laparoscopy is by no means to be considered an alternate definitive treatment strategy for PMP but that the aim of this treatment is solely to enhance fertility while postponing CRS and HIPEC till such a time that the disease returns and progresses.
During the laparoscopic procedure, the extent of PMP was carefully evaluated, the appendix was removed, all visible mucin was removed from the pelvis and ovaries, and the abdominal cavity was extensively washed out.
Patients successfully conceived after treatment
Further examination of the removed tissues showed that all four patients had low-grade PMP. All four patients successfully conceived subsequently and gave birth to full term healthy babies with only one requiring in vitro fertilization.
At the present time (up to 29 months after the laparoscopic washout procedure), all women are well with no evidence of return or progression of PMP as evidenced by normal imaging tests, normal tumour markers and, in one patient, a normal subsequent laparoscopy; ongoing imaging and clinical surveillance is planned.
An alternative approach that improves fertility
In selected women with relatively low volume low-grade PMP, especially those struggling with infertility, a laparoscopic approach aimed at removing the appendix and mucin from the ovaries, yields good short- to medium-term control of PMP whilst improving fertility. This approach should therefore be discussed with and offered to young women with low-grade, low-volume PMP, who still wish to have children, as an alternative to immediate CRS and HIPEC.
Read the original article here
Akash M. Mehta, on behalf of Lisa A. Sheehan, Saladin Sawan, Sanjeev P. Dayal, Faheez Mohamed, Brendan J. Moran, Tom D. Cecil: Preserving fertility in pseudomyxoma peritonei, a novel approach. 19.01.2017