Carcinomatosis is defined as a condition in which multiple carcinomas develop simultaneously, usually after dissemination from a primary source. It implies more than spread to regional nodes and even more than just metastatic disease. The term is usually taken to mean that there are multiple secondaries in multiple sites. Carcinomatosis is often restricted to tumors of epithelial origin, adenocarcinomas, while sarcomatosis describes the dissemination of tumors of mesenchymal origin, sarcomas.
"Peritoneal carcinomatosis can occasionally be treated with intraperitoneal and/or intravenous chemotherapy."
Carcinomatosis is commonly taken to mean there are multiple secondaries in multiple sites. Strictly, it should be used only for epithelial cancers or carcinomas and not sarcomas or lymphomas, yet has been extended to include all types of cancer which have spread. The word is now used to describe conditions with more limited spread, such as the following.
Pulmonary Lymphatic Carcinomatosis:
Pulmonary lymphatic carcinomatosis involves diffuse infiltration of the person's lungs with obstruction of their lymphatic channels. The condition may occur with a number of different cancers, to include breast, lung, large intestine and stomach.
Peritoneal carcinomatosis involves the spread of metastases into the peritoneum, often times from colorectal and ovarian cancers. The occurrence of peritoneal carcinomatosis has been shown to significantly decrease overall survival in people with liver and/or extraperitoneal metastases from gastrointestinal cancer.
Leptomeningeal carcinomatosis includes involvement of, 'leptomeninges,' through seeding via the person's cerebrospinal fluid, which happens either by direct spread or through the person's bloodstream. Any cancer may cause this, yet adenocarcinomas are most commonly involved. The condition classically presents with multifocal neurological signs and symptoms. A diagnosis is based on the evaluation of clinical presentation, cerebrospinal fluid cytology and neuroimaging. The condition is uncommon and usually a late complication of cancer.
Carcinomatosis may be a progression of known disease. It might be the presentation of recurrence, or it may be the main presenting feature. Presentation will depend on where is affected. For example, in:
When these features present, the question is whether this is part of the known disease or something else. For example; whether jaundice is due to metastatic carcinoma in the liver, or to gallstones. When carcinomatosis is the presenting feature, it is usual to seek a primary tumor. Histology might be anaplastic and give no help, although improvements in investigative technology are helping to narrow the differential diagnosis.
The purpose of investigations is to confirm the nature of the disease and assess its severity and extent. In instances of unknown primary, FBC might show iron deficiency suggestive of gastrointestinal malignancy, microscopic haematuria may reveal occult genitourinary malignancy and occult blood might point to a colorectal cause. In instances where the primary is not known, FBC, U&E, LFT's and creatinine may indicate severity.
Imaging techniques such as CT, ultrasound and MRI scanning as well as older investigations such as CXR provide good information and an exploratory laparotomy is rarely required. It might be desirable to obtain tissue for histology. Techniques now employed to assist with differential diagnosis include the following:
Often times, there is no realistic hope of curative therapy, although radiotherapy and chemotherapy might have a palliative effect. Surgery may be palliative and, 'debulking,' of the tumor prior to chemotherapy may be helpful. Resection of liver metastases secondary to colorectal cancer has had some success in limited disease. There are some subgroups of people who do fairly well with treatment. Multi-modality treatment; intrathecal chemotherapy, intravenous chemotherapy, whole brain radiotherapy and radiotherapy to spinal leptomeninges - has been found to improve survival rates in people with leptomeningeal metastases secondary to breast cancer.
Lymphatic carcinomatosis may at times be stabilized, or at least the progression reduced, through chemotherapy. Chemotherapy may be systemic, or through infusion into the person's cerebrospinal fluid. Radiotherapy might be required if the tumor tissue is bulky or causing symptoms.
Peritoneal carcinomatosis can occasionally be treated with intraperitoneal and/or intravenous chemotherapy. Treatment may be started postoperatively, or chemotherapy drugs may even be instilled in the person's abdominal cavity during surgery. The approaches have resulted in demonstrable improvements in survival rates. Intrathecal trastuzumab appears to represent a safe - and in some instances, effective option for the treatment of HER2-positive breast cancer patients with leptomeningeal involvement.
Transcatheter arterial chemoembolisation (TACE) has resulted in a successful outcome, especially in people with neuroendocrine tumors and colorectal metastases. A micro-catheter is inserted into the hepatic blood supply and a combination of chemotherapeutic agents and embolic agents is injected. Radio-embolisation promises serve an increasing role in the treatments available for treating and managing metastatic disease.
Palliative radiotherapy can often be used to reduce or eliminate pain from bone metastases, or palliate brain metastases. It can be used to relieve spinal cord compression, or compressive symptoms from visceral metastases. Palliative radiotherapy can be used to control bleeding and various ablative techniques have been used to destroy liver metastases, including microwaves, freezing, lasers and the use of alternating current within the radiofrequency range.
While palliative surgery for malignant bowel obstruction from carcinomatosis may benefit a person, it does come at the cost of high mortality and morbidity relative to the person's remaining survival time. Current evidence on the efficacy of cytoreduction surgery (CRS) followed by hyperthermic intraoperative peritoneal chemotherapy (HIPEC) for peritoneal carcinomatosis reveals some improvement in survival for selected people with colorectal metastases, yet evidence is limited for other types of cancer.
The surgical treatment of bone metastases may improve life expectancy and quality of life. For people who are incurable, a plain and honest discussion needs to take place. The discussion might require more than one session and the skills for breaking bad news are required. Additional considerations may be dying at home and dyspnea in palliative care. Pain control in terminal care and nausea and vomiting in palliative care might also be worthy of attention. Palliative care should not be perceived as a failure; it is highly demanding and rewarding.
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