THE USE OF INTRAPERITONEAL CISPLATIN AND SODIUM THIOSULPHATE IN PSEUDOMYXOMA PERITONEII
Shakthi K Kumar*, Simran Singh*, Marylatha Williams**, BG Ponnappa***, D Venugopala****, M Paul Korath*****, K Jagadeesan******
*DNB Resident, Radiodiagnosis; **DNB Resident; ***Registrar, General Surgery; ****Registrar, General Medicine; *****Chief Physician; ******Director, KJ Hospital, Chennai 600 084.
We present a case of pseudomyxoma peritoneii, malignant variety, treated with debulking surgery and intra peritoneal instillation with 10% dextrose and cisplatin and intravenous sodium thiosulphate infusion on the operating table and subsequently with two cycles of chemotherapy with cisplatin and intravenous sodium thiosulphate. The patient showed remarkable response to the above mentioned treatment.
A sixty four year old man was referred to our hospital for gel like material being found in his abdomen eight months ago during a surgery for umbilical hernia done elsewhere. The material was taken for biopsy and was reported as pseudomyxoma peritoneii in that centre. On physical examination he was moderately built and nourished not anaemic, jaundiced or cyanosed and there was no pedal oedema. He had gross abdominal distension. All his haematological and biochemical parameters were in the normal range. The ultrasonogram showed a multicystic mass in the liver and ascites. The computerised tomogram of the abdomen showed low attenuation fluid collection within the peritoneum which extended into the pelvis upto the bladder. An area of calcification was seen in the liver. The slides of the earlier biopsy material were reviewed by our pathologist who opined malignant pseudomyxoma peritoneii.
A laparotomy and debulking procedure was performed and during surgery nodular jelly like masses were seen adherent to the liver, gall bladder, the transverse colon and all over the peritoneum. The appendix was normal. Those masses which had not infiltrated into the intestinal walls were evacuated.
The abdomen was irrigated with warm 10% dextrose followed by irrigation with 170 mg (at 100 mg/sq. m) of cisplatin in one litre of water. The frozen section and the permanent section were reported as malignant pseudomyxoma peritoneii. The post operative period was stormy with prolonged ileus. The patient recovered and was discharged. The second dose of chemotherapy with intra peritoneal installation of cisplatin (170 mg/sq.m) was given one month later. Intravenous infusion of sodium thiosulphate 1 gm/hour for twelve hours was given to reduce the toxicity. He had one episode of convulsions four hours after the intraperitoneal instillation of cisplatin. Patient was treated with antiepileptics. The rest of his stay in the hospital was uneventful.
The patient had a third dose of intraperitoneal cisplatin with intra venous infusion of sodium thio sulphate over twelve hours one month after the second dose. There were no signs of toxicity (convulsions or renal toxicity). The mass in the abdomen had reduced in size considerably and the patient is now asymptomatic two years after the initial surgery. The patientís abdominal girth has grossly reduced and is back to his regular work.
Pseudomyxoma peritoneii is currently defined as a grade I mucinous adenocarcinoma that arises most commonly from the appendix. It is characterized by mucinous peritoneal implants and gelatinous ascites. It is most often caused by secondary metastasis from mucin producing adenocarcinoma of the ovary, appendix, colon and rectum although a few benign neoplasms of the ovary and the appendix may be responsible for the condition.  Grainger and Allison suggest that Pseudomyxoma peritoneii may result from rupture of any viscus lined by mucinous epithelium.  In our case we suspect the primary lesion to be from one of the biliary radicles. Ultrasonogram revealed multicystic lesions throughout the abdomen.
Fig 1 Fig 2 CT sections at various levels before treatment showing extensive lesions in the region of the liver, intestinal loops and over the bladder. The Hounsfield unitage was between 10 to 15 HU
Seshill et al have described discrete nodular lesions varying from hypoechoeic (cystic) to strongly echogenic throughout the peritoneal cavity.  The disease when treated by multiple surgical debulking procedures has a median survival of two years. Good results have been obtained with early diagnosis and modern treatment with peritonectomy and intraperitoneal chemotherapy. The conventional treatment for pseudomyxoma peritoneii is with repeated debulking procedures. Intraperitoneal instillation with chemotherapeutic agents have greatly improved the prognosis. We have used cisplatin intraperitoneally  with good results. The use of sodium thiosulphate  has in our
Fig 3 Fig 4 CT sections at the corresponding levels after treatment with cisplatin.
experience allowed us to use the maximum recommended dose of cisplatin without its toxic effects. Miller et al have described the occurrence of calcification after intraperitoneal chemotherapy.  There was no evidence of new calcification at review after one year.
We recommend an aggressive treatment for pseudomyxoma peritoneii with an initial debulking surgery followed by intra peritoneal instillation of 10% dextrose and cisplatin at a dose of 100 mg/sq.m and intravenous infusion of sodium thiosulphate at 1 gm/hour over twelve hours to reduce toxicity.
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