Carcinomatosis is a complication of primary cancer

If, during metastasis of the primary tumor, cancer cells move to the tissues of other organs, threatening to damage them, then carcinomatosis means the development of malignant tumors - metastatic carcinomas or adenocarcinomas - after spreading from the primary focus. Oncologists generally use this term for any type of secondary cancer tumors in any location.

In ICD-10, this pathological condition is defined as disseminated malignant neoplasm (unspecified) with code C80.0.

Epidemiology

According to some estimates, peritoneal carcinomatosis is detected in 5-8% of cancer patients with colorectal cancer - rectal adenocarcinoma, which is one of the most common oncological diseases in the world (diagnosed annually in 1.4 million people). At the time of diagnosis, peritoneal carcinomatosis is observed in almost 10% of patients with colorectal cancer and in about 70% of patients with ovarian carcinoma.

According to statistics, pulmonary lymphogenous carcinomatosis accounts for 6-8% of cases of secondary (metastatic) lung cancer. [ 1 ]

Leptomeningeal carcinomatosis accounts for 1-5% of solid tumors, 5-15% of hematological malignancies, and 1-2% of primary brain cancers.

Causes carcinomatosis

The development of carcinomatosis has no other cause than the presence of a primary malignant tumor and its metastasis. That is, such a condition is possible only in cancer patients and represents the dissemination of cancer and its progression. [ 2 ]

Distinguishing types of carcinomatosis by the method of spread of tumor cells, specialists note lymphogenous carcinomatosis (through the lymphatic vessels and lymphatic drainage system), developing with metastases in the lymph nodes, non-Hodgkin's lymphoma, ovarian cancer or neuroendocrine tumors.

In patients with leukemia, as well as with malignant tumors of the mammary gland and lungs, hematogenous spread of metastases may occur, with damage to the brain and abdominal organs, respectively.

And with implantation spread – direct invasion of cancer cells from tumors of the intestine, stomach, pancreas, uterus or ovaries – carcinomatosis can develop in the lungs, peritoneum and liver.

Secondary malignant tumors are also divided by localization. Lung carcinomatosis occurs with metastasis of tumors of the mammary gland, uterus or ovaries; kidney cancer, pancreatic or thyroid cancer, prostate cancer.

In malignant neoplasms of the lungs, mammary glands, stomach, as well as in any tumor capable of metastasizing to the lungs and mediastinal region, carcinomatosis of the pleura and pleural cavity can develop. [ 3 ]

Carcinomatosis of the abdominal cavity (cavum peritonei) is the result of metastases to the abdominal cavity. And the spread of cancer of the gastrointestinal tract or female reproductive system causes carcinomatosis of the peritoneum (peritoneum). As experts note, peritoneal carcinomatosis is most often caused by metastasis of malignant neoplasms of the stomach, pancreas, ovaries and colorectal carcinoma, as well as primary extra-abdominal tumors - mammary glands, lungs, malignant melanoma of the skin, highly malignant lymphomas.

In case of oncological disease of any organ of the abdominal and abdominal cavity, carcinomatosis of the omentum can be detected, the development of which occurs through the lymphogenous route - through the lymphatic system of the greater omentum - and leads to infiltration of soft tissues into the fat.

Primary gastric cancer is diagnosed very often, but gastric carcinomatosis – with metastases to this organ from squamous cell carcinoma of the esophagus, renal cell carcinoma, lobular carcinoma of the breast or ovarian cancer – is a rare condition.

In case of metastases in the intestine, which can spread from most tumors of the abdominal organs, intestinal carcinomatosis is observed, and in case of colon or rectal cancer, colon carcinomatosis (part of the large intestine) is observed.

Liver carcinomatosis is etiologically associated with melanoma, tumors of the lungs, ovaries, stomach and intestines, pancreas and prostate gland.

In most cases, ovarian carcinomatosis is a consequence of metastasis of tumors of the uterus, mammary gland, gastrointestinal tract and bladder.

A late and rare complication of malignant tumors of the breast, lungs and melanoma that metastasize to the brain through the blood or cerebrospinal fluid is carcinomatosis of the meninges or leptomeningeal carcinomatosis (leptomeninges are the arachnoid and pia mater of the brain).

Risk factors

The undisputed risk factors for the development of carcinomatosis are: the presence of a primary tumor with a high degree of malignancy, late stages of the primary tumor (T3 and T4), metastases to the lymph nodes and visceral metastases.

Thus, the risk of developing disseminated malignant neoplasms in the abdominal cavity or abdominal wall in colon cancer at stage T3 does not exceed 10%, and at stage T4 it is 50%.

There is also an increased risk of carcinomatosis in cases of non-radical resection of the primary tumor, and of leptomeningeal carcinomatosis in cases of surgical removal of the neoplasm without whole-brain radiotherapy.

Pathogenesis

Pathologically altered tumor cells are characterized by a disruption of the internal structure and metabolic processes (with a predominance of anabolism), as well as suppression of cellular immunity with the transformation of T-lymphocytes, which begin to act as toxins in the tissues surrounding cancer cells. In addition, under the influence of cancer cells, the growth of fibroblasts, adipocytes, endothelial, mesothelial and stem cells is activated - with the loss of their normal properties and functions. [ 4 ]

Particularly important in the mechanism of the oncological process is the disruption of the physiological cell cycle in tumor tissue, leading to uncontrolled proliferation of mutant cells both in the primary focus and when they spread beyond it.

The pathogenesis of secondary malignant tumors of various localizations in carcinomatosis is caused by desquamation - the ability of primary tumor cells to exfoliate, their spread through the lymphatic vessels, blood, peritoneal and cerebrospinal fluids and direct invasion, as well as adhesion (intermolecular connection) of healthy cells to cancer cells, which rapidly multiply, leading to nodular lesions of the superficial tissues of organs.

Symptoms carcinomatosis

The main symptoms depend on where carcinomatosis develops and how extensive the organ damage is.

Thus, the first signs of pulmonary carcinomatosis may manifest as shortness of breath and hemoptysis; peritoneal carcinomatosis - its abnormal enlargement and swelling of the upper abdomen; disseminated malignant neoplasm of the stomach often manifests itself as periodic abdominal pain, and liver - jaundice.

The most common symptoms of peritoneal carcinomatosis are ascites (which develops due to the blockage of lymph drainage by the malignant neoplasm or the release of fluid into the abdominal cavity), nausea, cachexia (general exhaustion with significant weight loss) and intestinal obstruction (due to compaction of the intestinal wall and compression of the rectum). With nodular formations on the intestinal walls (sometimes up to several centimeters in size), acute or nagging pain is possible. [ 5 ]

Affecting the ovaries, carcinomatosis can cause discomfort, pain, shortness of breath, bloating, and anorexia in patients.

In meningeal carcinomatosis, symptoms are caused by damage to nerves crossing the subarachnoid space, direct tumor invasion of the brain or spinal cord, cerebral circulatory disorders, and obstruction of cerebrospinal fluid outflow. The clinical picture is quite variable and may include headaches, vomiting, difficulty swallowing, confusion, and progressive neurological dysfunction.

Complications and consequences

The key consequences of carcinomatosis of any localization are decreased patient survival. Thus, in more than half of patients with stomach cancer, disease progression leads to peritoneal carcinomatosis, in the absence of treatment of which the average survival does not exceed three months, and after chemotherapy - ten months.

Without appropriate treatment, leptomeningeal carcinomatosis leads to death within a month to a month and a half, but chemotherapy can extend life to three to six months.

The most common complications of peritoneal carcinomatosis are: gastrointestinal motility disorder, portal hypertension, small bowel obstruction, splenomegaly, hepatic encephalopathy, intestinal obstruction, intestinal fistula formation, peritonitis. [ 6 ]

All cancer patients have a several-fold increased risk of thromboembolism in carcinomatosis, since the formation of blood clots in veins in cancer is caused by the influence of tumors on the homeostasis system and blood clotting.

Diagnostics carcinomatosis

In the case of carcinomatosis, diagnostics are intended to verify the nature of the disease and assess its severity.

Blood tests are required for tumor markers and serum creatinine levels; analysis of intra-abdominal fluid (in case of ascites) – for the number of neutrophils; analysis of cerebrospinal fluid – for the presence of malignant cells and the level of protein and glucose; general urine analysis. A biopsy and histological analysis of a tissue sample are required to select a treatment method.

Visualization of the pathological condition of the affected organs is provided by instrumental diagnostics: radiography, ultrasound, CT, MRI (if damage to the meninges is suspected - MRI with contrast enhancement). [ 7 ]

Differential diagnosis

Differential diagnosis is carried out with primary multiple malignant neoplasms; peritoneal carcinomatosis - with tuberculosis that imitates it, as well as lymphomatosis, pseudomyxoma and primary mesothelioma of the peritoneum. Pulmonary carcinomatosis should be differentiated from viral and lymphocytic interstitial pneumonia, radiation pneumonitis and pulmonary sarcoidosis.

Read more in the publications:

• Cancer diagnostics
• Cancer screening

Treatment carcinomatosis

Treatment of disseminated malignant neoplasms is carried out using the same methods as treatment of primary malignant tumors, but in many cases it is essentially palliative.

Surgical treatment consists of the most complete removal of the cancerous tumor – complete cytoreductive surgery. [ 8 ]

After that, radiation therapy is prescribed (if there is a significant volume of tumor tissue) and a course of chemotherapy: this is either intravenous chemotherapy or intrathecal (with the introduction of drugs into the cerebrospinal fluid by epidural injections). And patients with peritoneal carcinomatosis can undergo hyperthermic intraoperative peritoneal (intraperitoneal) chemotherapy (HIPEC). What drugs can be used in this case, read in detail in the materials:

• Anti-cancer drugs
• Chemotherapy drugs

It is also possible to prescribe drugs from the antimetabolite group, for example, Methotrexate, which suppresses the proliferation of cancer cells. And in targeted drug therapy, such antitumor drugs from the monoclonal antibody group as Ipilimumab, Pembrolizumab, Bevacizumab (Avastin), Trastuzumab (Herticad), Rituximab (Rituxan), etc. are used.

Prevention

Oncologists believe that the main prevention of secondary cancerous tumors is early detection of primary malignant tumors and their immediate treatment. As an example, they cite the situation with the diagnosis of one of the most deadly types of oncology in women - ovarian cancer, which in more than 70% of cases is detected only at stage III-IV.

Forecast

Analyzing the survival rates of patients with carcinomatosis, experts claim: the prognosis is poor. [ 9 ] Because in many cases there is no real hope for a cure.