DESCRIPTION
NOTE: This medical policy addresses cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of pseudomyxoma peritonei and peritoneal carcinomatosis of gastrointestinal origin only.
Pseudomyxoma peritonei is a clinicopathologic entity characterized by the production of mucinous ascites and mostly originates from epithelial neoplasms of the appendix. As the tumor grows, the narrow lumen of the appendix becomes obstructed and subsequently leads to appendiceal perforation. The neoplastic cells progressively colonize the peritoneal cavity and copious mucin production builds up in the peritoneal cavity. The conventional treatment of pseudomyxoma peritonei is surgical debulking repeated as necessary to alleviate pressure effects. However, repeated debulking surgeries become ever more difficult due to progressively thickened intra-abdominal adhesions, and this treatment is palliative, leaving visible or occult disease in the peritoneal cavity.
Peritoneal dissemination develops in approximately 10 to 15% of individuals with colon cancer, and despite the use of increasingly effective regimens of chemotherapy and biologic agents in the treatment of advanced disease, peritoneal metastases are associated with a median survival of 6 to 7 months.
Surgical cytoreduction in conjunction with hyperthermic intraperitoneal chemotherapy is done in an attempt to remove tumor deposits and the intraperitoneal chemotherapy is to address the remaining microscopic disease. By delivering chemotherapy intraperitoneally, drug exposure to the peritoneal surface is increased some 20-fold compared to systemic exposure.
Cytoreductive is a combination of peritoneal stripping procedures and resections. Surgical resection can be extensive, depending on the extent of disease, and may include: partial gastrectomy, splenectomy, resection of the tail of the pancreas, omentectomy, multiple small bowel resections, ileocecal resection, rectosigmoid resection, uterine resection and multiple peritonectomy procedures. The surgical procedure is followed intraoperatively by the infusion of hyperthermic chemotherapy (e.g., mitomycin C). Inflow and outflow catheters are placed in the abdominal cavity, along with temperature probes to monitor temperature. The skin is then temporarily closed during the chemotherapy perfusion, which typically runs for 1-2 hours. The temperature at the inflow line is approximately 44°C. An esophageal temperature probe is used to monitor the individual’s core body temperature. A cooling blanket is used to prevent systemic hyperthermia. After the intraoperative infusion is complete, the abdomen is suctioned dry of fluid. The abdomen is reopened and reconstructive surgery is performed. Following the procedure, the individual is maintained on parenteral feeding for several weeks.
POLICY
Cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of pseudomyxoma peritonei is considered medically necessary.
Cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal carcinomatosis from colorectal cancer is considered investigational.
Policy with similar title: Local or Whole Body Hyperthermia
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Well-developed scientific studies in peer-reviewed journals regarding cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal carcinomatosis from colorectal cancer are lacking. Issues such as, who should receive the treatment, comparison to other available treatments, recurrence rates, and risk verses benefit of the technology have not been answered.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2010). Cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of pseudomyxoma peritonei and peritoneal carcinomatosis of gastrointestinal origin (2.03.07). Retrieved March 14, 2011 from BlueWeb. (19 articles and/or guidelines reviewed)
Boutros, C., Somasundar, P., & Espat, N. J. (2010). Early results on the use of biomaterials as adjuvant to abdominal wall closure following cytoreduction and hyperthermic intraperitoneal chemotherapy. World Journal of Surgical Oncology, 8 (72).
Cao, C., Yan, T., Black, D., & Morris, D. (2009). A systematic review and meta-analysis of cytoreductive surgery with perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal origin. Annals of Surgical Oncology, 16 (8), 2152-2165.
Chua, T. C., Liauw, W., Saxena, A., Al-Mohaimeed, K., Fransi, S., Zhao, J., et al. (2011). Evolution of locoregional treatment for peritoneal carcinomatosis: Single-center experience of 308 procedures of cytoreductive surgery and perioperative intraperitoneal chemotherapy. The American Journal of Surgery, 201 (2), 149-156.
da Silva, E. G., & Surgarbaker, P. H. (2006). Analysis of prognostic factors in seventy patients having a complete cytoreduction plus perioperative intraperitoneal chemotherapy for carcinomatosis for colorectal cancer. Journal American College of Surgery, 203 (6), 878-886.
Elias, D., Benizri, E., DiPietrantonio, D., Menegon, P., Malka, D., & Raynard, B. (2007). Comparison of two kinds of intraperitoneal chemotherapy following complete cytoreductive surgery of colorectal peritoneal carcinomatosis. Annals of Surgical Oncology, 14 (2), 509-514. (Level 4 Evidence - Independent study)
Esquivel, J., Sticca, R., Sugarbaker, P., Levine, E., Yan, T. D., Alexander, R., et al. (2007). Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: A consensus statement. Annals of Surgical Oncology, 14 (1), 128-133.
Gammon, D., Duttone, T., Piperdi, B., Zybert, J., Wolfe, S., Nguyen, E., et al. (2009). Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy in the treatment of peritoneal carcinomatosis. American Journal of Health-System Pharmacy, 66 (13), 1186-1190.
Glockzin, G., Schlitt, H. J., & Piso, P. (2009). Peritoneal carcinomatosis: Patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. World Journal of Surgical Oncology, 7 (5).
Levine, E. A., Stewart, J. H., Russell, G. B., Geisinger, K. R., Loggie, B. L., & Shen, P. (2007). Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy: Experience with 501 procedures. Journal of the American College of Surgeons, 204 (5), 943-953.
Macri, A., Maugeri, I., Trimarchi, G., Caminiti, R., Saffioti, M., Incardona, S., et al. (2009). Evaluation of quality of life of patients submitted to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinosis of gastrointestinal and ovarian origin and identification of factors influencing outcome. In Vivo, 23 (1), 147-150. (Level 4 Evidence - Independent study)
McQuellon, R. P., Danhauser, S. C., Russell, G. B., Shen, P., Fenstermaker, J., Stewart, J. H., et al. (2007). Monitoring health outcomes following cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis. Annals of Surgical Oncology, 14 (3), 1105-1113.
McQuellon, R. P., Russell, G. B., Shen, P., Stewart, J. H., Saunders, W., & Levine, E. A. (2008). Survival and health outcomes after cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for disseminated peritoneal cancer of appendiceal origin. Annals of Surgical Oncology, 15 (1), 125-133.
National Comprehensive Cancer Network (NCCN). (2011, February). NCCN clinical practice guidelines in oncology™.Colon cancer - V.2.2011. Retrieved February 15, 2011 from http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf.
National Institute for Health and Clinical Excellence (NICE). (2010, February). Cytoreduction surgery followed by hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis. Retrieved February 15, 2011 from http://www.nice.org.uk/nicemedia/live/11152/47526/47526.pdf.
Rampone, B., Schiavone, B., Martino, A., & Confuorto, G. (2010). Current role of hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis from colorectal cancer. World Journal of Gastroenterology, 16 (11), 1299-1302.
Sugarbaker, P. H. (2011). Evolution of cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis: Are there treatment alternatives? The American Journal of Surgery, 201 (2), 157-159.
Tuttle, T. M., Zhang, Y., Greeno, E., & Knutsen, A. (2006). Toxicity and quality of life after cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy. Annals of Surgical Oncology, 13 (12), 1627-1632. (Level 2 Evidence - Independent study)
Winifred S. Hayes, Inc. Medical Technology Directory (2009, April). Intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis resulting from gastric cancer. Retrieved February 15, 2011 from www.Hayesinc.com/subscribers. (54 articles and/ or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2009, May). Intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis resulting from ovarian cancer, peritoneal mesothelioma, or abdominal sarcoma. Retrieved February 15, 2011 from www.Hayesinc.com/subscribers. (68 articles and /or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2009, May) Intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis resulting from cancers of the lower gastrointestinal tract. Retrieved February 15, 2011 from www.Hayesinc.com/subscribers. (59 articles and/ or guidelines reviewed)
Yan, T. D., Sim, J., & Morris, D. L. (2007). Selection of patients with colorectal peritoneal carcinomatosis for cytoreductive surgery and perioperative intraperitoneal chemotherapy. Annals of Surgical Oncology, 14 (6), 1807-1817.
ORIGINAL EFFECTIVE DATE: 9/9/2007
MOST RECENT REVIEW DATE: 7/9/2011
ID_BA
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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