What are the treatment options for liver cancer and lung cancer with peritoneal involvement?

Treatment of Liver Cancer and Lung Cancer with Peritoneal Involvement

For hepatocellular carcinoma (HCC) with peritoneal metastases, systemic therapy with sorafenib or combination immunotherapy (atezolizumab/bevacizumab) is the standard approach, with cytoreductive surgery plus HIPEC reserved only for highly selected patients in specialized centers after demonstrating response to systemic therapy. 1, 2, 3

For lung cancer with peritoneal metastases, systemic chemotherapy is the primary treatment, as peritoneal involvement represents advanced stage IV disease with poor prognosis and rapid progression. 4

Hepatocellular Carcinoma with Peritoneal Metastases

Initial Systemic Therapy Approach

• First-line treatment should be sorafenib (multikinase inhibitor), which improves median overall survival by approximately 3 months in advanced HCC. 1, 3

• Combination immunotherapy regimens (atezolizumab/bevacizumab) represent the current standard frontline option for advanced HCC. 2

• If progression occurs on immunotherapy and tyrosine kinase inhibitors, gemcitabine plus oxaliplatin (GEMOX) chemotherapy can be considered as salvage therapy. 5, 2

Role of Cytoreductive Surgery and HIPEC

• Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) should only be considered in highly selected HCC patients with peritoneal-limited disease who demonstrate profound response to systemic chemotherapy, with normalization of AFP and imaging response. 2

• This approach requires extensive multidisciplinary discussion and should only be performed at specialized centers with expertise in both HCC management and peritoneal surface malignancy treatment. 2

• Complete cytoreduction (removal of all visible macroscopic tumor) is mandatory for any potential benefit. 2

Treatment Algorithm for HCC with Peritoneal Metastases

1. Initiate frontline systemic therapy: atezolizumab/bevacizumab or sorafenib 2, 3
2. Monitor AFP and imaging every 2-3 months 1
3. If progression: switch to lenvatinib or regorafenib 5, 2
4. If further progression: consider GEMOX chemotherapy 5, 2
5. If profound response (normalized AFP, imaging response): multidisciplinary evaluation for potential CRS/HIPEC 2
6. If CRS/HIPEC performed: continue systemic chemotherapy postoperatively for 2 months 2

Lung Cancer with Peritoneal Metastases

Clinical Context and Prognosis

• Peritoneal metastasis from lung cancer is rare and typically indicates aggressive disease with multiple metastatic sites, though isolated peritoneal involvement can occur. 4

• When peritoneum is the sole metastatic site in lung adenosquamous carcinoma, the prognosis remains extremely poor with rapid progression (median survival <2 months). 4

Treatment Approach

• Systemic chemotherapy is the primary treatment modality for lung cancer with peritoneal involvement. 4

• Palliative intraperitoneal chemotherapy can be considered for symptomatic ascites control, though survival benefit is limited. 4

• Molecular testing (EGFR, ALK, ROS1, KRAS) should guide systemic therapy selection, though KRAS mutations (such as G12A) predict poor response to targeted therapies. 4

Critical Distinctions from Colorectal Peritoneal Metastases

Why CRS/HIPEC is NOT Standard for HCC or Lung Cancer

• The evidence supporting CRS/HIPEC exists primarily for colorectal cancer with peritoneal metastases, where complete cytoreduction in selected patients (PCI <20) can improve progression-free and overall survival. 1, 6

• For colorectal peritoneal metastases, complete cytoreductive surgery plus HIPEC can be considered in centers experienced with HIPEC for patients with limited peritoneal disease. 1

• The PRODIGE 7 trial achieved 91% complete cytoreduction rates in colorectal peritoneal metastases, but this expertise and outcome data do not translate to HCC or lung cancer peritoneal metastases. 6

Common Pitfalls to Avoid

• Do not extrapolate colorectal peritoneal metastasis treatment algorithms to HCC or lung cancer—the biology, response to therapy, and surgical outcomes are fundamentally different. 1, 2, 4

• Do not pursue CRS/HIPEC for HCC peritoneal metastases without first demonstrating profound response to systemic therapy with complete normalization of tumor markers. 2

• Do not delay systemic therapy in favor of surgical consultation—systemic therapy is the cornerstone of treatment for both HCC and lung cancer with peritoneal involvement. 2, 3, 4

• For lung cancer with peritoneal metastases, recognize that even isolated peritoneal involvement represents aggressive biology with extremely limited survival, and focus treatment goals on palliation rather than cure. 4