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Good Doctor. Hot Infusion | Reprint 2: Progress and achievements of PSOGI/PSM certified centers of excellence. Milan Cancer Institute's contribution to peritoneal oncology: Past, present and future
In the mid-1990s, the Italian National Cancer Institute (Fondazione IRCCS Istituto Nazionale dei Tumori) in Milan established a Peritoneal Surface Malignancies (PSM) program, becoming one of the pioneering centers for peritoneal tumors in Europe. After completing surgical training in Washington, D.C. with Dr. Paul Sugarbaker, Marcello Deraco assembled a specialized team to treat peritoneal malignancies, which were then considered largely incurable. At the time, systemic chemotherapy was considered to have limited efficacy against peritoneal malignancies, and surgery was viewed as purely palliative.
2025-04-29
The Milan Cancer Institute's Contribution to Peritoneal Oncology: Past, Present, and Future
By Marcello Deraco and Shigeki Kusamura
Past
In the mid-1990s, the Fondazione IRCCS Istituto Nazionale dei Tumori in Milan established a Peritoneal Surface Malignancies (PSM) program, becoming one of the pioneering centers for peritoneal tumors in Europe. After completing surgical training in Washington, D.C. with Dr. Paul Sugarbaker, Marcello Deraco assembled a specialized team to treat peritoneal malignancies, then considered largely incurable. Systemic chemotherapy was deemed of limited effectiveness, and surgery was viewed as purely palliative.
Based on the foundational work of internationally renowned experts such as Paul Sugarbaker, Brendan Moran, David Morris,
François Noël Gilly, Dominique Elias, and Frans Zoetmulder, the Milan team played a key role in validating and implementing cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in Southern Europe. Their major contribution was to incorporate this combined treatment into a systematized, reproducible, safe, and widely applicable clinical pathway.
In the late 1990s and early 2000s, the team refined the peritoneal resection techniques and perioperative management, developing expertise in rare diseases such as pseudomyxoma peritonei and peritoneal malignant mesothelioma. Through impactful single-center cohort studies and translational research to elucidate the pathophysiological mechanisms of these diseases, they advanced scientific understanding. A multidisciplinary approach, integrating surgical, medical, biological, and pathological expertise, led to deeper insights into tumor biology and progression, identifying new prognostic markers and improving selection criteria for patients undergoing combined treatment.
In 2006, the Milan center hosted a landmark international Peritoneal Surface Oncology Group (PSOGI) meeting, fostering consensus in the rapidly evolving field of peritoneal surface oncology. By the end of the first decade of the 21st century, Milan had become one of the leading international centers—not by working in isolation, but by translating innovative concepts into standardized, widely applicable clinical practice. Their efforts contributed to the transformation of CRS and HIPEC from experimental interventions to established treatments for peritoneal surface malignancies.
Present
Today, the Milan center is internationally recognized, having treated over 1500 patients with CRS and HIPEC. Its multidisciplinary team manages complex cases of all peritoneal surface malignancy subtypes, with particular expertise in pseudomyxoma peritonei and peritoneal mesothelioma. Treatment is highly personalized, combining surgical, systemic, and intraperitoneal therapies with comprehensive supportive strategies tailored to each patient's needs.
From a surgical perspective, the Milan team has been a pioneer in the continuous evolution of CRS techniques. They have refined and systematized complex procedures such as total peritonectomy and mesenteric peritonectomy, achieving complete cytoreduction even in challenging anatomical situations. Their innovations have addressed previously unsolvable technical challenges, such as safe dissection in traditionally high-risk areas near vessels. The team has also participated in recent consensus-building efforts on CRS promoted by PSOGI, the International Society for Peritoneal and Thoracic Oncology (ISSPP), and the European Society of Gynaecological Oncology (ESGO), working towards standardization of peritoneal resection procedures and terminology.
Supported by competitive research funding from national agencies such as the Italian Association for Cancer Research (AIRC) and the Ministry of Health, the center remains a leader in innovation and research, conducting numerous clinical trials and translational studies aimed at improving HIPEC efficacy, exploring new drug combinations, and optimizing perfusion protocols. There is a strong focus on tumor biology research to enable tailored treatment strategies.
In mesothelioma research, pathways involving tyrosine kinase receptors, telomerase dysregulation, apoptosis, epithelial-mesenchymal transition (EMT) and its reversal (MET), and tumor cell proliferation have been investigated. The identification of Ki-67 as a prognostic biomarker has provided important guidance for treatment decision-making.
The Milan team has also developed patient-derived organoids—an innovative platform for drug sensitivity testing, biomarker discovery, and target identification. Furthermore, the center coordinates the ACCELERATOR project, a European network focused on translational research in pseudomyxoma peritonei.
Clinicians from Milan have made significant contributions to national and international guideline development. Collaborating with RENAPE, they coordinated PSOGI recommendations for pseudomyxoma peritonei and mesothelioma, played a central role in the standardization of HIPEC, and led the recent multi-society consensus statement on CRS and HIPEC—released at the 2023 PSOGI international congress organized by the Milan team in Venice.
The Milan center disseminates knowledge of peritoneal surface oncology globally through the European School of Peritoneal Surface Oncology (ESPSO), widely publishing research and training professionals worldwide. In 2011, the center initiated the biennial ESPSO theoretical course on peritoneal surface malignancies, with the first edition held in Bergamo, Italy, and the most recent in Basingstoke, UK in 2024. Its leadership has raised standards globally and fostered the development of new expert centers internationally.
Future
Looking ahead, the Milan team is committed to advancing precision oncology. Ongoing research focuses on exploring the tumor microenvironment, particularly its interplay with cancer-associated fibroblasts (CAFs)—known tumor growth promoters—and their role in suppressing anti-tumor immunity. A major
challenge will be identifying strategies to reverse this immunosuppression and assessing the potential of targeting CAFs therapeutically. Concurrently, the potential role of immunotherapy in the treatment of peritoneal surface malignancies is under active investigation.
Innovations in imaging technology (such as radiomics) and intraoperative navigation will enhance surgical precision. Furthermore, the center plans to expand the application of artificial intelligence in clinical practice and research, building platforms for decision support, efficacy prediction modeling, and multi-omics data interpretation.
Currently, minimally invasive treatment approaches, including laparoscopic and robotic-assisted cytoreductive surgery, are being investigated through a prospective validation study. Similarly, other regional therapies such as pressurized intraperitoneal aerosol chemotherapy (PIPAC) and hyperthermic intraperitoneal chemotherapy are being explored to define their role in clinical management.
Efforts to improve perioperative care, such as through carefully designed preoperative rehabilitation programs, aim not only to improve patient survival but also to reduce the morbidity and mortality associated with cytoreductive surgery and HIPEC, thereby enhancing quality of life. Education and mentorship remain key elements, as the team continues to train the next generation of specialists and facilitate the expansion of expert centers globally.
Undoubtedly, these achievements would not have been possible without the collaboration of numerous international referral centers that constitute the global peritoneal surface oncology community, including Washington, Basingstoke, Lyon, Manchester, Paris, Montpellier, Eindhoven, Genk, Ghent, Madrid, Barcelona, Cordoba, Lausanne, Athens, Thessaloniki, Regensburg, Berlin, Uppsala, Odense, Oslo, Sydney, Beijing, Singapore, Kishiwada, Tokyo, Maryland, Connecticut, Lewis, San Diego, Salt Lake City, Winston-Salem, New York, Houston, Salvador, Sao Paulo, Rio de Janeiro, Rome, Padua, Turin, Bangalore, Ahmedabad, Tel Aviv, and Netanya, among many others.
From challenging the notion of "incurability" in the 1990s to establishing global treatment standards today, the Milan center will continue to strengthen the Peritoneal Surface Oncology Group International (PSOGI) network, pushing the boundaries of current understanding of peritoneal surface malignancies—bringing hope where there was once none.
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Internet Drug Information Service Qualification Certificate (Shaanxi)-Non-Operating -2023-0143