Heated Chemotherapy Can Tackle Tough Peritoneal Cancers

October 3, 2017 | by Samantha Bonar

Lee-Byrne Surgical oncologist Byrne Lee, M.D.
Cancers that affect or metastasize to the peritoneal cavity (the abdominal area that contains organs such as the stomach and liver) can be difficult to treat.
 
Previously, available treatments were largely palliative. Heated intraoperative peritoneal chemotherapy (HIPEC), combined with surgery, is a newer therapy that can help certain patients with some primary tumors and metastasis to this area. This treatment can keep cancer from progressing and prolong — or even save — life.
 
Surgical oncologist Byrne Lee, M.D., chief of the Upper GI and Mixed Tumor Surgery Service, leads the peritoneal surface malignancy team at City of Hope. While very few institutions in the United States perform HIPEC, City of Hope’s HIPEC center is one of the busiest in Southern California and one of the most successful in the nation.
 
Here, HIPEC is used to treat peritoneal mesotheliomas, primary appendiceal cancer and metastatic cancers to the peritoneum including colon, rectal, ovarian and stomach. (In addition, City of Hope currently is running a clinical trial of HIPEC to treat primary or recurrent carcinoma of ovarian, fallopian tube, uterine or peritoneal origin.)
 
Patients with cancers that are confined to the peritoneal cavity — and are accessible for tumor debulking — may benefit from this procedure. Lee and a multidisciplinary peritoneal surface malignancy team meet to evaluate each case and decide the best course of treatment. Not all patients will be candidates for HIPEC and aggressive surgery, but for those who are, HIPEC has been effective in improving long-term survival.
 
HIPEC is administered in the operating room immediately following surgery to remove all visible tumors, as surgery almost invariably leaves some cancer cells or small tumors behind. Infusion tubes and temperature probes are placed inside of the peritoneal cavity before it is temporarily closed with sutures. The chemotherapy is then heated to around 42 degrees Celsius (about 108 degrees Fahrenheit) before perfusion into the cavity. For 60 to 90 minutes, it circulates uniformly throughout the cavity to kill any microscopic tumor cells that might have remained after surgery. The chemotherapy fluid is then drained. The whole procedure takes about six hours.
 
“It’s an extensive procedure,” Lee said. “You will hear the term ‘the mother of all surgeries,’ and it really is. You really have to use all of the surgical skills that you’ve learned because you’re operating on every aspect of the abdominal cavity.”
 
Lee and his team at City of Hope perform about five to 10 HIPEC procedures a month, he said. To be a good candidate for HIPEC, the patient has to “be medically fit to have the operation, and have disease which can be completely removed surgically” he said. Cancer type is also a factor: “Colon, appendiceal and ovarian cancers are the ones that we know respond well,” he said. “Amount of tumor is also important. If there is tumor in every corner of the abdomen, the chances of you getting everything out is slim. The more disease that is present, the less effective this procedure can be.”
 
However, for the right candidates, the combination of heat and direct exposure makes HIPEC highly effective in killing residual tumor cells, while healthy cells are able to recover from the exposure.
 
There are many benefits to HIPEC over conventional chemotherapy. Unlike systemic chemotherapy, HIPEC is given one time immediately after surgery instead of through multiple infusions. HIPEC can be used at a higher dose than systemic chemotherapy to maximize effectiveness.
 
And because HIPEC is localized in the peritoneal cavity and then removed, it doesn’t cross into the bloodstream and patients don’t typically experience the side effects associated with systemic chemotherapy such as hair loss. Digestive side effects can still occur, however, because of the intense focus on the abdomen surgically, as well as with the chemotherapy. And because it is such an extensive operation, “recovery can be very slow,” Lee said.
 
HIPEC has been shown in studies to prolong survival such as in cases of recurrent epithelial ovarian cancer. Patients receiving HIPEC following surgery had a mean survival double that of patients who followed surgery with systemic chemotherapy (26.7 vs.13.4 months, respectively).
 
“Thirty to 40 percent of Stage 4 colon cancer patients will live five years or more after HIPEC. Historically, survival is less than a year,” Lee said. “For certain appendiceal cancers, we have seen 70 to 80 percent five year survival. Results like this are impressive. We will continue to use this treatment, and look for other cancers that may respond.”  
 
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