An NCI-designated Comprehensive Cancer Center
By Samantha Bonar | October 3, 2017
Mustafa Raoof Surgical oncologist Mustafa Raoof, 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 patients who have some primary tumors and metastasis to this area. This treatment can prevent cancer from progressing and prolong or even save a life.
Surgical oncologist Mustafa Raoof, M.D., leads the peritoneal surface malignancy team at City of Hope and the upper gastrointestinal and mixed tumor surgery service. While very few institutions in the United States perform HIPEC, the City of Hope’s HIPEC center is one of the busiest in Southern California and among the most successful in the nation. 
At City of Hope, HIPEC is used to treat peritoneal mesothelioma, primary appendiceal cancer and metastatic cancer to the peritoneum, e.g., colon, rectal, ovarian and stomach. City of Hope currently runs a clinical HIPEC trial to treat primary or recurrent carcinoma of the 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. The multidisciplinary peritoneal surface malignancy team meets to evaluate each case and decide the best course of treatment. While not all patients are good candidates for HIPEC and aggressive surgery, HIPEC has been effective in improving long-term survival.
Immediately following surgery, HIPEC is administered in the operating room 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.
“HIPEC requires a team of skillful surgeons to remove the many deposits of cancer. It requires experts in general surgery, liver surgery, gynecologic surgery, and urologic surgery working together to achieve these big operations safely,” said Yuman Fong, M.D., chair of the Department of Surgery.
“At City of Hope, we are fortunate to have such a team of expert surgeons dedicated to delivering the best resection and delivery of chemotherapy,” added Fong.
The combination of heat and direct tumor exposure to chemotherapy makes HIPEC highly effective in killing residual tumor cells while allowing healthy cells 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. HIPEC is also localized in the peritoneal cavity; once removed, HIPEC doesn’t cross into the bloodstream and cause side effects typically associated with systemic chemotherapy such as hair loss. Digestive side effects can still occur, however, because of the intense focus on the abdomen during surgery and chemotherapy.
HIPEC has been shown in studies to prolong survival, such as in cases of recurrent epithelial ovarian cancer. Patients receiving HIPEC following surgery have double the mean survival rate of patients who received systemic chemotherapy after surgery. The median survival of HIPEC is 26.7 months compared to 13.4 months with systemic chemotherapy.
Thirty to 40 percent of stage 4 colon cancer patients can live five years or longer after HIPEC. Historically, survival with systemic chemotherapy is less than a year. For certain appendiceal cancers, the results are even more encouraging, with five-year survival approaching 70 to 80 percent. 
The surgical team at City of Hope performs about five to 10 HIPEC procedures a month. In order to be a good candidate, the patient must have the disease, which can be near-completely removable, and medically fit enough to undergo the operation. Cancer type is also a factor; colon, appendiceal, stomach, and ovarian cancers typically respond well.
The experts at the City of Hope and from around the country recently published a definitive textbook on HIPEC called, “Regional Cancer Therapy.”

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