Peritoneal Malignancies

Hyperthermic intraperitoneal chemotherapy (HIPEC), also known as “hot chemotherapy,” is used to treat cancers that spread throughout the abdominal cavity. The procedure involves first surgically removing all visible cancer tumors within a patient’s abdomen and then circulating heated chemotherapy directly into the abdomen during surgery.

HIPEC is used in conjunction with surgery to treat cancers in the peritoneum (a membrane that lines the abdominal cavity and covers the abdominal organs). The procedure involves circulating chemotherapy that is heated to 108 degrees Fahrenheit (41-43 degrees Celsius) through the abdominal cavity for 60-90 minutesto treat small tumors or cancer cells. When heated, chemotherapeutic agents can penetrate deeper into the tissues with increased effectiveness and fewer side effects. Traditional chemotherapy is typically given intravenously and often is accompanied by unpleasant side effects. HIPEC has minimal absorption by the body and maximal effectiveness on tumor cells traditional chemotherapy cannot reach.

Cytoreductive surgery, also known as CRS, is a complex procedure used in the treatment of cancer that has spread throughout the abdominal cavity. CRS can be used in select cases to treat primary cancers of the peritoneum or cancer that has spread to the peritoneum (carcinomatosis) from other parts of the body. The procedure involves the removal or destruction of the majority of tumors or affected organs in preparation for HIPEC.

CRS is typically performed through a midline incision that enables the surgeon to identify and remove all visible tumors. Complete CRS, which can sometimes take several hours, is achieved when the largest remaining tumors are no more than 2.5 mm in size.

Our organs are covered with visceral peritoneum. When the disease extends into the underlying organ, the organ may need to be surgically removed. Small, superficial disease can be treated with electrofulguration, which refers to a process in which the tumor is burned away.

Following CRS, a specialized pump heats and circulates the chemotherapy throughout the abdomen for 60 to 90 minutes to treat microscopic cancerous cells or residual tumors. A minimal amount of the chemotherapy is absorbed into the body and, as a result, there are few if any side effects to the treatment. The most commonly used chemotherapeutic agents are mitomycin C, oxaliplatin, carboplatin and cisplatin.

HIPEC is used in conjunction with CRS to treat cancer that originates in the colon, appendix, stomach, ovaries and sarcomas, as well as other cancers. Mesothelioma, which is cancer that originates in the abdominal lining, can be treated with HIPEC if the cancer has not spread beyond the abdomen.

Patients with primary peritoneal tumors such as malignant mesothelioma have a very poor prognosis, averaging a survival of 9-14 months. Following treatment with CRS-HIPEC, more than two-thirds of patients (69 percent) survive beyond five years.

When colorectal cancer metastasizes (spreads) to the peritoneum, patients experience poor results. Even with the best systemic chemotherapy, the median survival is less than one year. Since CRS and HIPEC have become more available, about one-third of patients have no evidence of disease recurrence (disease-free survival) five years after complete CRS-HIPEC therapy.

Regarding mucinous tumors and pseudomyxoma peritonei (PMP) of the appendix, the five-year survival has increased to 50-80 percent. Because of the significant amount of tumor and associated abdominal distension, pain, and bowel obstructions that accompany these tumors, there is also a significant improvement in overall quality of life with treatment.

Studies show that patients with diffuse peritoneal carcinomatosis from ovarian cancer treated with CRS plus HIPEC have a three-year survival rate of 62%. By comparison, only 48% of patients who underwent surgery with conventional treatment were alive at 3 years and their disease returned sooner

CRS-HIPEC is a major procedure that has a post-operative (within 30 days of surgery) morbidity of 12-56 percent and a mortality of up to 12 percent. Although there are limited side effects from the chemotherapy because it is not absorbed into the system, most of the complications are the result of the type of surgery required. For example, the number of bowel resections performed increases the post-operative gastrointestinal leak rate, abscess formation, and fistula formation. In addition, impaired wound healing as a consequence of resecting abdominal wall tumors and delivery of HIPEC can lead to wound infections, as well as affect the integrity of the abdominal wall.

As our experience has grown significantly, we have improved techniques to reduce surgical complications at Jupiter Medical Center. We also evaluate patients more selectively to determine whether they are appropriate candidates to undergo this type of invasive procedure.

Depending on the extent of resection, the patient’s age and whether the patient has other medical problems, the typical length of stay in the hospital has been one to two weeks, on average. Patients typically are discharged from the hospital with the ability to tolerate a regular diet, walk with little or no assistance, and take oral medications to control any pain they may experience.

The complete exploration of the abdominal cavity and organ spaces is important to the success of the procedure. Most cases begin with a laparoscopic approach for initial exploration before a decision is made to proceed with an open incision. However, in select patients with minimal peritoneal disease or those who require a second-look surgery and prophylactic HIPEC, laparoscopic HIPEC can be performed. Benefits include avoiding a midline incision and associated wound complications, less postoperative pain, shorter hospital stay and earlier return to normal activities. Laparoscopic HIPEC has been successfully administered in palliating patients with ascites or fluid build-up from peritoneal metastases. It has shown to provide treatment benefits greater than conventional methods including diuretics, repeated paracentesis and systemic chemotherapy with complete resolution of the ascites being observed in up to 94 % of patients.

It is best to discuss with your doctor if this procedure is right for you. Dr. Shanel Bhagwandin, Jupiter Medical Center’s surgical oncologist, was trained in a complex general surgical oncology fellowship at Mount Sinai Hospital in New York, where he remains on faculty. He performed many HIPEC procedures alongside Dr. Daniel Labow within the Surgical Oncology Division at Mount Sinai Hospital. He has also researched its effects and outcomes. Doctors at Mount Sinai Hospital have been on the forefront of this groundbreaking procedure and are now bringing this revolutionary treatment to South Florida. Jupiter Medical Center and Mount Sinai Hospital review cases as part of a multidisciplinary team (surgery, radiology, pathology, medical oncology and case management) that is highly experienced in providing CRS and HIPEC.

HIPEC is not experimental and clinical research has verified its effectiveness and safety in a number of different cancers. The procedure is covered by insurance, and our experienced staff will help obtain insurance coverage for patients both in Florida and from out of state.