CRS and HIPEC
What is Peritoneal Surface Malignancy?
Peritoneal surface malignancy means the presence of cancer cells on the peritoneum. Peritoneum is the membrane that lines the inner surface of the abdomen and envelopes several intra-abdominal organs such as intestines, rectum, uterus, stomach, spleen etc.
The cancers that seen in the peritoneum – may arise from the peritoneum itself ( primary ) or it can spread from other organs to the peritoneum ( secondary )
Almost any cancer can spread to the peritoneum, but this is more commonly seen in tumors arising from abdominal organs like the stomach, large intestines ( colon ), ovaries and uterus. The tumor deposits can be as small as grains of sand, or can be large enough to be felt through the abdominal wall.
How can cancers reach
the peritoneum/
peritoneal cavity?
Once the cancer of an organ reaches its outer most layers, the cancer cells start shedding into the peritoneal cavity. Once in the peritoneal cavity, these cells are carried by the flow of peritoneal fluid to other parts of the abdomen in a predictable manner. These cancer cells establish adhesions to the peritoneum and develop as peritoneal metastasis. The size of these metastases varies from microscopic to large nodules.
How are Peritoneal surface malignancies treated traditionally?
The traditional approach to treat these malignancies was to give intra-venous chemotherapy. However, IV chemotherapy does not reach the peritoneal cavity in adequate concentrations to be completely effective, due to the inherent blood – peritoneal barrier.
Rationale behind
CRS and HIPEC
CRS removes all of the visibly affected peritoneum and organs, which is the corner stone for a successful outcome. Once all the visible disease is removed, the remaining invisible disease is treated by HIPEC. This ensures that all the residual microscopic disease is destroyed and there is no residual disease within the abdomen.
What is HIPEC?
HIPEC stands for Hyper thermic Intra Peritoneal Chemotherapy.It is a process where chemotherapy drugs are circulated inside the abdomen at high temperature for 60 to 90 minutes
A special HIPEC machine is used to deliver this heated chemotherapy at a sufficient high flow rate to ensure even distribution of the chemotherapy and the heat within the abdominal cavity. Studies done in the past have shown that chemotherapy agents of low molecular weight can diffuse across the cancer cell membrane and kill them. It has also shown that the heat has a synergistic effect on these chemotherapy drugs. This means that the effect of chemotherapy given in the abdomen is magnified 100-fold by just heating these drugs to 42-43 degree Celsius. It is shown to lower recurrence rates and improve survival in several types of PSM.
What types of cancers is
HIPEC used to treat?
HIPEC is used to treat peritoneal cancers like :
- Mesothelioma
- Pseudomyxoma Peritonei ( PMP )
- Primary Peritoneal cancers
- Peritoneal metastases from colon, appendix and stomach cancers.
- Ovarian cancer
Do all PSM have similar results?
All PSM are not the same.
The treatment and outcomes depend on the following factors :
The treatment and outcomes depend on the following factors :
- Primary tumor site
- Extent of Peritoneal Spread
- Extent of overall disease spread
What are the success rates
of the HIPEC procedure?
| Type of Peritoneal Malignancy | Median survival with CRS + HIPEC | Median survival with Chemotherapy |
|---|---|---|
| Colon Cancer | 48 months | 22 months |
| Mesothelioma | 50 months | 12 months |
| Appendix | 100 months | 36 months |
| Ovary | 45 months | Variable |
Which patients are suitable for Cytoreductive Surgery and HIPEC?
The patient selection depends on the following factors :
- The primary site of the tumor
- Disease extent, calculated by the PCI
- Patient conditions assessed by performance status, nutritional assessment and presence of comorbid illness.
Why CRS + HIPEC should be
performed by an expert?
The tumor related factors like disease spread and its sensitivity to chemotherapy affect the outcome of CRS + HIPEC treatment. However these factors cannot be controlled or modified.
One of the most important and controllable factor that decides the outcome in peritoneal cancers is the surgeon’s ability to remove all visible tumor. Studies have shown that it takes over 100 cases for a surgeon to overcome this learning curve. Annual case load has shown to have an influence. This means that a center or surgeon performing this procedure on a regular basis is far more likely to give a successful and safe outcome compared to a surgeon performing this procedure occasionally.
How is the recovery after CRS+HIPEC?
After CRS + HIPEC, the patient stays in ICU for 3-4 days. This may also involve ventilator support. This ICU stay is essential to closely monitor patients physiology and hemodynamic status so that timely interventions can be applied whenever necessary. CRS and HIPEC is generally associated with a slightly longer hospital stay compared to standard major abdominal surgeries as the patient tends to take a little longer to return back to normal diet and activity. During this period, the patient may require parenteral nutrition and other supplements. Total hospitalization is usually around 12-15 days in an uneventful recovery.