HIPECHyperthermic IntraPeritoneal Chemotherapy


Hyperthermic IntraPeritoneal Chemotherapy (HIPEC), in combination with Cyto-Reductive Surgery (CRS), is a specific type of chemotherapy for the cure of tumors originating from Peritoneal Carcinosis.

In this procedure, a highly concentrated, heated chemotherapics solution is delivered directly to the abdomen. This allows for higher doses of chemotherapy treatment. Heating the solution improves the absorption of chemotherapy drugs by tumors and destroy microscopic cancer cells which inevitably remain in the abdomen after surgery.

Peritoneal carcinosis: how it originates

Peritoneal Carcinosis represents the advanced evolutive stage of several tumors that develop into abdominal and pelvic organs, such as colon, ovary, appendix, stomach, pancreas and liver.

In particular, Colorectal cancer is one of the most common tumors throughout the world, especially in the developed countries, with a 47,7 rate over 100.000 men and 36,2 rate over 100.000 women. This tumor, as well as Stomach cancer have been constantly increasing in the last years, especially due to diet factors (consumption of high quantities of preserved food and scarce quantities of fruit and vegetables) and incorrect lifestyle behavior.

As to Ovarian cancer, familiarity is one of the main risk factors, with an incidence of 5-10% of total occurrences. Women whose first grade relatives (mother, sister or daughter) is affected by ovarian carcinoma, have a higher risk to develop this neoplasia.

Furthermore, there are also tumors developing directly from peritoneum (Mesothelioma) whose incidence, even though rare, is recently increasing and is strictly linked to asbestos exposure.

When the disease grows, the neoplastic cells reach and affect the membrane covering the same organs, the Peritoneum. Once this “barrier” is crossed, tumoral cells are able to move into the abdominal cavity, carried by the peritoneal fluid. Even in the case of Mesothelioma, that affects directly the peritoneum, tumoral cells can break off the membrane and fall into the peritoneal fluid. The tumoral cells present into the liquid can die or survive feeding on substances contained in the fluid itself. These cells tend to accumulate in the areas where a higher fluid re-adsorption occurs, creating agglomerates, that grow more and more, spreading into the whole abdomen and originating the carcinosis.

How to cure it

Peritoneal carcinosis has long been considered a disease with very poor prognosis and impossible to cure with surgical intervention, due both to its peculiarity and to the tendency of some drugs to concentrate at the peritoneum level, passing through it only gradually.

Today, thanks to the availability and evolution of novel therapeutic techniques it is possible to cure even this kind of neoplasia in an effective way.

The best possible approach today contemplates the combination of surgery and intraperitoneal chemo-hyperthermia, a complex intervention organized into two stages – separate but equally important for the treatment outcome – which have to be executed one immediately after the other:

1. CRS (Cyto-Reductive Surgery):  surgical removal of the all the neoplastic tissue, that it is visible to the naked eye by the surgeon.

2. HIPEC (Hyperthermic Intra-PEritoneal Chemotherapy):  “washing” of the abdominal cavity with chemotherapic drugs at high concentrations, in order to kill free cancer cells and small bulk of tumoral cells.

CRSCYTOREDUCTIVE SURGERY

It’s a long and complex intervention (it can last up to 16 hours) for the surgical removal of the tumor. The admission to hospital occurs one or two days before the operation. The pre-operating preparation includes a general objective exam, instrumental exams (thoracic, abdominal, and/or pelvic CT,  total body PET if necessary and, if indicated, a laparoscopic staging) and routine blood tests, tumoral markers, etc. The day before the operation, the patient is prepared with an enema evacuation and an prophylactic anticoagulant therapy

The intervention consists in the “en bloc” removal of the affected organ (colon, rectum, stomach, ovary, etc.), and of the parietal peritoneum, part of the visceral one and of all the adjacent organs infiltrated by the cancer. Moreover, all the agglomerates of visible tumoral cells are surgically removed or destroyed with very sophisticated tools such as radiofrequency, ultrasound or electrocauterization devices.

HIPECHYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY

Hyperthermic intraperitoneal chemotherapy (HIPEC) is a highly concentrated, heated chemotherapy treatment that is delivered directly into the peritoneal cavity after Cyto-Reductive Surgery.

It is a real “washing” of the abdominal cavity executed through the insertion of a variable number of drains utilized for the liquid infusion and withdrawal of a chemotherapics solution, pre-heated at 42-43 °C and re-circulated utilizing a dedicated equipment.

The solution remains into the body cavity for approx. one hour and a half and then it is completely drained.

This regional chemotherapy technique, which is confined into the peritoneal cavity, is able to destroy microscopic and invisible cancer cell deposits that remain in the abdomen after surgery, by allowing for  much higher doses of chemotherapy treatment, and minimizing at the same time many of the adverse effects of intravenous chemotherapy. Thanks to the heat effect on tissues, the absorption of chemotherapy drugs by tumors is improved.

This kind of intervention has already demonstrated its efficacy especially for the treatment of mesothelioma and peritoneal pseudomixoma (rare tumors), but ongoing studies are aimed to the estimation of the benefits and effectiveness of this therapy also in the treatment of colon, stomach and ovarian tumors.

Thanks to this therapy it is possible, today, to treat patients that, until a few years ago, couldn’t have the concrete possibility to be cured with remarkable results, both in terms of increased survival and of improvement in the life quality.

Clinical indications

  • Peritoneal Mesothelioma
  • Pseudomixoma Peritonei
  • Gastric cancer (clinical trials)
  • Colorectal cancer (clinical trials)
  • Ovarian carcinoma (clinical trials)

Advantages of HIPEC

  • Allows for higher doses of chemotherapy, in comparison to the intravenous administration
  • Enhances and concentrates chemotherapy within the abdomen, where the cancer is located
  • Minimizes the rest of the body’s exposure to the chemotherapy
  • Improves chemotherapy absorption and susceptibility of cancer cells
  • Reduces some chemotherapy side effects
Drugs used in HIPEC

Various chemotherapies are used and there is no clear consensus on which drugs should be used. Mitomycin C is the most commonly used agent because it was one of the first used drugs for this therapy. With the advent of platinum based chemotherapeutics, oxaliplatin has started gaining more popularity. Although both have proven similar efficacy so far, some argue that oxaliplatin tends to have better results.

Risks and undesired effects

The combination of CRS + HIPEC is an invasive and very aggressive intervention that requires hospitalization and admission to surgical intensive care unit (SICU). There are specific risks linked to each one of the two treatment steps: during the surgical intervention some complications can in fact occur (15% of cases on average), so that the return to the operating theatre is possible. In the same way, some reactions to the utilized drug can occur (20% of patients on average). After the CRS + HIPEC intervention, generally one or more cycle of additional systemic intravenous chemotherapy may be necessary.

Where it can be executed

As already said, this is a complex procedure that requires the intervention of a specialized medical staff and dedicated equipment. For this reason not all centers are able to offer this treatment: if you wish to know which is the nearest center to you, please send us an e-mail.


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