HIPEC (Hyperthermic Intraperitoneal Chemotherapy): This technique is also known as hot chemotherapy and involve surgical procedure and chemotherapy. In this, the cavity is made in the abdomen and heated chemotherapy drugs are filled at the site of a tumor, this procedure is used in advanced cancer cases. This procedure is done after the surgical removal of existing cancer as much as possible.
History of HIPEC
- In 1934, Joe Vincent Meigs of New York first described tumor removal surgery (cytoreductive surgery) for ovarian cancer, hypothesizing that the disease would regress sharply.
- This aggressive cytoreductive approach gained acceptance in the 1960s and 1970s.
- At that time, Dr. Kent Griffith of the National Cancer Institute also reported on prognostic survival rates in patients with stage II and III ovarian cancer and found that the size of the remaining tumor mass (<1.6 cm) after Cytoreductive procedures was significantly associated with prolonged survival.
- Around this time, research began to show that hyperthermia and Intraperitoneal chemotherapy were effective in killing cancer cells.
- The first ever successful trial of HIPEC on humans was in 1979 to treat advanced abdominal cancer.
- Further research in the 1980s revealed chemotherapy drugs in concentrations up to 30 times higher than those safely administered intravenously.
- In the mid to late 1980s, Sugar baker conducted additional research at the Washington Cancer Institute on the treatment of peritoneal gastrointestinal cancer and was able to report survival benefits.
- It quickly became clear that complete cytoreduction was associated with survival benefits. In 1995, Sugarbaker developed a stepwise approach to cytoreduction to standardize and streamline the process.
- The HIPEC technique has also been refined by proposing different delivery methods.
- The use of hot chemo drugs in the open abdominal area is devised by Dr. Paul Sugarbaker in 1999, along with the other technique known as Colosseum to treat cancer.
- The benefit of this open approach was the surgeon’s direct access to the cavity during hyperthermic administration to manipulate the fluid and bowel for rapid and even distribution of temperature and drug throughout the abdomen.
- In addition, care must be taken to ensure that all peritoneal surfaces, e.g., are evenly exposed and to avoid dangerous temperatures or overexposure of normal tissue.
- In comparison, the closed technique consists of closing the abdominal wall prior to the infusion of chemotherapy, reducing the problem of heat loss from the peritoneal surface.
- To combine the potential benefits of these two techniques, Sugarbaker used a semi-open approach and developed a new splinting instrument (the Thompson retractor) described in 2005 to assist in tightly elevating the abdominal skin margins.
- A laparoscopic approach to CRS with HIPEC has recently been described in highly selected patients with minimal disease burden.
- It is medically used generally after the maximum surgical removal of cancer. The surgical procedure may involve the removal of peritoneal areas.
- Till now, there is no evidence to support its use, but practitioners suggest its use in peritoneal colorectal carcinomatosis, gastric peritoneal carcinomatosis, malignant peritoneal mesothelioma, and disseminated mucinous neoplasm of the appendix.
- Although the successful case is ovarian cancer.
There is no specification in which drug to use the most common chemo drugs used in this procedure are –
- Mitomycin C – the AUC ratio of this drug is 23.5. 70% of the drug leaves the system within ninety minutes of injection. If this drug leaves the peritoneal space will lead to bone marrow toxicity.
- Oxaliplatin – its AUC ratio is between 16 and 25. It’s a 3rd generation platinum complex and can be administered with five percent dextrose. The standard dose of oxaliplatin is 360-460 mg/m2.
- Cisplatin – its AUC ratio is 7.8. It’s a platinum salt and has shown a good survival rate when administered with CRS. Although, its prolonged presence in the body leads to toxicity.
- Irinotecan –interacts with the topoisomerase I-DNA and prevents the breakage of a single strand. The standard dose of Irinotecan is 360-400 mg/m2.
Mechanism of administration
- This is a single-step process, unlike traditional chemotherapy sessions.
- This process is similar to peritoneal dialysis. And takes about 8-10 hours long and may have side effects as well.
- The chemo drugs were restricted to the space of the intestine, and tissues and are prevented to enter blood plasma by the intraperitoneal fluid
- Before this, a surgical procedure is done to remove the cancer tumor as much as possible from the abdominal area.
- After that surgical procedure, the chemo drug is heated to 42 degree Celsius (103 degrees Fahrenheit).
- This heated drug is then pumped into the abdominal cavity, while the patient is rested on the cooling bed to maintain the survival temperature of the body.
- After the insertion of drugs properly the surgeons rock the patient back and forth for about two hours to ensure the uniform distribution of the drugs in the abdomen.
- This is to be done to eradicate the remaining cancer cells.
- The plasma-peritoneum barrier stops the absorption of these drugs into the circulatory system and prevents their absorption in the blood, so 90% of the drugs stay in the abdomen. This keeps the toxic effect on the abdomen only.
- This procedure allows the high chemo drug dose.
The side effects can be mild such as, nausea, vomiting, pain, and weight loss, and can be severe such as leaky intestinal, inflammation of the pancreas, severe infection, and blood cells in the bone marrow. These symptoms can last from up to a few months to years. Other common symptoms may include fatigue, diarrhea, bloating, constipation, depression, etc.
- The doctors and other healthcare experts will keep you under observation for about 2 days in intensive care and 6-10 days under normal care, after the surgery.
- The doctors will check for the electrolytes and will perform a regular blood test, to see if everything is okay.
- If you are a diabetic patient, the doctor will give you insulin to control your blood sugar. Elevated blood sugar will slow down the healing process.
- You will get your nutrition from a feeding tube or IV till your digestive system recovers properly from this intensive therapy.
- A painkiller and antibiotics will be given to protect from infection and relieve pain.
HIPEC is more advanced in ways such as
1. It is given directly in the abdomen, therefore is targeted. Whereas, in traditional chemotherapy, the drugs are given intravenously and are not targeted.
2. It has fewer toxic effects as maximum drugs are restricted to the abdomen area.
3. Side effects of HIPEC are fewer and milder in comparison to traditional chemotherapy.
Well, it depends on the growth rate of cancer, its spread, stage of cancer. Moreover, it is ideal for pseudomyxoma peritonei, colorectal cancer, appendiceal cancer, gastric cancer, ovarian cancer, etc., that has not spread beyond the abdomen area.
No, your digestive system needs recovery after this intensive therapy. So you will get your nutrition from a feeding tube or IV till you recover properly.
The survival rate for patients with colorectal cancer is 7.8 to 15.2 months (chemotherapy alone), 22 to 47 months (CRS/HPEC), and for about 5 years (27% to 54 %) of patients who had undergone HIPEC.