PIPAC treatment for peritoneal cancer
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Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new treatment option for peritoneal carcinomatosis. The technique was developed in 2011 by scientists from the University Hospital of Louisiana, USA. The authors suggested PIPAC as an alternative to HIPEC (hyperthermic intraperitoneal chemotherapy) in patients with peritoneal lesions against the background of diverse oncologic diseases. This minimally invasive procedure involves treating the abdominal cavity with a pressurized chemotherapy solution.
Content
- When a doctor may recommend PIPAC
- Technical features and advantages of PIPAC
- HIPEC vs PIPAC treatment for peritoneal cancer
- Which is more effective: HIPEC or PIPAC?
- Impact on quality of life
- Limitations of PIPAC
- What to choose, PIPAC or HIPEC?
- Where to get treatment for peritoneal carcinomatosis with PIPAC?
When a doctor may recommend PIPAC
The PIPAC procedure is a type of localized chemotherapy. During the procedure, doctors treat the abdomen and peritoneum with a drug to kill cancer cells and reduce the size of tumors. The technique is used in peritoneal carcinomatosis, when cancer spreads through the peritoneum and forms multiple foci.
Diseases for which PIPAC treatment is recommended: cancer of the colon or rectum (colorectal cancer), stomach, ovaries, pancreas, liver, appendix, as well as mesothelioma and other primary tumors of the peritoneum. PIPAC is mainly the procedure of choice if cytoreductive surgery to remove the neoplasm cannot be performed.
Technical features and advantages of PIPAC
PIPAC is performed in the operating room, under general anesthesia, through small punctures in the anterior abdominal wall. A low-dose cytotoxic solution is used to treat the abdomen: only 10-20% of the standard therapeutic dose.
The solution is sprayed with a micropump, which turns the liquid into an aerosol and distributes it evenly over the peritoneum. After half an hour, the solution is removed by aspiration. The procedure is performed with high pressure in the abdominal cavity, which ensures active penetration of the drug into the tissues.
The choice of drug depends on the type of cancer. Most often it is cisplatin or doxorubicin. It is possible to use both drugs simultaneously, as well as their combination with systemic therapy, such as fluorouracil.
Benefits of the procedure:
- Even distribution of the drug throughout the abdominal cavity
- Deep penetration into the peritoneum
- Low toxicity of the treatment due to the use of low doses of drugs
- PIPAC with platinum works even in platinum-resistant cancer
- The technique is successfully combined with systemic chemotherapy
Side effects are virtually absent as the drug does not enter the systemic bloodstream. Absorption of cytostatics is prevented by the hematoperitoneal barrier.
HIPEC vs PIPAC treatment for peritoneal cancer
Patients often compare PIPAC with surgery and HIPEC. It should be understood that each method has its own advantages and disadvantages.
HIPEC for peritoneal carcinomatosis, a stage 4 cancer, has been used for decades. Therefore, the technique is much better investigated. Doctors know exactly how, to whom and when it is best to administer this procedure.
The PIPAC is relatively new, with a smaller evidence base. But it is a safer, minimally invasive technique compared to HIPEC, with much better tolerance and no lengthy rehabilitation. It does not require a wide incision through the entire anterior abdominal wall.
While HIPEC is used only after cytoreductive surgery, PIPAC can be performed as a stand-alone procedure, even in inoperable patients, including those with affected small intestine and terminal peritoneal carcinomatosis.
Another benefit of PIPAC therapy is that it can be repeated multiple times. In contrast, HIPEC is performed only once.
After several PIPAC procedures for inoperable peritoneal carcinomatosis, the cancer may regress and become operable. This is not possible with HIPEC because treatment can only begin with surgery to remove the tumors, and if the patient is considered inoperable, he does not receive hyperthermic intraperitoneal chemotherapy.
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Which is more effective: HIPEC or PIPAC?
Several clinical trials comparing the efficacy and safety of the new PIPAC therapy and classic HIPEC have already been conducted.
In a large-scale clinical trial by Girshally et al. involving more than 400 patients, surprising results were demonstrated: after several PIPAC cancer treatments, survival rates were as good as after cytoreductive surgery followed by HIPEC. This is despite the fact that patients in the PIPAC group initially had a worse prognosis because they had inoperable cancer. On average, it took four treatment sessions and six months for patients with advanced peritoneal carcinomatosis to convert to focal carcinomatosis.
Thus, some studies show that in the PIPAC vs HIPEC debate, the new technique is at least as effective. At the same time, it is less traumatic and can be performed without prior cytoreductive surgery.
Impact on quality of life
PIPAC has advantages over cytoreductive surgery and HIPEC in terms of quality of life. A systematic review and meta-analysis in 2022 (Li, Zhenyue et.al.) showed that PIPAC treated patients with ovarian and gastric cancer suffer less from carcinomatosis symptoms. The procedure itself is better tolerated and the incidence of abdominal pain and bowel obstruction is reduced.
A trial by Oyais, A. et.al conducted in Germany demonstrated the high efficacy of PIPAC chemotherapy as a palliative procedure because:
- In 63.3% of cases, it relieved the pain syndrome
- In 60% of cases, it reduced the manifestations of ascites (fluid accumulation in the abdominal cavity)
- It eliminated gastrointestinal discomfort in 45.5% of cases
In addition, 64.5% of patients had a decrease in the peritoneal carcinomatosis index of 4 points or more after two procedures. Based on the high PIPAC success rate, the authors concluded that in inoperable patients it is reasonable to use the procedure as a neoadjuvant treatment, when preparing for cytoreductive surgery.
Limitations of PIPAC
The main relative limitation is the small evidence base. The PIPAC method is still under development. Many studies need to be conducted to determine which types of cancer this method should be used for, at what stages, at what carcinomatosis index, what PIPAC should be combined with, and what drugs should be used.
Another disadvantage is the impossibility to perform PIPAC in case of extensive adhesions in the abdominal cavity and massive tumor lesions that prevent adequate access to the abdominal cavity. In patients who have undergone more than one oncologic surgery, PIPAC is impossible in one in three patients.
What to choose, PIPAC or HIPEC?
In most cases, a patient who suffers from peritoneal carcinomatosis from colorectal cancer or another cancer does not have to choose between HIPEC or PIPAC. The two procedures are not interchangeable; they have different indications.
In standard cases, cytoreductive surgery and HIPEC, an intraoperative lavage of the abdomen with a heated solution of chemopreventive agents, are considered the first line of treatment for peritoneal carcinomatosis.
At the same time, PIPAC is used if:
- Surgery is contraindicated due to poor general condition, high carcinomatosis index, small intestine lesions or any other reasons
- The patient refuses surgical intervention
- Peritoneal carcinomatosis has recurred after previous cytoreductive surgery
PIPAC and HIPEC for peritoneal carcinomatosis are not mutually exclusive procedures either. If a person has undergone several courses of PIPAC and the carcinomatosis index has decreased to the degree where the physician feels it is possible to perform surgery, then cytoreductive surgery with HIPEC may be used. The order can also be reversed: first the person undergoes surgery and HIPEC, and then he can use PIPAC if the cancer starts to progress again in the distant period after surgery.
However, PIPAC is more often used as a stand-alone procedure rather than as a preparation for surgery. It is recommended for inoperable patients.
HIPEC is often performed for colorectal cancer with peritoneal carcinomatosis and ovarian cancer, while most patients with gastric, liver, pancreatic carcinomatosis are not candidates for surgery. For these patients, PIPAC remains a good treatment option. This technique is minimally invasive as opposed to HIPEC and can help keep the disease under control for a longer period of time, reduce symptoms and reduce the risk of complications.
Where to get treatment for peritoneal carcinomatosis with PIPAC?
If you want to be treated for intestinal carcinomatosis or other oncologic diseases using PIPAC, use Booking Health service. The Booking Health portal presents the best hospitals in the world, here you can find out the current prices and choose a specialized clinic.
Leave a request at the Booking Health website to get a consultation with a medical tourism specialist. The best PIPAC center specializing in the treatment of certain cancer diseases will be selected for you. The cost of medical services when making an appointment through our service will be lower for you due to the exclusion of additional charges for foreign patients, and the travel management team will fully organize your trip.
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Authors:
The article was edited by medical experts, board certified doctors Dr. Nadezhda Ivanisova and Dr. Vadim Zhiliuk. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!
Our editorial policy, which details our commitment to accuracy and transparency, is available here. Click this link to review our policies.
Sources:
NIH, National Library of Medicine
EJSO - European Journal of Surgical Oncology
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