HIPEC - Hyperthermic Intraperitoneal Chemoperfusion in the Best Hospitals in the World

Overview

Carcinomatosis is one of the most unfavorable types of colorectal cancer metastasizing. However, it is very common.

Generally, carcinomatosis is a process of the malignant cells spreading, which subsequently leads to damage of the various organs in the human body. Such a process is often observed at the last stages of colorectal cancer. It manifests itself in the form of damage to organs such as the abdominal cavity organs and pleura.

Peritoneal carcinomatosis isn’t considered an independent pathological process. It is rather a complication of previous cancerous formations.

The malignant cells move inside the body through the blood. Moving along the abdominal cavity, the altered cells penetrate its structures, which leads to damaging other organs, regardless of where they are located.

In most cases, doctors find out that patients with carcinomatosis have a severe form of cancer, which is very difficult to cure.

Symptoms of peritoneal carcinomatosis

Since peritoneal carcinomatosis is not an independent disease, its clinical picture is determined by both the clinical manifestations of the primary tumor and the signs of the secondary malignant lesions.

The most common symptom is the presence of the fluid in the abdominal cavity, the so-called ascites. Ascites is often the only symptom in patients with peritoneal carcinomatosis. Also, there may be some non-specific signs, such as significant weight loss, nausea, vomiting, severe fatigue, and weakness.

The main signs indicating the development of a malignant lesion of the peritoneum include:

• Dull, aching pain in the abdomen. It can be either permanent or disturb the patient for periods of several hours or days.
• Abdominal enlargement with rapid weight loss. An enlarging abdomen is formed due to the accumulation of fluid in the abdominal cavity (ascites).
• Severe indigestion. Patients have nausea and pain in the abdomen; vomiting is also possible. Difficulties arise with defecation; often constipation is interchanged with diarrhea.
• Increasing symptoms of intoxication. Severe weakness, sweating, fever, pain in muscles, and headaches. Patients feel exhausted.
• Presence of a tumor that is palpable through the anterior abdominal wall.

The diagnosis is established taking into account the medical history of patients, clinical manifestations, laboratory and instrumental research data.

Diagnostics

Modern oncology centers have all the resources for accurate diagnostics of peritoneal carcinomatosis.

On the day of arrival at the oncology center, a consultation with the attending physician takes place. Doctors examine patients and study the anamnesis.

Further, all diagnostic measures are taken. The standard examination plan for peritoneal carcinomatosis includes the following procedures:

• CT. CT is conducted to obtain layer-by-layer images of the affected organ.
• Blood tests.
• Abdominal ultrasound examination. Modern ultrasound equipment detects even small loci of colorectal cancer.
• MRI.
• Biopsy. A biopsy is conducted to obtain material for histological examination.
• Diagnostic laparoscopy.

After receiving the results, doctors elaborate the therapeutic scheme for patients.

Treatment of patients with diagnosed peritoneal carcinomatosis is rather complicated. Currently, there are no standard methods of radical treatment of this cancerous process, so the colorectal cancer treatment is strictly individual.

Treatment of peritoneal carcinomatosis

For almost the entire history of oncology, it was believed that peritoneal carcinomatosis in patients with colorectal cancer did not respond to any of the existing treatments.

For a long time, patients with peritoneal carcinomatosis were considered incurable. And to this day, many doctors hold the same opinion. Patients with colorectal cancer are often "discharged" from the hospital because "there are no oncologists in hospitals treating carcinomatosis." When they come to modern oncology centers and find information about the possibility of colorectal cancer treatment with HIPEC, it turns out that this is the first time they hear about such a technique.

In most hospitals treating patients with colorectal cancer radiation therapy is not used due to its inefficiency in the treatment of peritoneal carcinomatosis. High doses of radiation are dangerous for patients with colorectal cancer and this treatment is usually connected with severe complications.

Conventional surgical treatment is also ineffective as metastases on the surface of the peritoneum can be very small, or located in inaccessible places, and the doctor simply does not see them during the surgery.

Systemic chemotherapy has almost no effect on peritoneal carcinomatosis as cancer cells of this type practically do not contact the system of blood vessels, and therefore are not available for systemic intravenous chemotherapy.

Treatment of peritoneal carcinomatosis is now possible by combining surgical intervention with the use of hyperthermic intraperitoneal chemotherapy.

The goal of the procedure is to destroy the maximum amount of cancer cells that remain even after the most thorough surgical removal of the lesions and cause colorectal cancer recurrence.

The essence of the HIPEC technique is that immediately after the cytoreductive (that is, aimed at removing tumor cells) surgery on the abdominal organs, patients are perfused for 60-90 minute with a concentrated chemotherapy drug, heated up to 42-43°C.

Both adjectives are important in the name "hyperthermic intraperitoneal chemotherapy"."Hyperthermic" stands for the rise of temperature.

The high temperature itself is capable of causing damage or death of cancer cells. Besides, it makes them more vulnerable to chemotherapy drugs.

Another important feature of hyperthermic intraperitoneal chemotherapy (HIPEC) is that it promotes more active penetration of the drugs into the tissues. This is enough to destroy most metastases remaining after surgery.

Hyperthermic intraperitoneal chemotherapy (HIPEC) acts directly on cancer cells. Moreover, drugs practically do not "leak" into the general bloodstream through the peritoneum.

This makes it possible to use the concentration of chemotherapy drugs in HIPEC that are 20, 50, and sometimes 100 times higher than the ones used in systemic chemotherapy. Cancer cells inside the abdominal cavity receive lethal doses, and the whole body practically does not suffer from side effects.

One of the main advantages of HIPEC is that sometimes it can be the only way to prolong the life of a person at the last stages of colorectal cancer.

Indications for HIPEC

For surgery followed by HIPEC to be effective, several conditions must be met:

1. Patients must be able to undergo both surgery and chemotherapy at the same time. Health conditions of patients should allow the treatment. Before the procedure, patients are examined thoroughly.
2. The spread of metastases should be limited to the abdominal cavity only.

How HIPEC is carried out

Surgical intervention with the use of hyperthermic intraperitoneal chemotherapy is carried out in two stages: first, surgical removal is conducted, and then the chemotherapy drugs are introduced.

Surgical intervention and hyperthermic intraperitoneal chemotherapy are separate but equally important steps in a single therapeutic regimen. For maximum cancer treatment efficacy, both stages should be carried out one after the other.

The HIPEC procedure is the second half of a whole range of measures. Without the cytoreductive surgery, HIPEC can be performed in a few cases with specific indications. Typically, the HIPEC is a continuation of the surgical procedure, which significantly improves the prognosis of survival.

Together with the surgical removal of the cancerous tumor, the entire intervention takes from 6 to 18 hours. The process can be divided into 4 stages.

1. Additional examination of the abdominal cavity.

It is carried out to understand whether treatment with HIPEC is indicated for patients and whether it will increase the life expectancy. The examination is performed intraoperatively, just before the main surgical intervention.

2. Cytoreductive surgery.

Some sections of the peritoneum, where the primary tumor originates from, adjacent internal organs, or their parts, are removed if they are also affected by metastases. Often these are areas of the intestines, spleen, and gallbladder.

3. Hyperthermic intraperitoneal chemotherapy.

The actual HIPEC. Catheters and temperature sensors are inserted into the abdominal cavity, connected to a special device, and a container with a chemotherapy drug. After the procedure, the drug is removed from the abdominal cavity, it is washed with saline solution, and the sensors and catheters are removed.

4. Reconstructive surgery.

If parts of the intestine are removed, the surgeon restores the functioning of the intestine with the help of a colostomy (brings the end of the intestine to the surface of the abdomen for defecation restoring).

On average, patients spend 2-4 weeks in the oncology center. A control examination is performed in 2-3 weeks after the surgical intervention. It must be repeated in 3 months, and after that the frequency of examinations is reduced to one per year.