Peritoneal Carcinomatosis- Treating the enigmaSeptember 6, 2019
Peritoneal surface malignancies are considered to be an enigma and one of the most difficult to treat cancers. They are a group of advanced stage cancers that develop on the lining of the abdomen, called the peritoneum. These cancers in which there is a high incidence of peritoneal deposits can arise form colorectal cancer, ovarian cancer, gastric cancer, biliary tract cancers, pancreatic cancer and breast cancer. It is one of the most dreadful cancers as it is rapidly progressing leading to severe pain, fluid in abdomen, blockage of intestines and very poor quality of life. Unfortunately the only treatment option available to them was palliative chemotherapy. Even chemotherapy has been found ineffective as the drug was not able to reach the peritoneal cavity. In order to combat these unique cancers, conventional cancer treatments are not sufficient. Therefore peritoneal cancers were considered a death sentence by the oncologists as cure was not possible.
For the first time in cancer history thanks to a new breakthrough surgical technology in the form of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) and Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) there is now hope for curing these patients. “The premise of this breakthrough treatment is that the traditional chemotherapy is ineffective as the drug is not able to reach the peritoneal cavity. Now with advent of HIPEC and PIPAC the chemotherapy is directly applied to the peritoneal cavity leading to cancer being melted away” explained Dr Somashekhar S P Studies have shown that this new revolutionary treatment has shown dramatic response which was never seen till now. It is truly heartening to see improved survival in patients, in what was considered until recently to be incurable cancers.
Manipal Hospitals, Bengaluru which pledges for a ‘Cancer Less Future’ has recently started the Manipal Center of Excellence for Hyperthermic Intraperitoneal Chemotherapy (HIPEC) and Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC). Manipal comprehensive cancer center has an established HIPEC & PIPAC program since 2010 and is the number “One Referral Center” for peritoneal cancer treatment in Asia. The surgical oncology team of Dr Somashekhar S P, Dr Shabber S Zaveri and Dr Ashwin Rajagopal are experts in performing complex abdominal surgery for peritoneal cancers and have
performed over 300 surgeries. Presence of experienced team, including medical oncologists, intensivists, physical rehabilitation specialists, seasoned nurses and other clinicians who are familiar with the needs of patients undergoing treatment for peritoneal carcinomatosis makes Manipal hospital a world renowned center of excellence.
What is HIPEC?
Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery. Unlike systemic chemotherapy delivery, which circulates throughout the body, HIPEC delivers chemotherapy directly to cancer cells in the abdomen. This allows for higher doses of chemotherapy treatment. Heating the solution may also improve the absorption of chemotherapy drugs by tumors and destroy microscopic cancer cells that remain in the abdomen after surgery. A specially trained surgeon first performs complex Cytoreductive surgery which typically lasts for 7-8 hours. The procedure is of a radical nature in order to remove all tumors within the abdomen. Once tumor been removed, heated, sterilized chemotherapy solution is delivered to the abdomen to penetrate and destroy remaining cancer cells. The solution is 41 to 42 degrees Celsius, about the temperature of a warm bath. It’s circulated throughout the abdomen for approximately 1 ½ hours.
λ Allows for high doses of chemotherapy
λ Enhances and concentrates chemotherapy within the abdomen
λ Minimizes the rest of the body’s exposure to the chemotherapy
λ Improves chemotherapy absorption and susceptibility of cancer cells
λ Reduces chemotherapy side effects
What is PIPAC?
PIPAC is Pressurized Intraperitoneal Aerosol Chemotherapy. It is the newest method of giving chemotherapy to patients with advanced abdominal cancer. In PIPAC, chemotherapy vapour is generated using a special device called ‘Capnopen’. This procedure is performed through laparoscopy where the pressure in the abdominal cavity is raised. The combined effect of this increased pressure and vaporized chemotherapy, increases the drug concentration in the cancerous tissue. A very small dose of chemotherapy is used leading to lesser side effects. Recent studies have shown that this form of chemotherapy delivery can be as effective as intravenous chemotherapy.
λ Simple procedure for which the patient is in the hospital for one day
λ Multiple sessions of PIPAC can be given at intervals of 6 weeks each
λ Surgical pain is minimal and the recovery is very fast
λ Shown to be effective when systemic chemotherapy has stopped working or in patients who cannot tolerate systemic chemotherapy.
λ 1/10 the dose is used to produce the same effect as systemic chemotherapy.
The author is Chairman, Manipal Comprehensive Cancer Centre, Manipal Health Enterprises and HOD of Surgical Oncology Adjunct Professor, KMC, Manipal University Consultant Surgical & Gynec. Oncologist & Robotic surgeon Manipal Hospital, HAL Airport Road, Bangalore