Breaking through the barricade
“Our goal is to surgically remove all of the disease that we can,” explained Ramsay Camp, M.D., FACS, a surgical oncologist who performs hyperthermic intraperitoneal chemotherapy (HIPEC) with Virgilio George, M.D., a gastrointestinal surgeon, in a recent discussion with Progressnotes, MUSC’s medical magazine. “And then we use HIPEC to treat residual cells that we can’t see throughout the whole abdomen.”
Walls are designed to do one of two things: contain or keep out. And the peritoneum is no exception. As the lining of the abdominal cavity covering the organs within, the peritoneum provides protection from infection as well as storing fat. It keeps the organs in place while allowing blood vessels, lymph vessels and nerves to pass through. It is also extraordinarily effective at keeping everything else out, which makes treating cancer in the abdominal cavity difficult to target with systemic chemotherapy.
To get around the “plasma-peritoneal barrier,” physicians like George and Camp turn to HIPEC to help patients with an otherwise poor prognosis.
By combining both tumor removal surgery and HIPEC, researchers studying colorectal cancer found the percentage of patients who were free of disease rose from 3-12% to 55-74%, and their 10-year survival rate rose from 21-32% to 60-80%.Primary colorectal cancer, ovarian cancer, gastric cancer, appendiceal cancer, mesothelioma and peritoneal carcinomatosis can be treated with HIPEC as long as they are contained in the peritoneum.
“The combination approach provides the only chance for long-term survival in patients with these diseases,” said George.After surgically removing as much of a patient’s tumor as they can, George and Camp treat the abdomen with a heated chemotherapy solution. Administered via catheters, the solution is heated to just above the patient’s body temperature in an effort to destroy any remaining microscopic cancer cells. The heat helps with absorption while also degrading proteins in these cells and increasing their pH levels. These changes activate lysosomes within the cancer cells and encourage cell death.
Using a HIPEC perfusion system to maintain a consistent temperature and push the solution through the catheters into the abdomen, chemotherapy is circulated throughout the patient’s peritoneum for 90 minutes. The physician team also keeps cooling blankets, ice and cool IV fluids on hand to control the patient’s body temperature during the procedure.
HIPEC offers a solution for patients with peritoneal metastasis by delivering a higher concentration of the drug while also being less toxic to the rest of the body.
The plasma-peritoneal barrier confines chemotherapy to that specific area, allowing HIPEC doses that are more concentrated than those for traditional systemic chemotherapy. Side effects from the procedure usually stem from the duration of the tumor removal surgery rather than the exposure to the solution.
HIPEC in conjunction with surgery involves a coordinated effort between multiple teams to remove the tumors and administer the heated chemotherapy. Because of the complex nature of this treatment, HIPEC is usually only performed at tertiary care centers in the U.S.
“We are excited to no longer have to send patients outside the state,” said Camp. “We can perform it right here at MUSC.”
To read the full version of this article, see the Summer 2019 issue of Progressnotes.
To view surgical footage of a HIPEC procedure performed by Dr. Camp and Dr. George, see the MUSC Health Medical Video Center.