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HIPEC - PIPAC (Cancer)

Centre of excellence- for management of peritoneal cancer (Cytoreductive surgery, HIPEC, PIPAC)

What is peritoneal cancer?

Cancer that has spread to the peritoneum (lining of the abdominal cavity containing the liver, the stomach and the intestines) is called peritoneal cancer. It is considered stage 4 cancer.

Which peritoneal cancer can be treated with HIPEC?

  • Colon and rectal cancer
  • Appendix cancer and pseudomyxoma peritonei
  • Stomach cancer
  • Ovarian cancer
  • Rare cancers like primary peritoneal cancer, mesothelioma, desmoplastic small round cell tumor

How does peritoneal cancer develop?

cancer from other sites like the intestines, stomach and ovaries can spread to the peritoneum or cancer can arise from the peritoneum itself.

Why Zydus?

This center is run by one of the most experienced surgeons in the country in HIPEC for peritoneal cancer

Our strengths -

  • Specialized training and experience- surgeons trained and experienced in performing such procedures
  • Team work- surgeries are performed by a team
  • Multidisciplinary effort- other specialities like medical oncology, anesthesiology, intensive care, pathology and radiology focus and specialize in the management of these patients
  • After care, quality of life and survivorship- The care continues after discharge to enable return to a normal quality of life. Not just recovery from surgery but long term survival is one of the main goals of treatment
  • Wholistic approach- patients who are not candidates for radical / curative surgery are cared for with equal vigor to provide longevity and symptom control by surgical and non-surgical interventions
  • Cost effective procedure- all our effort is to minimize the financial burden of such procedures to the patient

HIPEC

HIPEC stands for Hyperthermic Intraperitoneal Chemotherapy. In this procedure, a solution containing a chemotherapeautic agent in circulated in the abdominal/ peritoneal cavity and a high temperature for 30-90 mins.

HIPEC is done during surgery. During surgery, first all the tumor is removed which is called Cytoreductive Surgery (CRS) and then the hot solution containing the anti cancer drug (chemotherapy drug) is circulated in the abdominal cavity. By this process 1-2mm sized tumors can be destroyed. Microscopic tumor is also destroyed.

HIPEC is a single procedure done during surgery. Only 1 session is done at a time. Some patients can undergo a second HIPEC is the cancer comes back.

Cytoreductive surgery comprises of removal of tumor from the peritoneal /abdominal cavity. The aim of this surgery is to remove all the visible tumor. To achieve this the peritoneum that has tumor is stripped off the abdominal wall and from the organ surfaces. Sometimes a part of the small or large intestine, gall bladder, liver, spleen, stomach or pancreas may also have to be removed to completely remove the tumor. This is a very important part of the surgery which is done before HIPEC is performed. Complete tumor removal depends on the expertise of the surgeon and also the extent of tumor itself.

Is HIPEC a high risk surgery?

Cytoreductive surgery and HIPEC is very complicated surgery and the risk of complications is a little high as compared to other cancer surgeries. After a HIPEC, complications occur in about 15- 30% of patients. Complications that are possible after any surgical intervention, such as infection or bleeding, can occur after a HIPEC too. Some complications are more specific to a HIPEC:

  • An increased risk of leakage of bowel junctions (anastomoses) due to the heated chemotherapy. In case of increased risk of leakage, the surgeon can judge that it is safer to temporarily create a stoma (the bowel is exteriorized through the abdominal wall)
  • Fluid accumulation in the pleural cavity (the space between the lungs and the thoracic cage), especially when tumor was removed from the diaphragm. In case of tumor at the diaphragm, the surgeon will put a tube (thoracic drain) in the thorax as a preventive measure to drain any fluid after the operation for some days
  • Slow emptying of the stomach for about two weeks. Complications of the chemotherapy itself (lowering of white blood cell count, lowering of platelet count) can occur after a HIPEC, depending on the drug and the dose that is used

Is HIPEC worth the risk?

Cytoreductive surgery and HIPEC is the only treatment which can cure certain patients with peritoneal cancer and prolong the life of others significantly. Hence, patients with peritoneal cancer should consult a specialist if this treatment is an option for them.

Most of the complications resolve with proper treatment and patients get back to their normal life. The risk is minimized when an experienced surgical team performs the procedure.

There are certain conditions in which there is a clear benefit of HIPEC and in such patients it is worth the risk like patients with appendix cancer and pseudomyxoma peritonei, mesothelioma, and selected patients of colorectal, ovarian and gastric cancer.

For each patient, the decision needs to be individualized and the surgeon will clearly explain to the patient and family the risk versus benefit of the procedure.

Points to Ponder

In India, the patient’s family plays an integral role in the decision making process for any kind of cancer treatment and is vital in providing after care to the patient. Family members provide a strong support system filling on paramedical and medical staff at various time points in the treatment.

Cytoreductive surgery and HIPEC is one of the most complex abdominal surgeries often called the ‘mother of all surgeries’ given its extensive nature, risk of complications and its impact on the physiological and psychological well being of the patient leading to a prolonged recovery period compared to other procedures.

Decision making

It is not uncommon for family members to not reveal the diagnosis of cancer to the patient till long after the treatment has been completed. However, this is not the right thing to do for a patient undergoing CRS and HIPEC and ‘conspiracy of silence’ comes into play in this situation. It is important the one or more counseling sessions and held with the patient and the family and they fully understand what the surgery entails- the potential benefits and risk. The patient needs to be mentally prepared for a longer than usual post operative stay and the prolonged recovery period thereafter.

Preparing for the procedure

Patients often have to travel to another city to obtain treatment since the required expertise may not be available in their own city or country. This means one or more family members having to take at least 2-3 weeks off from work. Once the patient returns home, after care in needed in the form of supporting the patient’s day to day activities, providing frequent nourishing meals among other things. Hence, the care-givers need to plan their time off from work accordingly.

Managing finances

In India the cost of HIPEC procedure ranges from 3-5 times that of a surgery for resection of colorectal primary tumor. This may represent a substantial financial burden especially for those who have had multiple prior treatments and have exhausted their resources and/or insurance; it is an out-of-pocket expenditure for many Indian patients. The same needs to be discussed and planned.

CRS and HIPEC may be followed by other therapies like systemic chemotherapy in a large proportion of the cases

Psycho-social impact

The patient may take 6-12 weeks to regain his/her strength and well-being and the immediate family / spouse/ children have to be extremely supportive during this period. Depression and psychosis are not uncommon and family support is vital in overcoming these. There is fear about the long term impact of such a treatment especially in young patients who are just starting their careers and family life. Patient’s quality of life may also be influence by a temporary of permanent digestive stoma

Child bearing after HIPEC

With careful prior planning having children after CRS and HIPEC is possible in selected patients, both male and female. These issues should be brought out prior to the procedure and treatment planned accordingly.

Survivorship and long term outcomes

There is apprehension in the minds of both the patient and the family about tumor recurrence and regular follow ups are needed. Many patients undergo a second procedure for tumor recurrence.

This is the only treatment that can cure some patients, add few extra years to the lives of others and provide a better quality of life, and keeping these benefits in mind, patients and families should approach the procedure with confidence and bravado to derive the maximum benefit from it.

FAQs

What is peritoneal cancer?

Peritoneal cancer means the presence of cancer cells on the peritoneum which is the lining of the abdominal cavity and the organs that it contains like the liver, spleen and the intestines. Any cancer can spread to the peritoneum and is called peritoneal cancer. Commonly, cancers of the ovary, colorectum (large intestine), stomach and appendix spread to the peritoneum. There are some other rare cancers like pseudomyxoma peritonei and mesothelioma which commonly affect the peritoneum.

Peritoneal cancer is stage 4 cancer

What is the treatment of peritoneal cancer?

Peritoneal cancer is usually treated with systemic chemotherapy. An aggressive surgical treatment called cytoreductive surgery (CRS) and HIPEC- hyperthermic intraperitoneal chemotherapy is used to treat patients with peritoneal cancer resulting in a prolonged survival and even cure in some patients.

How many sittings/ treatments are needed for HIPEC?

HIPEC is a single time treatment performed in the operation theatre during surgery.

If HIPEC is performed, can chemotherapy be avoided?

In some cases, if HIPEC is performed chemotherapy may not be required. However, it is not a replacement for chemotherapy and in many cases, it is still required.

Is there any age limit for this surgery?

Generally, it is offered to patients below 70 years, but in patients who are older and ‘fit’ it can still be performed.

What is the risk of complications?

The risk of complications depends on the experience of the team performing the procedure. In experienced and expert centers, it is 10-15 %.

Can a repeat HIPEC be performed?

Yes, it can be performed in selected patients.

Is HIPEC useful for ovarian cancer?

Currently, HIPEC is under trial and is NOT the standard treatment for ovarian cancer.

PIPAC is pressurized intraperitoneal aerosol chemotherapy. It is a new method of giving chemotherapy to patients with advanced abdominal cancer in which chemotherapy is given directly into the abdominal cavity. Routinely, chemotherapy (cancer directed therapy) is administered intravenously (through the veins) as a drip. Intra-peritoneal chemotherapy is given directly into the abdominal cavity in patients who have cancer spread to the peritoneum that is the lining of the abdominal cavity and its organs.

What is the need for this treatment?

Patients who have peritoneal cancer spread have a very limited life span and experience discomforting symptoms like fluid accumulation in the abdominal cavity and inability to take food. Radical surgery with HIPEC (a method of giving chemotherapy directly to the abdominal cavity ) has resulted in improved survival in some patients. Yet a large number of patients are not eligible for this therapy and for these patients, new treatments like PIPAC are being developed.

How does PIPAC work?

In PIPAC, a chemotherapy vapor is generated using a special device called ‘Capnopen’. This procedure is performed through laparoscopy. In laparoscopic surgery, 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.

What are the benefits of PIPAC?

It is a simple procedure for which the patient has to be in the hospital for one or two days only. The side effects are minimal and the recovery is fast. It has shown to be effective when systemic chemotherapy has stopped working or in patients who cannot tolerate systemic chemotherapy. Multiple sessions or PIPAC can be given at intervals of 6 weeks each. 1/10 the dose is used to produce the same effect as systemic chemotherapy. PIPAC does not interfere with routine chemotherapy and both can be given together to produce a better effect.

Which patients benefit from PIPAC?

Currently, PIPAC is used for patients who have peritoneal tumor deposits arising from ovarian cancer, colon cancer, stomach cancer, appendix cancer and some rare cancers of the peritoneum. Patients who have fluid build up in the peritoneal cavity from any cancer that does not respond to chemotherapy can benefit from this treatment. PIPAC is given to patients who have received chemotherapy before and usually more than 1 type of chemotherapy.

Can PIPAC cure cancer?

PIPAC is currently used for controlling symptoms and reducing the disease burden. In some cases the tumor can disappear completely or may reduce drastically and surgical removal of the remaining tumor can be performed. These patients may experience a prolonged survival.

Can all patients benefit from PIPAC?

Patients who are bed ridden and cannot eat, those who are malnourished or have massive ascites do not benefit from PIPAC. Sometimes there are adhesions between the intestines and abdominal wall due to which laparoscopy is not possible and hence these patients cannot receive PIPAC.

What are the side effects of PIPAC?

Some of the common side effects of PIPAC are abdominal pain, nausea, alteration in the liver and kidney functions. Most of these side effects resolve within a few days. More serious side effects usually do not occur with PIPAC.

Is PIPAC an experimental therapy?

First we should go back to what an experiment means- an experiment is a scientific procedure undertaken to determine something. The effects of PIPAC are known. It has been used in human patients and has been effective. This is in certain conditions mentioned above- when chemotherapy has stopped working or the fluid does not reduce with chemotherapy. In these cases, PIPAC is not experimental.

There are other situations in which the results are not known- like is PIPAC an alternative to chemotherapy? In these situations, it is experimental and its effect is been studied in clinical trials and other experimental studies.

Can PIPAC be used outside clinical trials?

Yes, PIPAC can be used outside clinical trials.

What is the difference between HIPEC and PIPAC?

HIPEC is a single treatment usually given during open surgery and higher doses of chemotherapy drugs are used in it. PIPAC is given laparoscopically and multiple sessions are possible, doses of drugs used are lower.

Which is better? HIPEC or PIPAC?

Right now both have different uses. HIPEC is used along with radical surgery that comprises of complete tumor removal (cytoreductive surgery). It can cure certain patients. PIPAC is used for patients who cannot undergo HIPEC. Its role is palliative. Sometimes PIPAC is used to shrink the tumor before cytoreductive surgery and HIPEC.

Cytoeductive surgery and HIPEC require a greater expertise to perform compared to PIPAC.

Which is the best place to take this treatment?

These procedures are best performed by a surgeon specializing in peritoneal cancer management; in institutes that are experienced in the management of peritoneal cancers.