Uploaded byMary Ondinee Manalo Igot
Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies
Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is emerging as a new standard treatment for peritoneal surface malignancies. Traditionally, peritoneal carcinomatosis was considered incurable and treated only with palliative chemotherapy. However, CRS-HIPEC aims to remove all visible tumor deposits surgically and then uses heated chemotherapy in the abdominal cavity to target any remaining microscopic disease. Studies show CRS-HIPEC provides significantly longer survival times compared to intravenous chemotherapy alone, with median overall survivals of 16-36 months. Experts indicate CRS-HIPEC should now be considered the standard of care for select patients with peritoneal metastases from conditions like ovarian
More Related Content
Similar to Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies
More from Mary Ondinee Manalo Igot
Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies
- 1. Cytoreductive Surgery plus HIPEC: NEWSTANDARD for Treating Peritoneal Surface Malignancies Mary Ondinee M. Igot, MD, MSCM, FPCP, FPSO, FPSMO Medical Oncologist / Neuro – Oncologist
- 2. Outline • Peritoneal Metastases •Cytoreductive Surgery plus Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC) for Peritoneal Metastases • Fundamentals • Technical Requirements • Chemotherapy Used • The Right Patient
- 3. Peritoneal Metastases • Peritonealdissemination from gastrointestinal and gynecological malignancies is common. • Traditionally, it has been regarded as an end-stage disease which was only amenable to palliation and systemic chemotherapy. • Poor literature on effective treatments because they are often excluded from clinical trials because they have “non-measurable disease.”
- 4. Peritoneal Metastases • NIHILISTICATTITUDE toward this condition. • Second most common cause of death after liver metastases • Prone to frequent hospitalizations because of recurrent obstruction and intraabdominal infections • Virtually incurable • AVERAGE LIFE EXPECTANCY: 6 months • With best systemic chemotherapy, • MEDIAN OVERALL SURVIVAL: 20 months • MEDIAN DISEASE FREE SURVIVAL: 10 months
- 5. Cytoreductive Surgery (CRS)= Peritonectomy + Organ Resection • 1930s, attempting to remove all visible deposits was reported for ovarian cancers and eventually was accepted as a treatment with survival benefit. • Attempts have been done in various non-gynecologic malignancies.
- 6. “It is whatthe surgeon does not see that kills the patient.” • Paul Sugarbaker • Peritoneal metastases should not be equated with generalized disease. • Involvement of the peritoneal surfaces may occur in the absence of hematogeneous metastases or it may represent the dominant clinical picture. • Peritoneal metastases = Locoregional disease The Sugarbaker Technique
- 7. Strong Rationale forLocoregional Treatment • Treatment of macroscopic disease • Cytoreductive surgery • Peritonectomy procedures • Treatment of microscopic disease • Heated intraperitoneal chemotherapy • Treatment of systemic disease • IV chemotherapy
- 8.
- 9. Principles and Rationalebehind HIPEC • “Plasma – Peritoneal Barrier” • Targets microscopic disease that cannot be completely eradicated by surgery. • Provides pharmacokinetic advantage of attaining high local concentrations of chemotherapeutic agents, 12-15x the maximum tolerated plasma concentration • Median peak peritoneal concentration 1,116x that of the normal plasma level of chemotherapy can be achieved. • High temperature increases drug penetration and provides a synergistic effect with intraperitoneal chemotherapy. • Effect of IP chemotherapy on tumour cells also enhanced because adhesions have not been formed. • Mitomycin C, oxaliplatin, etc.
- 10. CRS + HIPECvs IV chemo + Palliative Surgery
- 12.
- 14. Predictors for Success •Cancer deposits in 6 or more regions of the abdomen HIGH TUMOR LOAD • Completeness of cytoreduction (R0, R1, R2) • Number of resections and anastomoses
- 15. N = 2298 Averageoperating time: 9.5 hours 80% had complete tumor removal Average hospital stay: 21 days Post-operative mortality: 2% Major morbidity: 24%
- 17. 9 comparative studiesand 28 studies Primary and/or recurrent ovarian cancer Primary Recurrent DFS (months) 19.2 17.8 OS (months) 16.1 35.8 Morbidity (%) 31.3 26.2 Mortality (%) 1.8 1.8
- 19. Present Indications • Pseudomyxomaperitoneii or jelly belly • Appendiceal adenocarcinoma • Peritoneal mesothelioma • Colorectal cancer with peritoneal metastases • Ovarian cancer with peritoneal metastases • Gastric cancer with peritoneal metastases
- 20. The Eligible Patient •Patient-Related Criteria • Good performance status • No major comorbidities • BMI > 35 is a relative contraindication • Physiologic age is considered • Patients less than 65 yrs are good candidates • If more than 65 yrs, carefully selected • Patient must be motivated and must understand and accept the risks of the procedure
- 21. • Disease-Related Criteria •Primary cancer: Ovarian, CRC, primary peritoneal, mesothelioma considered as part of standard care already • Others: gastric, sarcoma, etc… • Histology: Signet ring, poorly differentiated/undifferentiated The Eligible Patient
- 22. • Absolute Contraindications: •Extra-abdominal disease • Extensive intra-abdominal disease • Cancer of unknown primary The Eligible Patient
- 23. Why should Irefer my patient? • It more than doubles the survival. • Just last year, it has already been incorporated in the NCCN 2017 First Quarter Guidelines.
- 26. Why should Irefer my patient? • It more than doubles the survival. • Just this year, it has already been incorporated in the NCCN 2017 First Quarter Guidelines. • Now a standard treatment. Offer to avoid legal complications.
- 28. “They thought Iwas overly aggressive. Turned out, I was right all along.” -Dr Paul Sugarbaker
- 29.