intraperitoneal chemotherapy in ca ovary

4. Intraperitoneal Chemotherapy
Rationale :
 Direct tumor penetration
 Clearance from a body cavity is delayed compared to the
systemic circulation, achieving more prolonged exposure
to higher regional concentrations of active agents.
 Tumor size < 1cm
Principles and Practice of Gynaecologic Oncology 6th Edition

5. Timing of IP chemotherapy
 At the time of Cytoreductive Surgery
 Post op Period
 Note :: Walker et al. found that rectosigmoid or descending
colon resection, but not other types of bowel resections or
colostomy, at the time of primary surgery was associated with a
higher risk of failing to start IP chemotherapy
Devita, Hellman and Rosenberg’s Principles and Practice of oncology, 10th edition

6. Procedure
 IP administration requires placement of a catheter with a
subcutaneous access port in the anterior chest wall region,
just below the breast, which then tunnels subcutaneously
downward to the mid abdomen, where it enters the
peritoneal cavity
Devita, Hellman and Rosenberg’s Principles and Practice of oncology, 10th edition

7.  A 5 to 6 cm transverse incision is made two to three finger
breadths above the left inferior costal margin in the
midclavicular line.
 A subcutaneous pocket is created to house the port.
 The port is sutured to the fascia at the four corners.
 A tonsil clamp is tunneled subcutaneously above the fascia for
approximately 10 cm from the port.
 At a point about 6 cm lateral to the umbilicus, a small aperture
is made in the peritoneum.
Devita, Hellman and Rosenberg’s Principles and Practice of oncology, 10th edition

8.  The proximal end of the catheter is grasped with the clamp and
brought through from the peritoneal cavity, through the
subcutaneous tunnel, to the port.
 The catheter is connected to the port, and it is trimmed to allow
approximately 10 cm of catheter within the peritoneal cavity
 The catheter is flushed with heparinized saline to check
patency.
 The transverse skin incision is closed
Devita, Hellman and Rosenberg’s Principles and Practice of oncology, 10th edition

11.  IP instillation of chemotherapy agent is performed by
mixing the drug in a volume of 1 L, prewarmed, and
allowed to infuse under gravity drip over 1 to 2 hours.
 Failure of the solution to infuse over a reasonable
period of time may indicate the presence of adhesions
that preclude further administration of the IP agent
Devita, Hellman and Rosenberg’s Principles and Practice of oncology, 10th edition

12.  Once the first liter of fluid has been infused IP, a second
prewarmed liter of fluid, which does not contain drug, is
infused.
 To promote homogeneous drug distribution.
Devita, Hellman and Rosenberg’s Principles and Practice of oncology, 10th edition

13. Complications
 Port related
 Infusion related
 Chemotherapy related
Helm C. Ports and complications for intraperitoneal chemotherapy delivery. BJOG
2012;119:150–159.

14. Port related complications

15. Obstruction to Infusion
 Most common : 37.6%
 Causes
 Direct obstruction
 Kinking of catheter
 Blockage of fenestrations or catheter tip
 Fibrous adhesions
Helm C. Ports and complications for intraperitoneal chemotherapy delivery. BJOG 2012;119:150–159.

16. Infection
 31.4%
 Look for any features of peritonitis
 Avoidance of placement during grossly contaminated
surgeries
Helm C. Ports and complications for intraperitoneal chemotherapy delivery. BJOG 2012;119:150–159.

17. Access
 Problems :
 Difficulty inserting needle into port
 Detachment of port
 Possible solutions :
 Place the portal above costal margin and securely fix the portal to
deep fascia
 Use a longer Huber needle where more subcutaneous fat is
expected
Helm C. Ports and complications for intraperitoneal chemotherapy delivery. BJOG 2012;119:150–159.

18. Retraction
 Occurs when catheter withdraws itself back out of the
peritoneum and up towards the portal
 Possible solution :
 Leave sufficient catheter length in the peritoneal cavity (>12cm)
 Use additional sutures
Helm C. Ports and complications for intraperitoneal chemotherapy delivery. BJOG 2012;119:150–159.

19. Bowel perforation
 Can occur
 During placement of device
 During IP treatment
 After treatment
 Solution : Exploratory Laparotomy
Helm C. Ports and complications for intraperitoneal chemotherapy delivery. BJOG 2012;119:150–159.

20. Leakage
 Possible sites :
 around the access site
 portal
 Subcutaneous track of the catheter
 Causes
 faulty needle connection to the portal
 needle falling out
 a faulty portal
 failure in the portal–catheter connection
 backflow up the tunnel from the peritoneal cavity
Helm C. Ports and complications for intraperitoneal chemotherapy delivery. BJOG 2012;119:150–159.

21. Prevention of leakage
 Appropriate length Huber needle
 Care with securing the needle to the port
 Restriction of patient movement during infusion.
 A test run of saline should always be done
 Nursing staff should always be vigilant for evidence of
leakage
Helm C. Ports and complications for intraperitoneal chemotherapy delivery. BJOG 2012;119:150–159.

22. Infusion and Chemotherapy
Related

23. Abdominal Pain And Discomfort
 Due to 2L infusion
 Most common reason
 Relieved within 24 – 48 hours
 Possible solutions
 Warming the infusate prior to infusion
 Reducing the rate of flow
 Reducing the volume of the second litre infused after the
chemotherapy infusion
 Associated with the portal and catheter
Helm C. Ports and complications for intraperitoneal chemotherapy delivery. BJOG 2012;119:150–159.

24. Other Complications
 Electrolyte imbalance
 Chemotherapy induced toxicity : Adequate premedication
and hydration

25. Hyperthermic Perioperative
Chemotherapy (HIPEC)
 Highly concentrated, heated chemotherapy treatment that
is delivered directly to the abdomen during surgery.
 HIPEC is delivered once tumor cytoreduction has been
concluded and before any digestive reconstruction or
diversion is made.
González-Moreno S et al . HIPEC: Rationale and Technique

26. Cytoreductive Surgery
Chemotherapy solution (41-42⁰ C)
Circulation through abdomen for 1-1.5
hours
Drainage of fluid and incision
closure

28. Bidirectional Hyperthermic
Perioperative Chemotherapy : HIPEC
plus
 Concurrent administration of intraperitoneal and
intravenous chemotherapy
Principles and Practice of Gynaecologic Oncology 6th Edition

29. Early Postoperative Intraperitoneal
Chemotherapy : EPIC
 May gain access to all peritoneal surfaces because no
significant wound healing has occurred at this point in
time
 Distribution within the peritoneal space may be
augmented by gravity distribution.
 This means that the patient turns from an extreme
right lateral to left lateral position postoperatively in a
repeated manner.
Principles and Practice of Gynaecologic Oncology 6th Edition

30. Thank You