Cytoreductive surgery and HIPEC offers effective treatment for selected patients with peritoneal carcinomatosis
In cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC), visible cancerous tumors are first removed from the abdominal cavity surgically. The cavity is then bathed with hot chemotherapy — heated to 42 degrees Celsius — to kill any microscopic cancer cells that remain. Hyperthermia augments the cytotoxicity of chemotherapy, and intraperitoneal installation allows for delivery of much higher doses locally than are possible systemically, while minimizing toxicity.
HIPEC in Arizona
Nabil Wasif, M.D., with the Department of General Surgery at Mayo Clinic's campus in Arizona, and a team that includes Kelly K. Curtis, M.D., and Thorvardur R. Halfdanarson, M.D., both with the Department of Hematology/Oncology, have used HIPEC to treat nearly 50 patients with peritoneal surface malignancies and peritoneal carcinomatosis since 2010.
"With HIPEC, it is possible to completely cure 25 to 30 percent of patients with these types of cancer," says Dr. Wasif. "That's a vast improvement on systemic chemotherapy, which is essentially palliative at this point."
There is a window of opportunity. "We recommend a HIPEC consult as soon as a patient is diagnosed with peritoneal carcinomatosis, because if the patient waits too long, the cancer grows and spreads and HIPEC is not feasible," says Dr. Wasif. Patients and physicians should also consider HIPEC after systemic chemotherapy has stopped working.
HIPEC in Florida
Sanjay P. Bagaria, M.D., with the Department of General Surgery at Mayo Clinic's campus in Jacksonville, Florida, and a team that includes Kabir Mody, M.D., with Department of Hematology/Oncology, and Matthew W. Robertson III, M.D., with the Department of Gynecology, Medical and Surgical, have performed cytoreductive surgery and HIPEC for patients with peritoneal carcinomatosis since November 2012. "We have treated 21 patients," says Dr. Bagaria, "and we've just started to offer laparoscopic HIPEC to select patients."
HIPEC in Minnesota
Mayo Clinic's campus in Rochester, Minnesota, does not offer HIPEC currently.
In an abstract presented at the annual meeting of the Southwestern Surgical Congress in April 2015, Dr. Wasif and his team presented findings from a retrospective study of intermediate-term outcomes for patients with peritoneal carcinomatosis treated with cytoreductive surgery and HIPEC.
The study comprised 48 patients — 24 men and 24 women — who underwent cytoreductive surgery and HIPEC at Mayo Clinic's campuses in Arizona and Florida from December 2010 to October 2014. The median age of the patients was 58, and 89.6 percent of the patients were white.
The most common primary tumor was mucinous adenocarcinoma of the appendix (56.3 percent). The second most common primary tumor was colorectal adenocarcinoma (31.3 percent). The majority of tumors were low-grade (60.4 percent) with equal numbers of high- and intermediate-grade (12.5 percent).
Systemic therapy was given to 45.8 percent of patients prior to cytoreductive surgery and HIPEC. The majority of operations were performed with curative intent (81.3 percent).
Study results indicate:
- A completeness of cytoreduction score of CC0/CC1 was obtained in 64.1 percent of patients operated on with curative intent.
- There was no 30-day postoperative mortality, and 60.4 percent of patients developed a postoperative complication, of which 34.4 percent were grade IV.
- With a median follow-up of 12 months, 47.9 percent patients have no evidence of disease, 29.2 percent are alive with disease, 18.8 percent have died of disease and one patient has died of other causes.
- For all patients, median recurrence-free survival, defined as alive with no evidence of disease as the primary endpoint, was 19.3 months and 19 percent at two years.
- For the patients undergoing surgery with curative intent, median recurrence-free survival was 23 months and 25 percent at two years.
"We've found that HIPEC is most successful in the treatment of selected patients — those with resectable metastatic appendiceal cancer, metastatic colon cancer and peritoneal mesothelioma," says Dr. Wasif. "With increasing experience and refinement of selection criteria, we hope to improve on these initial outcomes."
HIPEC is now the standard of care for metastatic appendiceal cancer and peritoneal mesothelioma in the U.S. Whereas HIPEC is accepted as standard of care for metastatic colon cancer in Europe, in the United States a randomized trial for patients with metastatic colon cancer failed to accrue and was closed.
For more information
Contact Dr. Wasif in Arizona at 480-342-2849 or firstname.lastname@example.org.
Contact Dr. Bagaria in Florida at 904-953-2523 or email@example.com.
Ashfaq A, et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for patients with peritoneal carcinomatosis: Intermediate term outcomes from Mayo Clinic. Abstract presented at: The Southwestern Surgical Congress. 2015; Monterey, Calif.
Fiction becomes reality: Surviving metastatic appendiceal cancer. Sharing Mayo Clinic. Mayo Clinic. 2014.