Heated Intraperitoneal Chemotherapy
Currently, heated intraperitoneal chemotherapy is offered at specialized, high-volume centers such as The University of Kansas Cancer Center, a National Cancer Institute-designated cancer center. The procedure requires extensive resources, including surgical oncologists and gynecologic oncologists who are specifically trained to do the procedure safely. Our surgical oncologists and gynecologic oncologists perform a high volume of these very complex procedures.
The University of Kansas Cancer Center is the region’s only NCI-designated cancer center, providing you with more treatment options and access to more clinical trials.
What is heated intraperitoneal chemotherapy?
Hyperthermic, or heated, intraperitoneal chemotherapy is a cancer treatment that involves delivering heated chemotherapy drugs to an affected area. HIPEC, sometimes referred to as “hot chemotherapy,” is performed after your surgeon first removes all cancerous tissue.
Who can have heated intraperitoneal chemotherapy?
When combined with cytoreductive surgery (removing all visible signs of cancer), HIPEC can improve outcomes for people with advanced, complex and recurrent abdominal and primary peritoneal cancers and select ovarian cancers. This also includes cancers of the appendix, fallopian tube, colon, lung, rectum and stomach.
How does heated intraperitoneal chemotherapy work?
Unlike systemic chemotherapy that is administered intravenously, HIPEC delivers chemotherapy directly into the abdomen. This allows for higher doses of chemotherapy treatment to target microscopic cells that traditional chemotherapy may miss. Depending on the type of disease being treated, HIPEC can be combined with systemic chemotherapy.
HIPEC is a surgical procedure that begins with removing all visible tumors from the abdomen. HIPEC then delivers heated chemotherapy directly inside the abdomen to help destroy any microscopic cancer cells and tumors that cannot be seen by the surgeon. The heated chemotherapy circulates inside the abdomen, which allows it to reach more of the internal surface area. The goal of HIPEC is to prevent cancer cells from growing into new tumors that allow the cancer to return.
Benefits and risks of heated intraperitoneal chemotherapy
HIPEC offers several benefits when compared to traditional chemotherapy treatment:
- It allows for a higher and more targeted dose of chemotherapy.
- Treatment is administered as a single dose in the operating room, instead of multiple treatments over a series of weeks.
- Almost all of the chemotherapy drug remains within the abdominal cavity so that toxic effects are minimized in other areas of the body.
Because HIPEC subjects the digestive system to a strong dose of chemotherapy, patients will need to receive nutrition for a short time through a feeding tube or IV. This lasts for approximately 2 weeks before normal eating can be resumed.
What happens during heated intraperitoneal chemotherapy?
Performing heated intraperitoneal chemotherapy is a lengthy procedure that occurs together with surgery to remove tumors and microscopic cancer cells. Once the surgeon removes as much of the tumor as possible, heated chemotherapy is administered directly into the peritoneal cavity. This chemotherapy runs through a warming machine before it enters your body.
The surgeon bathes the abdominal cavity with chemotherapy by rocking the body back and forth on the table or manually moving it into targeted areas. The chemotherapy is maneuvered throughout the peritoneal cavity for about 2 hours to ensure it reaches all lingering cancer cells. Unlike traditional chemotherapy, HIPEC targets the cancer cells directly without traveling throughout your body and bloodstream.
The University of Kansas Cancer Center has been at the forefront of this innovative therapy for years. Not only do we offer a number of HIPEC clinical trials, we design and lead clinical research trials for HIPEC, and our physicians serve on national committees to establish HIPEC guidelines.
Announcer: Welcome to Bench to Bedside, a weekly series of live conversations about recent advances in cancer, from the research bench to treatment at the patient's bedside. Now, your host and the director of the University of Kansas Cancer Center, Dr. Roy Jensen.
Dr. Jewell: Hi. I'm Dr. Annie Jewell, gynecologic oncologist at the University of Kansas Cancer Center. Thank you for joining us today for today's episode of Bench to Bedside. With me are surgical oncologist Dr. Joshua Mammen and Dr. Mazin Al-Kasspooles. Dr. Mammen focuses on treating sarcoma and melanoma, while Dr. Al-Kasspooles focuses on treating esophageal, colon, complex abdominal, rectal, and peritoneal cancers. Today, we're discussing regional chemotherapy vs. systemic chemotherapy approaches to cancer treatment. Dr. Mammen, what is the difference between regional and systemic chemotherapy, and could you provide some examples?
Dr. Mammen: Sure. So the aim of chemotherapy, of course, is to try to cure cancer cells - often, cancer cells that we can't really even see or we're not really sure that they're there. Systemic chemotherapy is kind of the traditional, usual type of chemotherapy when we think of chemotherapy, where someone gets a port or an IV in their arm, and then they get chemotherapy usually every few weeks to treat their whole body, to try to kill the cancer cells wherever they may be. Regional chemotherapy's a little bit different. Typically, it's done in the operating room, not done in a clinic or an outpatient setting, and the aim of regional chemotherapy is to just treat one part of the body, and maybe the part of the body where we know the cancer is. For example, if we know that the cancer's only in the belly, it would be to treat just the cancer in the belly, or if we know it's just in an arm or a leg, it's just to treat the arm or the leg and not treat the rest of the body.
Dr. Jewell: All right. Dr. Al-Kasspooles, what are the benefits of regional chemotherapy vs. systemic chemotherapy?
Dr. A.: Yeah, that's a good question. I think describing exactly what's being treated will help. It's good to think of the organs within the abdomen of being able to spread in one of two ways. One way is for it to go into the bloodstream and then go into the meat of an organ. For instance, within the actual meat of the liver is an example for colorectal cancer. That's best treated with systemic therapy, just like Dr. Mammen mentioned, because that attacks the blood. Well, there's another way that organs within the abdomen can spread. One way is for them to actually shed cells within the abdominal cavity - and I truly mean the abdomen is a cavity - and those cells, think of them as seeds. They can land on the surfaces within the abdomen, including the organs. So we know that systemic chemotherapy's really good at attacking the cancer in the meat of an organ, but there's a procedure out there called cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Very fancy words, but it basically means going inside the abdomen, removing all those types of cancers that are on the surfaces, and then giving heated chemotherapy while the patient is asleep, for anywhere between 60 to 90 minutes. So, just like Dr. Mammen mentioned, what that chemo does is really just take care of the cells that we can't possibly see after what we call the cytoreduction, or debulking. There are studies that have shown that, for certain cancers ... For instance, the classic is appendiceal cancers, but, most recently, we've been doing it for colorectal cancer and ovarian cancer, because those are two classic examples of that kind of spread, and the data shows that it's effective. It's used with systemic chemotherapy. So it doesn't replace systemic chemotherapy. It's just part of the treatment plan.
Dr. Jewell: So it's done in addition to?
Dr. A.: In addition to, yeah. Exactly.
Dr. Jewell: Absolutely. What's the name of the chemotherapy again, the term that you used? Was it HIPEC?
Dr. A.: Yes, it's HIPEC. Exactly. So if you look in, for instance, the Internet, the best way to find information is just type in "HIPEC" - H-I-P-E-C.
Dr. Jewell: Okay.
Dr. A.: Yeah.
Dr. Jewell: So then how do we determine what patients will benefit from this regional or HIPEC chemotherapy?
Dr. Mammen: Sure, and one point that Dr. Al-Kasspooles made that I think is a really important point is that it's really not a replacement therapy for typical treatment of the whole body, either systemic chemotherapy or immunotherapy or the other ways that we treat the whole body. It's kind of an additional treatment. But it's really in individuals who have cancer just in a certain part of the body. It's not the cancer that's spread all over the body. So, as Dr. Al-Kasspooles mentioned, he sees a lot of patients who have cancer within their abdomen. I see individuals who have cancer that may have tried to crawl up their arm or their leg, and there are so many spots, for example, that I can't go in and just cut each of them out, and I also worry that if I cut out each of those spots, a new one would just pop up right next to it. So, in individuals like that, where we know that the entire arm or leg might be affected, it's a really great treatment to just treat the arm or just treat the leg. Really, kind of the benefit of doing that is that you can provide a really high dose of this chemotherapy that the rest of the body just couldn't tolerate. Such a high dose would be incredibly effective, but it's too dangerous for the rest of the patient.
Dr. Jewell: All right. So what would be some of the risks of these procedures that you talked about?
Dr. Mammen: Yeah, and each of these procedures is a little bit different. So, for the procedure that I focus on, which is called a limb perfusion or infusion, really, the risks are remarkably low, which is ... It's really quite amazing for such a big surgery. Similar to what Dr. Al-Kasspooles described, for the chemotherapy in the arm or leg, we put in the chemotherapy for an hour and circulate the chemotherapy in the arm or leg. It's like putting the arm or leg on bypass. But, afterwards, patients feel great. I actually watch them in the ICU a day. I often tell patients they're the most boring person in the ICU - not because they're boring people ...
Dr. Jewell: Yeah. Dr. Mammen: ... but just because they're not sick.
Dr. Jewell: Yeah.
Dr. Mammen: They actually feel great, and they're kind of ... They're just waiting. The reason they're in the ICU, I just need to keep a close eye on their arm or leg. One of the risks is that the arm or leg could get really swollen because of the chemotherapy, because chemotherapy is a toxin, and it can cause more arm swelling or leg swelling that you would want. That's usually temporary. So I like to watch for that 24 hours, but, thankfully, we've had no problems with that, really, and most people get to go home in a couple days.
Dr. Jewell: Okay. Then what about the abdominal? What would be some of the risks associated with that?
Dr. A.: Yeah. I mean, unlike limb perfusions, there are some risks of major complications from doing the HIPEC, and it really depends a lot on how much disease is in the abdomen, that surface disease, because sometimes, in order to get all the cancer out, we have to remove organs like the spleen, part of the liver, bowel. You could imagine that you have that big operation, but you also ... When we give that HIPEC, that high-dose chemotherapy, although we can give a high dose and it does stay within the abdomen, for the most part, and we wash it out, some of it leaks into the system. So, as these patients recover, where they have all the risks of a major abdominal surgery, you can add that second punch, where they get some of that systemic chemotherapy and their immune system is knocked down. I mean, some of the systemic chemo that got in the bloodstream, and you can imagine if their immune system is knocked down while they're recovering from this big operation, that it increases risks, most notably infectious types of risk. Yeah. So we do a high volume at the University of Kansas Cancer Center. We do approximately 50 a year, which is a very high volume. So, luckily, our actual morbidity and mortality from this operation is quite low, because the institution is better at ...
Dr. Jewell: Yeah.
Dr. A.: It's not just the surgeon is better at these patients ...
Dr. Jewell: At taking care of them from beginning to end.
Dr. A.: At recovering, yeah. That, I think, is an important point.
Dr. Jewell: Yeah.
Dr. A.: It's not just the surgeon. It's a team involved.
Dr. Jewell: Yeah. Yeah.
Dr. A.: That's why we have a low mortality, and we have excellent results.
Dr. Jewell: Yeah.
Dr. A.: Yeah.
Dr. Jewell: It really illustrates the importance of going somewhere that is a high-volume center ...
Dr. A.: Yes. Yes.
Dr. Jewell: ... that does this procedure and sort of any newer procedures or anything like that.
Dr. A.: Yeah. Yeah.
Dr. Jewell: If you're just joining us, we're here with cancer surgical specialists Dr. Joshua Mammen and Dr. Mazin Al-Kasspooles, and we're discussing regional and systemic chemotherapy approaches in cancer treatment. Pauline Horton is here in the studio to take your questions if you have any, and remember to share this link with people you think might benefit from our discussion today using the hashtag #BenchtoBedside. So, Dr. Al-Kasspooles, what types of cancer ... You mentioned these a little bit before, but to talk about that again, what types of cancers is this type of treatment appropriate for?
Dr. A.: Yeah, that's a great question. So, classically, it has been done for appendiceal cancer, because appendiceal cancer is one of those types of cancers where the appendix can burst, and those seeds can spread pretty early. It's been done for many years for appendiceal cancer, but, in recent times, over the past decade, we have literature that supports that it works for, most importantly, colon cancer when it spreads that way, ovarian cancer, as well as something called mesothelioma. Although we think of mesothelioma as happening in the chest, it could also happen in the abdomen. Again, there is data that supports that this is effective when it's used as part of the treatment plan.
Dr. Mammen: You've used it for other cancers as well, with pretty amazing results.
Dr. A.: Yeah. Yeah, exactly. We've used it for ... This is sort of outside the box, but we have used it, for instance, for liver cancers, for breast cancer, and other types of cancers, and we have had great results, although those are rare instances. So no one has a lot of these patients, so we don't have a lot of what we call literature on these. But I offer it for patients.
Dr. Jewell: That would be something that a patient could come for a consultation ...
Dr. A.: Yes. Exactly.
Dr. Jewell: ... with either one of you to talk about that further, if maybe they are a good candidate ...
Dr. A.: Yes.
Dr. Jewell: ... to be considered?
Dr. Mammen: Sometimes those patients don't have other great options.
Dr. A.: Yes, yes.
Dr. Mammen: So, as you're exploring your options, sometimes it's good to have a conversation, I think.
Dr. Jewell: Yeah, absolutely. So, Dr. Mammen, why does it matter where patients go to receive this type of treatment?
Dr. Mammen: Yeah, I would echo what Dr. Al-Kasspooles stated already, which is really it's about the team. Certainly, for limb perfusions, I rely extensively on the team, particularly the vascular surgeons I work with. Dr. Hance is one of our vascular surgeons, our division chief here of vascular surgery. I do all the limb perfusions with him. Frankly, he's great at handling blood vessels, and that's what I need for that procedure.
Dr. Jewell: Yeah.
Dr. Mammen: Also, the perfusionists, the folks that actually run the pumps, they're used to doing this. They have the right machines. This is a very specialized technique, and it's great to have folks that have done 100 or so of these cases with me over the years.
Dr. Jewell: Absolutely.
Dr. Mammen: Then as Dr. Al-Kasspooles already mentioned is having the ICU doctors that are used to these procedures and kind of know what to expect and won't be surprised when there's something that's a little different than what is typical, because they'll say, "Oh, we've seen that before."
Dr. Jewell: Yep.
Dr. Mammen: I think all of those kind of components are really, really critical ...
Dr. Jewell: Yeah.
Dr. Mammen: ... and not to ... Yeah, another one: The pharmacy's actually really important, too.
Dr. Jewell: Yeah, absolutely.
Dr. Mammen: I mean, they're the ones that mix the chemotherapy in the right way, and that's really important. The nuclear medicine department, because, as Dr. Al-Kasspooles alluded to, there's a risk of leak of chemotherapy into the rest of the body. That's the same for the limb perfusions as well, and I monitor with a radionucleotide to check for a leak. So the nuclear medicine department here is very familiar with the fact of how we do this, and they're ready to get the blood labeled in the way that I need and get everything ready for me on the day of surgery. So all of those steps are really, really important.
Dr. Jewell: Yeah. It's sort of ... It's one of the things they talk about a lot, and you hear this word a lot, but it actually is very important, this multidisciplinary ...
Dr. Mammen: Yes.
Dr. A.: Yes.
Dr. Jewell: ... and how important that really is in just ... You named at least 10 to 12 different teams that are coming together, and you can really only get that if you're coming to a NCI-accredited center, where we have that type of care.
Dr. A.: Yeah. To add to that, when you read about cancer care, you hear about rescuing patients. So it's not just rescuing someone's life. So if a patient has a major complication at an institution like this, we have, for instance, radiologists that can help us rescue the patient from that major complication and even death. We have ICU doctors, just like Dr. Mammen mentioned. So it is just ... Even beyond the team that treats the patient, it's the other folks that can rescue if there is a major complication, and that's important, because if we rescue someone from a major complication, we can probably take them away not only from dying, but from a major consequence. The patient won't be as debilitated.
Dr. Jewell: Yeah. Absolutely.
Dr. Mammen: I certainly think that volume matters in that, because if you're only doing something every now and then, folks forget.
Dr. Jewell: Yeah.
Dr. Mammen: They forget that little detail that would've been really important to make sure you do the procedure really well. So just doing it over and over again, that repetition, really makes our care a little bit better.
Dr. Jewell: Yeah, and we know that from the literature. There's actually prospective literature that shows us that patients that get their care with high-volume surgeons or high-volume hospitals have better outcomes. So it is a really important thing for people to consider. So, Dr. Al-Kasspooles, what about research and clinical trials about regional chemotherapy?
Dr. A.: Yes. So that's a really good point. HIPEC is kind of somewhat in its infancy, and so we're trying to discover better delivery systems and potentially use better agents. There is a semi-standard agent that we use. I'm part of a HIPEC group that is associated with an oncology group, where we're trying to set guidelines for treatment, and we're also involved in clinical trials for HIPEC. For instance, I am running a national trial right now, which is comparing one agent to the other. You literally randomize, meaning flip of a coin, of receiving one or the other. Those are the kind of studies, I think, which will be very helpful in determining what treatment, what type of HIPEC, and how we give it was really effective. Again, we're in the early phases, but I think it's happening now, so ... Yeah. Yeah.
Dr. Jewell: Yeah. Agreed. With ovarian cancer, which it's been, again ... Now we're having more prospective data in ovarian cancer, but just this year, we finally now have a large trial ...
Dr. A.: Yes.
Dr. Jewell: ... that showed that there is a benefit for our IPEC patients and that we have trials now open at KU in both colon and ovarian cancer.
Dr. A.: Yes. Yes.
Dr. Jewell: We're actually one of the only two in the United States for ovarian cancer ...
Dr. A.: Yes.
Dr. Jewell: ... which I think is pretty exciting. Yeah, the fact that Dr. Al-Kasspooles and myself are both on these HIPEC committees that are national committees, where we're looking at the guidelines and the right patients, so I think that's a pretty exciting opportunity for patients in this area ...
Dr. A.: Yes.
Dr. Jewell: ... to be able to come here ...
Dr. A.: Absolutely.
Dr. Jewell: ... and receive that type of care. So you talked about the clinical trial that you have open right now, and we have my ovarian trial. So if a patient was interested and wanting to be involved in that clinical trial, that would be something that they could come and get a consult with you in the clinic?
Dr. A.: Absolutely. Yeah. Yeah, so yeah, and that's an important point. There are studies that have shown that only 12% of patients who have GI cancers and have this type of spread go to see the right people or go to the right institution. So the important thing is to educate the public, but also physicians, in order to get these patients early. So, once I see a patient, not only am I seeing the patient, I present their case, we call it, at what we call a tumor conference, where the radiologist, pathologist, other surgeons, medical oncologist, radiation therapist, where we come up with a treatment plan as a group. It's like getting all these other doctors, I guess, for the price of one.
Dr. Jewell: Yeah.
Dr. A.: It's a really neat thing, and we can ... The key, again, is we need to see the patients early. The more the public knows and the more the referring physicians know, I think, the better we will be at treating the disease, meaning this type of spread.
Dr. Jewell: Absolutely.
Dr. A.: Yeah.
Dr. Jewell: Well, we're getting close to coming to the end of today's episode. Dr. Mammen, is there anything you would most like our listeners to take away with them today?
Dr. Mammen: Sure, and it would really just echo Dr. Al-Kasspooles' point. It's really about knowing your options and exploring other options. I certainly think that it's important that we continue to let folks know that these options exist, because some of these cancers are a little complicated, and maybe some of these types of spread are maybe not as common as some physicians in the community know about. So I really think that we'll need to continue to provide information and spread the word that there are maybe more options out there than folks have heard about.
Dr. Jewell: Absolutely. So Pauline Horton is here in the studio, taking questions. Any final questions, Pauline?
Pauline Horton: We have no more questions at this time, but please continue to leave your comments and questions on the Facebook post, and we will respond throughout the day.
Dr. Jewell: All right. Perfect. Well, thank you very much, Dr. Mammen and Dr. Al-Kasspooles.
Dr. Mammen: Thank you.
Dr. A.: It was a wonderful session.
Dr. Jewell: That's it for today.
Dr. A.: Great.
Dr. Mammen: Perfect.
Dr. Jewell: To learn more, please visit kucancercenter.org, and join us next Wednesday at 10 AM as Bench to Bedside explores sex after cancer. Thank you for watching.
Request your appointment today.
To make an appointment at The University of Kansas Cancer Center, call 913-588-1227.